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Since nonalcoholic fatty liver disease (NAFLD) has become the leading cause of liver disease in the Western world, clinicians need reliable noninvasive tools for the identification of NAFLD-associated fibrosis. Limited evidence on the performance of the novel shear wave elastography technique Elast-PQ (EPQ) in NAFLD is available.In this prospective, European multinational study we assessed the diagnostic accuracy of EPQ using vibration-controlled transient elastography (VCTE) as a reference standard.Among 353 NAFLD patients, 332 (94.1%) fulfilled reliability criteria of VCTE and EPQ (defined by IQR/median ≤0.3; 41.3% female, mean age: 59 [IQR: 16.5], mean BMI: 29.0 (7.1)). 4/353 (1.1%) and 17/353 (4.8%) had unreliable VCTE and EPQ measurements, respectively. VCTE-based NAFLD fibrosis stages were F0/F1: 222(66.9%), F2: 41 (12.3%), F3: 30 (9.1%), F4: 39 (11.7%). We found a strong correlation (Pearson R=0.87; p0.0001) and concordance (Lin's concordance correlation coefficient =0.792) of EPQ with VCTE. EPQ was able to identify NAFLD-fibrosis risk with the following EPQ cutoffs: ≥6.5 kPa for significant fibrosis (≥F2) (≥1.47 m/s; sensitivity: 78%; specificity: 95%; AUROC: 0.94), ≥6.9 kPa for advanced fibrosis (≥F3) (≥1.52 m/s; sens.: 88%, spec.: 89%; AUROC: 0.949), and ≥10.4 kPa for cirrhosis (F4) (≥1.86 m/s; sens.: 87%; spec.: 94%; AUROC: 0.949).The point shear wave elastography technique EPQ shows excellent correlation to and concordance with VCTE. EPQ can reliably exclude NAFLD fibrosis6.0 kPa (1.41 m/s) and indicate a high risk of advanced fibrosis ≥10.4 kPa (≥1.86 m/s).Die nichtalkoholische Fettleber (NAFLD) ist mittlerweile die häufigste Lebererkrankung in der westlichen Welt. Daher besteht ein Bedarf an nichtinvasiven Methoden zur Einschätzung des Fibrose-Risikos bei NAFLD. Über die Aussagekraft der neue Scherwellen-Technologie Elast-PQ (EPQ) liegen nur wenige Daten vor.Diese prospektive, europäische multinationale Studie untersuchte die diagnostische Genauigkeit von EPQ bei NAFLD-PatientInnen im Vergleich zur Vibrations-kontrollierten transienten Elastografie (VCTE).Von 353 NAFLD-Patient*innen erfüllten 332 (94,1%) die Zuverlässigkeitskriterien für VCTE und EPQ (definiert als IQR/median ≤0,3). Die Studienpopulation war zu 41,3% weiblich, mit einem medianen Alter von 59 [IQR: 16,5] Jahren und einem medianen BMI von 29 [IQR: 7] kg/mDie Punkt-Scherwellen-Elastografie-Methode EPQ zeigt eine exzellente Korrektion und Konkordanz mit der VCTE. Bei NAFLD-Patient*innen wird durch EPQ6,0 kPa (1,41 m/s) eine signifikante Fibrose ausgeschlossen und durch EPQ ≥10,4 kPa (≥1,86 m/s) ein hohes Risiko für eine fortgeschrittene Fibrose angezeigt.

The present, updated document describes the fourth iteration of recommendations for the hepatic use of contrast enhanced ultrasound (CEUS), first initiated in 2004 by the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). The previous updated editions of the guidelines reflected changes in the available contrast agents and updated the guidelines not only for hepatic but also for non-hepatic applications.The 2012 guideline requires updating as previously the differences of the contrast agents were not precisely described and the differences in contrast phases as well as handling were not clearly indicated. In addition, more evidence has been published for all contrast agents. The update also reflects the most recent developments in contrast agents, including the United States Food and Drug Administration (FDA) approval as well as the extensive Asian experience, to produce a truly international perspective.These guidelines and recommendations provide general advice on the use of ultrasound contrast agents (UCA) and are intended to create standard protocols for the use and administration of UCA in liver applications on an international basis to improve the management of patients.

