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Primary biliary tract neuroendocrine tumors (NETs) are extremely rare tumors that account for 0.2-2% of all gastrointestinal neuroendocrine tumors. The typical presentation is with jaundice and other symptoms related to biliary obstruction.We present a case of right hepatic duct NET in a 27-year-old female patient, asymptomatic, presented for a routine ultrasound examination that revealed moderate dilatation of the intrahepatic biliary ducts and a 20 mm hyperechoic lesion in the right hepatic biliary duct. Additional imaging was performed with the presumptive diagnosis of cholangiocarcinoma. After surgery, the histopathological and immunohistochemical report was conclusive for the diagnosis of G2 well-differentiated NET. [ABSTRACT FROM AUTHOR]

Background and Aim: Contrast enhanced ultrasound (CEUS) has been proven to be a reliable method for the characterization of focal liver lesions (FLL). The aim of this paper was to evaluate the performance of CEUS for the diagnosis of liver hemangiomas in a large cohort of patients.Material and Method: We performed a multicentre prospective study which included successive CEUS examinations from fourteen centers from Romania. CEUS examinations were performed in de novo FLL, using low mechanical index ultrasound, following an intravenous bolus of 2.4 ml SonoVue. CEUS was considered conclusive for hemangioma if a typical pattern was present following contrast (centripetal fill in during the arterial phase, hyperenhanced lesion during venous and late phases). In all cases a reference method was available (contrast CT or MRI or biopsy). The trial was registered in clinicaltrials.gov (Identifier NCT01329458).Results: During February 2011 - May 2015, 1153 CEUS examinations were performed for the evaluation of de novo FLL. Out of the 1153 de novo FLL, 238 cases were diagnosed as hemangiomas by CEUS (typical enhancing pattern). Contrast CT/MRI and biopsy diagnosed additional 24 hemangiomas. From the 238 cases diagnosed as hemangiomas by CEUS, in 11 the final diagnosis was different. Considering contrast CT/MRI and biopsy as reference methods, CEUS had 90.4% sensitivity, 98.8% specificity, 95.4% positive predictive value, 97.4% negative predictive value, resulting in 96.9% diagnostic accuracy for the diagnosis of hemangiomas.Conclusion: CEUS is a sensitive and very specific method for the diagnosis of hemangiomas. [ABSTRACT FROM AUTHOR]

The aim of our study was to evaluate the accuracy of CEUS in the characterization of pancreatic solid lesions, considering cross sectional imaging techniques (CE-CT/MRI) as the "gold standard" methods. Material and methods: We performed a retrospective, monocentric study that included 91 solid pancreatic lesions which were evaluated by CEUS and by a second-line contrast imaging technique (CT or MRI), considered as the reference method. Results: The rate of a conclusive diagnosis based on a typical enhancement pattern was 94% (78/83 cases). In 72 cases out of 83 (86.7%) there was a perfect concordance between CEUS and the "gold-standard" imaging method (CE-CT/MRI). In our study, 88% (73/83) of the pancreatic lesions were categorized as malignant due to their typical wash-out aspect in the late phase. The overall accuracy of CEUS for the differential diagnosis of solid pancreatic tumors was approximately 81%. The accuracy of CEUS for the diagnosis of hypoenhancing pancreatic tumors was approximately 89.1%; while for the diagnosis of hyperenhancing pancreatic tumors it was approximately 72.8%. Conclusion: CEUS allows the differentiation between hypo- vs. hyperenhancing pancreatic solid lesions, with a considerable diagnostic accuracy, a fundamental step in the precise diagnosis of pancreatic tumors. [ABSTRACT FROM AUTHOR]

Unlabelled: The Aim: of this study was to summarize the spectrum of pancreatic pathology assessed by contrast enhanced ultrasound (CEUS) in a single Gastroenterology Center and to emphasize its accuracy in assessing two of the most important pancreatic lesions: solid tumors and necrotic lesions in acute pancreatitis. Material and Methods: Our retrospective study included 197 patients with pancreatic lesions (de novo pancreatic masses; acute, severe pancreatitis; other pathologies) evaluated by CEUS from October 2009 to May 2013, in which a reference method (contrast CT/MRI) was available. Results: A conclusive diagnosis was established according to the EFSUMB Guidelines in 87.8% of the 197 cases. In 87.3% cases there was a perfect concordance between CEUS and the reference method (contrast CT/MRI). 95 examinations were made for pancreatic solid masses: 41.1% (39) were hypoenhanced, 34.7% (33) were hyperenhanced, and 20% (19) were isoenhancing - chronic pancreatitis and autoimmune pancreatitis - while in 4.2% (4) cases CEUS was inconclusive. 60 examinations were made in severe acute pancreatitis and in 50% (30) cases pancreatic necrosis was diagnosed. 42 examinations were performed for other lesions: 64.2% (27) pancreatic pseudocysts, 11.9% (5) cystic tumors, 23.8% (10) other pathologies (abscesses, fibrosis, etc). CEUS accuracy for solid tumors was 92.9%. For necrotic lesions the accuracy was 97.4%. Conclusions: CEUS has turned to be a good method for the characterization of different pancreatic pathologies and for evaluating acute pancreatitis. CEUS was conclusive in 90% cases and it should be considered as a first line imaging method in clinical practice. [ABSTRACT FROM AUTHOR]

Objective: Liver stiffness measurement (LSM) using Transient Elastography (TE) for liver fibrosis assessment is difficult to be performed in obese and overweight patients by standard M probe, thus the XL probe was developed. The aim of our paper was to assess the usefulness of the XL probe in daily clinical practice.Material and Method: Our study included 216 patients (mean BMI 30.1+/-4.1 kg/m2) with chronic hepatopathies, in which paired measurements were made using the M (3.5MHz) and XL (2.5 MHz) probes in the same session. In each patient 10 valid LSM were acquired with each probe, a median was calculated, expressed in kiloPascals (kPa). Unreliable TE measurements were considered: fewer than 10 valid shots; with a success rate (SR) <60% and/or interquartile range interval (IQR) ≥30%.Results: In 127 patients reliable LSM could not be obtained by standard M probe, 10 of them normal weight, 25 of them overweight, and 92 obese. By XL probe reliable measurements were obtained in 80/127(63%) of these patients: 8/10 (80%) of the normal weights, 17/25 (68%) of the overweight and 55/92 (59.8%) of the obese. In 98 patients with reliable M probe measurements, XL probe LSMs were also performed. XL LS values strongly and significantly correlated with those obtained by M probe (Spearman r=0.789, p<0.0001), but were significantly lower [median 6.4 kPa (range 3.1 - 53.8) vs 7.7 kPa (range 3.7-69.1), Wilcoxon paired t test p<0.001)].Conclusion: By using the XL probe, reliable LSM by TE can be obtained in more than 60% of patients with unreliable measurements by M probe. LSM by XL probe are significantly correlated, but lower, than those obtained by M probe. [ABSTRACT FROM AUTHOR]

Aims: Ultrasound (US) is an essential diagnostic and educational tool in medical practice, and its effective implementation into medical curricula is critical. This study aimed to compare the efficacy of two disparate educational approaches-an optional semester course and a specifically curated intensive workshop-on the learning curve of medical students in abdominal ultrasonography. Material and methods: Engaging fourth and fifth-year medical students, this study, incorporated both theoretical and practical elements of US, providing participants with hands-on experience and evaluative assessments pre- and post-training. Students were segregated into two groups: one experienced a 14-hour optional semester course and the other a 6-hour intensive workshop, both yielding distinct teaching methodologies yet aspiring for synonymous educational outcomes. Results: Involving a total of 93 participants, findings elucidated that regardless of the educational method employed, post-training identification of US structures exhibited a significant enhancement compared to pre-training. Interestingly, no substantial disparities were discerned between the two educational approaches nor gender-based differences in learning outcomes. Conclusions: This investigation provides pivotal insights into the versatile utility of different educational strategies in abdominal US training for medical students, affirming that varied pedagogical methods can achieve comparable augmentations in student proficiency. Further research is paramount to ascertain the optimal integration of US education into medical curricula, considering aspects such as duration, depth, and mode of delivery. [ABSTRACT FROM AUTHOR]