This manuscript describes the use of ultrasound elastography, with the exception of liver applications, and represents an update of the 2013 EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) Guidelines and Recommendations on the clinical use of elastography.Diese Arbeit beschreibt den Einsatz der Ultraschall-Elastografie mit Ausnahme der Leberanwendungen und ist eine Aktualisierung der Leitlinien und Empfehlungen der EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) von 2013 zum klinischen Einsatz der Elastografie.

An interdisciplinary task force of European experts summarizes the value of gastrointestinal ultrasound (GIUS) in the management of acute appendicitis and diverticulitis. Based on an extensive literature review, clinical recommendations for these highly common diseases in visceral medicine are presented.In patients with acute appendicitis, preoperative sonography has been established as a routine procedure in most European countries for medical and legal reasons. Routine sonography in these patients may reduce the rate of unnecessary surgery by half. The sensitivity, specificity, and accuracy of ultrasound reach values above 90 % and are equivalent to CT and MRI. However, the high operator dependence may be a problem, for example in point-of-care ultrasound in emergency departments. Structured training programs, quality controls and standardized ultrasound reporting should be increasingly implemented.In the case of suspected acute diverticulitis, "ultrasound first" should also be a basic element in the approach to all patients. Sonography can confirm the diagnosis and allows early risk stratification. As treatment strategies have become less aggressive and more tailored to the stage of diverticulitis, accurate staging has become increasingly important. GIUS and CT have proven to have similar sensitivity and specificity. Especially in cases of uncomplicated diverticulitis, GIUS will be the one and only imaging procedure. CT may work as a backup and has particular advantages for diverticulitis located in the distal sigmoid, inflammation deep in the small pelvis and insufficient ultrasound scanning conditions. This step-up approach (ultrasound first and CT only in case of a negative or inconclusive ultrasound result) has proven to yield the best accuracy.Im Rahmen des EFSUMB-Leitlinienprojekts zum gastrointestinalen Ultraschall (GIUS) gibt eine interdisziplinäre Arbeitsgruppe von europäischen Experten einen Überblick zum Nutzen der Sonografie bei akuter Appendizitis und Divertikulitis. Basierend auf einer umfangreichen Literaturrecherche werden klinische Empfehlungen zu diesen häufigen Erkrankungen der Viszeral-Medizin vorgestellt.Bei Patienten mit akuter Appendizitis haben medizinische und juristische Erwägungen die präoperative Sonografie heute als Routineverfahren in den meisten europäischen Ländern fest etabliert. Die Sonografie kann hier die Rate unnötiger Operation halbieren. Sensitivität, Spezifität und Genauigkeit des Ultraschalls erreichen Werte von über 90 % und entsprechen CT oder MRT. Eine hohe Untersucherabhängigkeit kann jedoch problematisch sein, beispielsweise beim bettseitigen Ultraschall in der Notaufnahme oder Praxis. Strukturierte Trainingsprogramme, Qualitätskontrollen und ein standardisierter Befundbericht sollten deshalb Einzug in den klinischen Alltag finden. Auch beim Verdacht auf eine akute Divertikulitis sollte die „ultrasound first“-Strategie Anwendung finden.Die Sonografie kann die Diagnose einer Divertikulitis bestätigen und den Schweregrad abschätzen. Da heutige Therapiestrategien weniger aggressiv und mehr auf das Stadium der Divertikulitis zugeschnitten sind, ist eine genaue Einteilung des Schweregrads immer wichtiger geworden. GIUS und CT haben hier eine ähnliche Sensitivität und Spezifität. Gerade bei unkomplizierter Divertikulitis ist die Sonografie völlig ausreichend. Das CT kann als Backup dienen und hat Vorteile bei der Divertikulitis im distalen Sigma, bei einer Entzündung tief im kleinen Becken oder bei unzureichenden Untersuchungsbedingungen. Eine solche Stufendiagnostik (Ultraschall zuerst und CT nur im Falle eines negativen oder nicht eindeutigen Befundes) hat bei der Divertikulitis die höchste Genauigkeit bewiesen.