Aim: Nonalcoholic Fatty Liver Disease (NAFLD) is increasing in frequency in daily practice and evaluation of liver steatosis, fibrosis and inflammation severity are essential for prognosis assessment. The aim was to evaluate the usefulnessof a new liver steatosis quantification system - Ultrasound-Guided Attenuation Parameter (UGAP) from General Electric Healthcare, using Controlled Attenuation Parameter (CAP) as the reference method.Material and Method: 179 consecutive subjects, in whom liver steatosis was assessed in the same session using UGAP, implemented on LOGIQ E10 system (GE Healthcare), and CAP (FibroScan, EchoSens). To discriminate between steatosis stages by CAP, we used the cut-offs recommended by the manufacturer: S1 (mild) - 230 dB/m, S2 (moderate) - 275 dB/m, S3 (severe) - 300 dB/m.Results: We classified our cohort by means of CAP into the following groups: S0 (no steatosis): 48/176 (27.2%), S1 (mild): 56/176 (31.6%), S2 (moderate): 14/176 (7.3%) and S3 (severe): 59/176 (33.9%). The mean UGAP values increased with the steatosis grade and for each group were the following: S0: 198.3±25.7 dB/m, S1: 216.86±26.3 dB/m, S2: 237.79±26.3 dB/m, and S3: 270.8±31.62 dB/m respectively (p<0.001). A very good positive correlation was found between UGAP and CAP values (r=0.73, p<0.0001). The best cut-off values for predicting different grades of liver steatosis using CAP as the reference were: S1 - 192.5 dB/m (AUC 0.83); S2 - 231 dB/m (AUC 0.90) and S3 - 248 dB/m (AUC 0.91).Conclusion: UGAP seems to be a good method for liver steatosis quantification and correlates strongly with CAP values. [ABSTRACT FROM AUTHOR]

Ultrasound elastography including transient elastography (TE), point shear wave elastography, (pSWE) and two (three)- dimensional shear wave elastography (2D-SWE) have been introduced mainly for the evaluation of the liver. All the techniques are also feasible for the examination of spleen, whereas pSWE and 2D-SWE can be used for the assessment of the pancreas, kidney, gastrointestinal tract and other organs. Strain elastography also plays a role for non-liver applications. The aim of the current report is to highlight unique features and techniques for the elastographic examinations in children and to report initial results in non-liver applications. [ABSTRACT FROM AUTHOR]

Non-invasive tests have been developed to determine the severity of liver disease in patients with alcohol use disorder (AUD). We aimed to assess the severity of liver steatosis and liver fibrosis (LF) in a cohort of patients with AUD using liver elastography and biological scores. Materials and methods: A prospective study was performed on 172 subjects, without previously known liver disease, with a positive AUDIT-C score, serum markers, and vibration-controlled transient elastography (VCTE) with Controlled Attenuation Parameter (CAP). Results: From 172 subjects with positive AUDIT-C test, VCTE diagnosed advanced fibrosis (F3) in 13.9% (24/172) of the subjects and liver cirrhosis (F4) in 17.5% (30/172). Moderate and severe steatosis was found in 18.6% (32/172), respectively 52.3% (90/172). Significant correlations were found between liver stiffness and APRI (r=0.33, p=0.001), FIB-4(r=0.31, p=0.0012) and the age-platelet index (r=0.25, p=0.008). FIB-4 (p=0.01) and age-platelet index (p=0.03) were independently associated with the presence of advanced fibrosis. Age-platelet index (AUC-0.82) performed significantly better than AST/ALT (AUC-0.55) and APRI (AUC-0.58) (p= 0.0001 and p= 0.0014, respectively), but no differences were found when compared to FIB-4 (AUC-0.77) (p=0.35) for predicting advanced fibrosis. Conclusion: In conclusion, in a cohort of patients with AUD, 70.9% presented moderate and severe liver steatosis and 17.5% were newly diagnosed with liver cirrhosis. [ABSTRACT FROM AUTHOR]