In October 2014 the European Federation of Societies for Ultrasound in Medicine and Biology formed a Gastrointestinal Ultrasound (GIUS) task force group to promote the use of GIUS in a clinical setting. One of the main objectives of the task force group was to develop clinical recommendations and guidelines for the use of GIUS under the auspices of EFSUMB. The first part, gives an overview of the examination techniques for GIUS recommended by experts in the field. It also presents the current evidence for the interpretation of normal sonoanatomical and physiological features as examined with different ultrasound modalities.

This is the second part of the series on interventional ultrasound guidelines of the Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). It deals with the diagnostic interventional procedure. General points are discussed which are pertinent to all patients, followed by organ-specific imaging that will allow the correct pathway and planning for the interventional procedure. This will allow for the appropriate imaging workup for each individual interventional procedure (Long version).

Purpose: To assess the value of contrast-enhanced ultrasound (CEUS) for differentiating malignant from benign focal liver lesions (FLLs) and for diagnosing different FLL types. Material and Methods: CEUS performed in 14 Romanian centers was prospectively collected between February 2011 and June 2012. The inclusion criteria were: age > 18 years; patients diagnosed with 1 – 3 de novo FLLs on B-mode ultrasound; reference method (computed tomography (CT), magnetic resonance imaging (MRI) or biopsy) available; patient’s informed consent. FLL lesions were characterized during CEUS according to the European Federation of Societies for Ultrasound in Medicine and Biology guidelines. For statistical analysis, indeterminate FLLs at CEUS were rated as false classifications. Results: A total number of 536 cases were included in the final analysis, 344 malignant lesions (64.2 %) and 192 benign lesions (35.8 %). The reference method was: CT/MRI – 379 cases (70.7 %), pathological exam – 150 cases (27.9 %) and aspiration of liver abscesses – 7 cases (1.4 %). CEUS was conclusive in 89.3 % and inconclusive in 10.7 % of cases. To differentiate between malignant and benign FLLs, CEUS had 85.7 % sensitivity, 85.9 % specificity, 91.6 % positive predictive value, 77.1 % negative predictive value and 85.8 % accuracy. The CEUS accuracy for differentiation between malignant and benign liver lesions was similar in tumors with diameter ≤ 2 cm and those with diameter > 2 cm. Conclusion: CEUS represents a useful method in clinical practice for differentiating between malignant and benign FLLs detected on standard ultrasonography, and the results of this study are in concordance with previous multicenter studies: DEGUM (Germany) and STIC (France).

The clinical part of these Guidelines and Recommendations produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology EFSUMB assesses the clinically used applications of all forms of elastography, stressing the evidence from meta-analyses and giving practical advice for their uses and interpretation. Diffuse liver disease forms the largest section, reflecting the wide experience with transient and shear wave elastography . Then follow the breast, thyroid, gastro-intestinal tract, endoscopic elastography, the prostate and the musculo-skeletal system using strain and shear wave elastography as appropriate. The document is intended to form a reference and to guide clinical users in a practical way.

Introduction: Liver biopsy is the “gold standard” method for staging liver fibrosis, but it's an invasive procedure and is associated with risk of some complications. There are also noninvasive techniques for assessment of liver fibrosis such as elastography and biological tests, but these techniques can fail or generate false measurements depending on subjects conditions: food intake, ascites, obesity, etc. The aim of this study is to determine whether liver fibrosis can be evaluated using the parametric arrival time imaging (PAT) using contrast enhanced ultrasonography (CEUS). Material and method: Ultrasonography was performed using the LOGIQ E9 (GE Healthcare, Chalfont St. Giles-UK) system. CEUS using SonoVue as contrast was performed in each subject. Liver scanning during the first 30 s following the injection of contrast agent through the cubital vein were saved as raw data on hard disk. The examination was performed with the patients in left lateral position with the right arm elevated above the head and the patients were instructed to hold their breath for some seconds. Images showing liver parenchyma and the right kidney in a single screen were used for analysis. Following ultrasonography, parametric imaging was performed using the proprietary image analysis software of the ultrasound system. A parametric color scale was used: red-first 5 seconds, yellow 5 – 10 seconds, green 10 – 15 seconds, blue 15 – 20 seconds, purple 20 – 25 seconds, brown 25 – 30 seconds. Results: A ratio of the arrival parametric time was calculated between the kidney and the liver. Previous studies showed that, the faster the contrast arrives in the liver as compared with the kidney, the higher is the severity of fibrosis. This ratio is compared with liver stiffness assessed by Transient Elastography (performed before the CEUS examination). Conclusion: Our preliminary study on 10 patients showed that the method is feasible, but more patients are needed to draw a conclusion.