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Aim: The updated Baveno VI guidelines recommend that screening for high-risk varices (HRV) by esophago-gastro-duodenoscopy (EGD) can be avoided in patients with compensated advanced chronic liver disease (cACLD) who have liver stiffness LSM<20 kPa and platelet count PLT>150,000/L. The aims of this study were to validate extended Baveno VI criteria in patients with chronic liver disease and to establish cut-off values for our cohort.Materials and Methods: This retrospective study included 839 patients with liver cirrhosis evaluated by Transient Elastography (TE), biological tests, and upper endos-copy, all within one year. The Baveno VI criteria were validated on a sub-group of 728 patients (Cohort 1, randomly selected from the study sample) and tailored cut-off points were determined. The remaining 111 patients comprised the validating set (Cohort 2) for these specific cut-off values.Results: In Cohort 1, Baveno VI criteria had 86.2% accuracy. The calculated cut-offs to rule-in HRV were PLT<150,000/mm3 and LSM >35.3 kPa; while to rule-out HRV they were PLT >150.000/mm3 and LSM <19.6 kPa. In patients in the "grey-zone", by multivariate analysis, albumin was independently associated with HRV at a cut-off of ˂3.4 g/dl. In the validation cohort, the calculated rule out cut-offs had 100% accuracy.Conclusions: The Baveno VI criteria had a good accuracy for exclusion of HRV in this large cohort of cirrhotic patients. Adding an albumin-related threshold increased performance and broadened applicability. Using the calculated rule-out criteria for HRV, all unnecessary EGD could be excluded. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the range of liver stiffness (LS) cut-off values for predicting different stages of liver fibrosis (LF) for 2D-SWE-GE implemented on three different systems from General Electric Healthcare (LOGIQ E9, LOGIQ S8, LOGIQ P9).Material and Method: We performed a comparative study evaluating the performance of 2D-SWE-GE (LOGIQ E9, S8, P9) for predicting different stages of LF using Transient Elastography (TE) as the reference method. All patients (with or without chronic hepatopathies) were evaluated by TE, 331 patients were included in the LOGIQ E9 study, 179 in the LOGIQ S8 study and 234 in the LOGIQ P9 study. Reliable liver stiffness measurements (LSM) were defined for TE as the median value of 10 measurements with an interquartile range/median ratio (IQR/M)≤0.30 and for 2D-SWE-GE as the median value of 10 measurements and IQR/M≤0.30.Results: Reliable LSM was obtained by both methods in 91.5% subjects of the LOGIQ E9 group, in 95.5% subjects from the LOGIQ S8 group and in 87.6% subjects in the LOGIQ P9 group. The performance of 2DSWE-GE for predicting F≥2 with LOGIQ E9, LOGIQ S8 and LOGIQ P9 systems were: cut-offs 6.7 kPa, 6.9 kPa and 6.8 kPa; AUCs 0.95, 0.92 and 0.93. For predicting F≥3, the performances were: cut-offs - 8.2 kPa, 8.2 kPa and 7.6 kPa; AUCs - 0.97, 0.93 and 0.94. For predicting F4, the performances were: cut-offs - 9.3 kPa, 9.3 kPa and 9.3 kPa; AUCs - 0.96, 0.91 and 0.91.Conclusion: The LS cut-off values for 2D-SWE-GE implemented on different systems for predicting F≥2, F≥3 and F=4 are not significantly different. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the feasibility of two elastographic methods, point Shear Wave Elastography (pSWE) and two dimensional Shear Wave Elastography (2D-SWE), integrated in the same ultrasound machine, for liver fibrosis (LF) assessment, using Transient Elastography (TE) as the reference method.Material and Methods: We included in the study 115 subjects in which LF was evaluated in the same session by TE (FibroScan, EchoSens), pSWE and 2D-SWE (Samsung-Medison RS85). Reliable liver stiffness (LS) measurements were defined: for TE the median value of 10 measurements with interquartile range (IQR/M)≤30%,while for pSWE and 2D-SWE the median value of 10 measurements, with a reliability measurement index (RMI)≥0.5 and IQR/M≤30%. For classification of LF severity we used TE as the reference method with the following cut-offs: F2≥7kPa, F3≥9.5kPa and F4≥12kPa.Results: Reliable measurements by TE were obtained in 98.2% of cases (113/115), by pSWE in 93.9% of cases (108/115) and by 2D-SWE in 92.1% of cases (106/115), so the final analysis included 101 patients. We divided the cohort into 3 groups: fibrosis 5.9 kPa [AUROC=0.95, 95%CI(0.89;0.98), p<0.0001, Se=94.1%, Sp=89.5%, PPV=82.1%, NPV=96.8%]; F4 LS >8 kPa [AUROC=0.98, 95%CI(0.94;0.99), p<0.0001, Se=94.4%, Sp=95.1%, PPV=81%, NPV=98.7%], while for 2D-SWE they were: F≥2 LS >6.1 kPa [AUROC=0.93, 95%CI(0.86;0.97), p<0.0001, Se=91.1%, Sp=80.6%, PPV=70.5%, NPV=94.7%]; F4 LS >7.6 kPa [AUROC=0.98, 95%CI(0.93;0.99), p<0.0001, Se=100%, Sp=91.5%, PPV=72%, NPV=100%]. We observed strong correlations between LS values obtained by TE and 2D-SWE (r=0.85), between TE and pSWE (r=0.88) and between pSWE and 2D-SWE (r=0.90) (p=0.37), respectively. There were no significant differences between the mean values obtained by pSWE and 2D-SWE (p=0.96).Conclusion: The pSWE and 2D-SWE are feasible methods for assessing liver fibrosis, both techniques strongly correlating with TE results. [ABSTRACT FROM AUTHOR]