The purpose of this study was to evaluate the diagnostic performance of a point shear wave elastography using ARFI technique- ElastPQ, in patients with B and C chronic hepatopathies, using Transient Elastography (TE) as the reference method, since it is a validated method for liver fibrosis assessment. Materials and methods: The study included 228 consecutive subjects with chronic hepatopathies (26% HBV, 74% HCV) from whom 51% had liver cirrhosis. Liver stiffness (LS) was evaluated in the same session by means of 2 elastographic methods: TE (Fibroscan, Echosens) and ElastPQ (Philips, Affinity). Reliable LS measurements (LSM) were defined as follows: for TE – the median value of 10 LSM with a success rate≥60% and an interquartile range< 30%. For ElastPQ- the median value of 10 LSM in the liver parenchyma, at least 1 cm below the capsule, avoiding large vessels. For differentiating between stages of liver fibrosis we used the following cut-off values for TE – mild fibrosis (F1)-6.1 kPa, moderate fibrosis (F2)- 7.2 kPa, severe fibrosis (F3)-9.6 kPa and for liver cirrhosis (F4) -14.5kPa (1). Results: Reliable LSM were obtained in 90.7% (207/228) by means of TE and in 98.7% (225/228) with ElastPQ. In the final analysis 205 patients were included. The areas under the receiver operating characteristic curve for ElastPQ were: 0.90 for patients with mild fibrosis (F1), 0.95 for moderate fibrosis (F2), 0.96 for severe fibrosis (F3) and 0.94 for cirrhosis. The best cut-off values for discriminating mild, moderate, severe fibrosis and cirrhosis were 6.4, 7.2, 8.5 and 9.9 kPa. Conclusions: ElastPQ is a method that seems to be good for the diagnosis of all stages of liver fibrosis with good diagnostic accuracy. Reference: [1] Tsochatzis et al. Elastography for the diagnosis of severity of fibrosis in chronic liver disease: a meta-analysis of diagnostic accuracy. J Hepatol. 2011 Apr; 54 (4): 650 – 9.

To compare two methods of noninvasive assessment: transient elastography (TE) and acoustic radiation force impulse elastography (ARFI).Our study included 114 subjects: 38 healthy volunteers, (considered to have no fibrosis - F 0) and 76 patients with chronic liver disease: 53 who had undergone liver biopsy (LB) (7 with F 1, 24 with F 2, 22 with F 3 Metavir) and 23 previously diagnosed with cirrhosis (F4 Metavir). In each patient we performed a liver stiffness measurement by means of TE and ARFI. ARFI (shear wave velocity quantification) was performed at 3 points: at 0 - 1 cm, at 1 - 2 cm and at 2 - 3 cm under the capsule. For each depth, 5 valid measurements were made, and a median value was calculated, measured in m/sec.A direct, strong, linear correlation (Spearman rho = 0.848) was found between TE and the stage of fibrosis (p0.001). A significant, direct correlation was found between ARFI measurements made 1 - 2 cm and 2 - 3 cm below the liver capsule and the severity of fibrosis (rho = 0.675 and 0.714 respectively). The subcapsularly measured ARFI values showed a poor correlation with fibrosis (rho = 0.469). The best test for predicting significant fibrosis (F ≥ 2) was TE, with the area under receiver-operating characteristic curve (AUROC) 0.908, significantly larger than the AUROCs for ARFI. If only ARFI is considered, measurements made 1 - 2 and 2 - 3 cm below the capsule have the best predictive value, with AUROCs not significantly different from each other (0.767 and 0.731, respectively). For predicting fibrosis (F0), TE had the best predictive value: optimized cut-off 5.65 kPa (AUROC -0.898). For ARFI, the cut-offs were: 1.4 m/sec, AUROC -0.747 (1 - 2 cm), and 1.26 m/sec AUROC -0.721 (2 - 3 cm). For predicting cirrhosis (F = 4 Metavir), the optimized cut-offs were: TE -12.9 kPa (AUROC -0.994); ARFI - 1.78 m/sec for measurements made 2 - 3 cm below the capsule, AUROC - 0.951.At present, liver elasticity evaluation by means of ARFI is not superior to TE for the assessment of liver fibrosis. For ARFI, the most reliable results are obtained if measurements are made 1 - 2 and 2 - 3 cm below the liver capsule. ARFI is an accurate test for the diagnosis of cirrhosis.

PURPOSE: Chronic viral hepatopathies can be evaluated through invasive or noninvasive methods. The aim of this paper was to assess the indications and results of transient elastographic (TE) evaluation of the liver in patients with chronic viral hepatitis and cirrhosis. MATERIALS AND METHODS: We retrospectively assessed all the liver stiffness measurements (LSM) (FibroScan®) performed over a two-year period (2007 - 2009). RESULTS: 3,459 TE evaluations were made mainly for the assessment of: HCV hepatitis, HBV infection (chronic hepatitis and inactive HBV carriers), biviral hepatitis (B + C or B + D), cirrhosis and in 176 normal subjects (to establish the normal values of LSM). From the 3,459 FS evaluations, we could not obtain valid LSM in 183 cases (5.3 %). 93.9 % of the patients in the failure group were overweight (BMI > 25 kg/m 2 ). In 527 cases (16 %) the SR (success rate = number of valid measurements/total number of measurements) was < 60 %. TE reproducibility was analyzed in 287 cases. The ICCs for the three operators were 0.985, 0.949, and 0.874 respectively, and the overall ICC was 0.982. 596 cases of cirrhosis were evaluated. A cut-off value of 23.3kPa was found to predict the presence of at least grade 2 esophageal varices. CONCLUSION: LSM by means of TE is a promising noninvasive evaluation method, which can be used in numerous clinical situations, some in which its value is well established (suspicion of LC, predicting significant fibrosis) and some in which its value is less known (HBV chronic hepatitis, inactive HBV carriers or severity of portal hypertension).

We present here the first update of the 2013 EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) Guidelines and Recommendations on the clinical use of elastography, focused on the assessment of diffuse liver disease. The first part (long version) of these Guidelines and Recommendations deals with the basic principles of elastography and provides an update of how the technology has changed. The practical advantages and disadvantages associated with each of the techniques are described, and guidance is provided regarding optimization of scanning technique, image display, image interpretation, reporting of data and some of the known image artefacts. The second part provides clinical information about the practical use of elastography equipment and the interpretation of results in the assessment of diffuse liver disease and analyzes the main findings based on published studies, stressing the evidence from meta-analyses. The role of elastography in different etiologies of liver disease and in several clinical scenarios is also discussed. All of the recommendations are judged with regard to their evidence-based strength according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence. This updated document is intended to act as a reference and to provide a practical guide for both beginners and advanced clinical users.Dies ist die erste Überarbeitung der 2013 publizierten EFSUMB-Leitlinien zur klinischen Anwendung der Elastographie und konzentriert sich auf die diffusen Lebererkrankungen. Der erste Teil dieser Leitlinien und Empfehlungen handelt von den Grundlagen der Elastografie und erläutert die Weiterentwicklungen der Technologie während dieses Zeitraumes. Die praktischen Vor- und Nachteile der verschiedenen Techniken werden beschrieben. Auch die Optimierung der Untersuchungstechnik, Bilddarstellung, Bildinterpretation und die Befundbeschreibung sowie Artefakte werden dargelegt. Der klinische Teil dieser Leitlinien erläutert die praktische Anwendung der Elastografie bei der Beurteilung diffuser Lebererkrankungen unter Berücksichtigung der Geräteausstattung und Interpretation der Ergebnisse. Die aktuelle Literatur wurde analysiert unter besonderer Beachtung von Metaanalysen. Die klinische Anwendung der Elastografie wird unter Reflexion unterschiedlicher klinischer Szenarien und der unterschiedlichen Ätiologien diffuser Lebererkrankungen erläutert. Alle Empfehlungen erfolgten gemäß der Evidenz basierten Methodik der Oxford-Klassifikation. Das hier vorgestellte Update soll dem Anfänger und fortgeschrittenen Nutzer eine praktische Hilfe darstellen.