Aims: Non-invasive methods to assess the severity of chronic liver diseases have become more and more popular. The aim of our study was to evaluate the correlation of four Shear Waves Elastographic methods in a cohort of patients with chronic liver diseases of mixed etiologies and to compare their performances for liver fibrosis evaluation.Material and Methods:  A prospective study was conducted on 127 consecutive patients with chronic liver diseases of mixed etiologies. LS measurements were performed in all subjects, in one session, during the same day, by means of 4 elastographic methods: Transient Elastography (TE), Virtual Touch Quantification (VTQ), ElastPQ and 2D-SWE.SSI. The diagnosis accuracies of VTQ, ElastPQ, 2D-SWE.SSI were then compared using TE as reference method.Results: Valid LS measurements by all four shear waves ultrasound elastographic methods were obtained in 116/127 subjects with VTQ, in 108/127 subjects with 2D-SWE.SSI, in 111/127 with TE and in 109/127 with ElastPQ, so the final analysis included 82/127 subjects (64.5%). A good and significant correlation was found between all 4 elastographic methods. The diagnostic accuracy of VTQ, 2D-SWE.SSI and ElastPQ for the diagnosis of significant and severe fibrosis (F2/F3), and liver cirrhosis were similar for all elastographic techniques: VTQ vs 2D-SWE.SSI vs ElastPQ: 84.1% vs 85.3% vs. 84% (p>0.05); 93.9% vs 94% vs 94% (p>0.05).Conclusion: considering TE as the reference method for liver fibrosis evaluation, VTQ, ElastPQ, and 2D-SWE.SSI obtained similar accuracies for diagnosing at least significant fibrosis (F≥2) and liver cirrhosis. [ABSTRACT FROM AUTHOR]

Aim: To analyze the relationship between shear wave velocity in the kidney measured by point shear wave elastography using Virtual Touch Quantification (VTQ) (Siemens Acuson S2000) and histological parameters obtained from renal biopsies, in patients with chronic glomerulonephritis (CGN).Material and Methods: The study group included 20 patients (mean age 47.95±13.59 years) with different types of CGN, that had underwent renal biopsy and 57 normal controls (mean age 38.07±17.32 years). In all patients, five valid stiffness measurements were obtained in each kidney, with the patient in lateral decubitus. Regarding the histological results, we assessed the presence or absence of glomerulosclerosis, interstitial fibrosis, and arteriolo-hyalinosis.Results: In patients with CGN we obtained the following mean values of VTQ values: right kidney: 2.12±0.81 m/s, left kidney 1.65±0.54 m/s, while in the normal controls significantly higher VTQ values were obtained: right kidney 2.69±0.72 m/s (p=0.004), left kidney 2.48±0.73 m/s (p<0.0001). In patients with CGN no statistically significant correlations between VTQ values and eGFR (r=0.37, p=0.12) or proteinuria (r=0.2, p=0.37) were found. We found significantly lower VTQ values in patients with interstitial fibrosis (1.46 vs. 1.99 m/s, p<0.05) and also in patients with arteriolo-hyalinosis (1.55 vs. 2.47 m/s, p<0.05).Conclusion: Our pilot study shows that shear wave velocity values in patients with CGN are significantly lower compared to normal controls, and there is a tendency to decrease with the decrease of eGFR, with the presence of interstitial fibrosis and of arteriolo-hyalinosis. [ABSTRACT FROM AUTHOR]

Aim: Contrast enhanced ultrasound (CEUS) improved the characterization of focal liver lesions (FLLs), but is an operatordependent method. The goal of this paper was to test a computer assisted diagnosis (CAD) prototype and to see its benefit in assisting a beginner in the evaluation of FLLs.Material and Method: Our cohort included 97 good quality CEUS videos[34% hepatocellular carcinomas (HCC), 12.3% hypervascular metastases (HiperM), 11.3% hypovascular metastases (HipoM), 24.7% hemangiomas (HMG), 17.5% focal nodular hyperplasia (FNH)] that were used to develop a CAD prototype based on an algorithm that tested a binary decision based classifier. Two young medical doctors (1 year CEUS experience), two experts and the CAD prototype, reevaluated 50 FLLs CEUS videos (diagnosis of benign vs. malignant) first blinded to clinical data, in order to evaluate the diagnostic gap beginner vs. expert.Results: The CAD classifier managed a 75.2% overall (benign vs. malignant) correct classification rate. The overall classification rates for the evaluators, before and after clinical data were: first beginner-78%; 94%; second beginner-82%; 96%; first expert-94%; 100%; second expert-96%; 98%. For both beginners, the malignant vs. benign diagnosis significantly improved after knowing the clinical data (p=0.005; p=0,008). The expert was better than the beginner (p=0.04) and better than the CAD (p=0.001). CAD in addition to the beginner can reach the expert diagnosis.Conclusions: The most frequent lesions misdiagnosed at CEUS were FNH and HCC. The CAD prototype is a good comparing tool for a beginner operator that can be developed to assist the diagnosis. In order to increase the classification rate, the CAD system for FLL in CEUS must integrate the clinical data. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the performance of 2D shear-wave elastography from General Electric (2D-SWE.GE) for the noninvasiveassessment of liver fibrosis and to identify liver stiffness (LS) cut-off values for predicting different stages of fibrosisusing Transient Elastography (TE) as the reference method.Material and Method: We included 331 consecutive subjectswith or without chronic hepatopathies in whom LS was evaluated in the same session by means of 2 elastographic techniques:TE and 2D-SWE.GE. Reliable LS measurements were defined for TE as the median value of 10 measurements with a successrate of ≥60% and an interquartile range (IQR)<30% and for 2D-SWE.GE as the median value of 10 measurements acquiredin a homogenous area and an IQR<30%. To discriminate between TE fibrosis stages we used the following cut-offs: F2- 7;F3- 9.5 and F4- 12kPa.Results: Reliable LS measurements were obtained in 95.8% subjects by 2D-SWE.GE, and 94.2%by TE (p=0.44). Based on TE cut-off values we divided our cohort into four groups: F<2: 30.1%; F=2: 10.2%; F=3: 12.2%;F=4: 47.5%. A strong correlation was found between the LS values obtained by the 2 methods: r=0.83, p<0.0001.LS valuesobtained by 2D-SWE.GE were significantly lower than those obtained by TE: 10.14±4.24 kPa vs. 16.72±13.4 kPa (p<0.0001).The best cut-off value for F≥2, F≥3 and for F=4 were 6.7, 8.2 and 9.3 kPa.Conclusions: The best 2D-SWE.GE cut-off valuesfor predicting F≥2, F≥3 and F=4 were 6.7, 8.2 and 9.3kPa. [ABSTRACT FROM AUTHOR]