Purpose: To establish the influence of glomerular filtration rate (eGFR) on KS values assessed by ARFI elastography. Methods: Our study included 88 subjects: 50 “normal” subjects (56.8%) (hospitalized patients for various diseases with normal renal ultrasonography, normal serum creatinine and blood nitrogen urea, without proteinuria or hematuria) and 38 (43.2%) patients with various kidney diseases. The mean age of subjects was 57.1 ± 13.6 years, 37.5% being women and 62.5% men. Five valid ARFI measurements were performed in the parenchyma of the each kidney with the subjects in left or right lateral decubitus, median values were calculated and expressed in meters/second (m/s). The eGFR was estimated using the MDRD4 formula. Results: Valid ARFI measurements were obtained in all subjects in the right kidney and in 97.7% of cases in the left kidney. The mean ARFI values obtained in the right and left kidney were similar in “normal” kidneys and also in kidneys with pathology: 2.21 ± 0.80 m/s vs. 2.16 ± 0.75 m/s, p = 0.35 and respectively 2.08 ± 0.77 m/s vs. 2.02 ± 0.86 m/s, p = 0.62. Because the mean value of KS was similar in the right and left kidney in both “normal” subjects and those with kidney pathology, the chose to study the influence of eGRF on KS values obtained in the right kidney. The mean ARFI values obtained in the right kidney according to the eGFR rate were: > 90 ml/min/1.73 m2 (35 subjects) -2.27 ± 0.79 m/s; 30 – 89 ml/min/1.73 m2 (45 subjects) -2.16 ± 0.78 m/s and 90 ml/min/1.73 m2 (2.27 ± 0.79 m/s) vs. < 30 ml/min/1.73 m2 (1.62 ± 0.58 m/s), p = 0.03 and respectively 30 – 89 ml/min/1.73 m2 (2.16 ± 0.78 m/s) vs. < 30 ml/min/1.73 m2 (1.62± 0.58 m/s), p = 0.04. Conclusion: KS values obtained by ARFI elastography were significantly lower in patients with moderate and severe alteration of kidney function (eGFR< 30 ml/min) as compared with subjects with normal renal function or those with mild alteration of renal function.

Hepatic steatosis or “fatty liver“ is one of the most frequent hepatic diseases. n this study we try to find a correlation between the presence of hepatic steatosis (HS) and age, gender, body mass index (BMI), hypercholesterolemia (HCL), hyperglycemia (HG) and Hypertriglyceridemia (HTG). Can they predict the occurrence of hepatic steatosis? The study was randomized and prospective. We studied 727 subjects for 7 months. The subjects were from a physician's cabinet. The group was formed of 40% men and 60% women with age between 20 and 97 years old. For the evaluation of hepatic steatosis we used Ultrasound Siemens Sonoline 2 with a transducer of 3.5MHz. And for the determination of level of hepatic steatosis we used visual scale by comparing the liver with renal cortical. We splitted the level of steatosis in: absent (0), low (1), moderate (2) and severe (3). We considered abnormally high these values: hyperglycemia>120mg%, hypercholesterolemia>200%, hypertriglyceridemia>160%. 72.35% of our subjects had different levels of steatosis. The most important prognostic factor for steatosis is HCL (Odds ratio=22.58) followed by HTG (Odds ratio=6.25) and high BMI (ODDS ratio=5.65). Subjects's gender is not a prognostic factor, gender distribution being uniform (Pearson Chi square p=0.14). The prediction of steatosis level is linked through a linear relation with the BMI value and the cholesterol's level, while age and hyperglycemia are not predictors for hepatic steatosis. Concluding, there is a direct and very strong correlation between HCL and SH level (rho=0.679. p=0.000), the prediction is very strong in association with HTG. Secondary factors of prediction are HTG (without HCL) and obesity. Indifferent factors are gender, sex and HG. People with HCL, HTG and high values of BMI are more likely to be discovered on an ultrasound examination with steatosis liver.