Aim: Reliable liver stiffness measurements (RLSM) using Transient Elastography (TE) with the standard M probe are difficult to obtain in overweight (BMI≥25kg/m2) and obese (BMI>30kg/m2) patients. The aim of our paper was to assess the feasibility of TE in daily practice using both M and XL probes. Material and Method: We studied retrospectively 3235 patients with chronic liver disease assessed by TE first by the M probe (standard probe – transducer frequency 3.5 MHz), and if the measurements were unreliable, with the XL probe (transducer frequency 2.5 MHz). Reliable measurements were defined as the median of 10 valid measurements with a success rate ≥ 60% and an interquartile range < 30%. Results of liver elasticity were expressed in kilo Pascals (kPa). Results: RLSM by M probe were obtained in 62.2% (2015/3235) patients, and by XL probe in 1011/1220 (80%) of patients with unreliable measurements by M probe; thus we obtained RLSM in 93.5% of 3235 cases. In overweight patients we obtained RLSM in 89.9% (1039/1156) cases: in 63.1% (729) by M probe and in 26.8% (310) by XL probe. In obese patients we obtained RLSM in 83.8% (746/890): in 18.4% (164) by M probe and in 65.4% (582) by XL probe. Thus, by using both probes, RLSM were obtained in 1785 (87.2%) of overweight and obese patients. Conclusion: The feasibility of the M probe was 62.2% in our Department. Reliable measurements using M or XL probe allowed the evaluation of liver stiffness in 93.5% of cases. By using both M and XL probes, reliable LSM by TE can be obtained in the majority of obese and overweight patients (87.2%). [ABSTRACT FROM AUTHOR]

Unlabelled: Liver abscess is a potentially lethal condition that requires prompt recognition and adequate treatment for a good outcome. The aim of this study was to assess the value of contrast enhanced ultrasound (CEUS) in the management of liver abscesses in the clinical practice of a single centre.Material and Methods: A retrospective analysis was performed including all patients diagnosed with liver abscesses during 5 years (2010-2014) in a tertiary Department of Gastroenterology and Hepatology. The demographic data, the presence of risk factors, the cause of liver abscess, the B-mode conventional US aspect, the CEUS appearance and the patient's outcome were documented and analyzed.Results: The study group included 41 patients diagnosed with liver abscesses (17 women and 24 men, mean age 63.3+/-13.2 years), 16/41 (39%) of them with diabetes mellitus. A single lesion was found in 28 (68.3%) patients, and 13 (31.7%) patients had multiple abscesses. The CEUS study was conclusive for the diagnosis of liver abscess in clinical context in 38/41 cases (92.7%). All conclusive cases presented rim enhancement in the arterial phase and no enhancement in the liquid areas. The honeycomb appearance with septa enhancement was present in 17/41 (41.5%) patients. Washout of the marginal rim was found in 22/41 (53.6%) lesions.Conclusions: In our group the most frequent CEUS features found were the rim enhancement in the arterial phase and the presence of no enhancement areas, followed by the honeycomb appearance. CEUS was able to be conclusive for the diagnosis of liver abscess in almost 93% of cases. [ABSTRACT FROM AUTHOR]

The use of liver elastography has substantially developed in the past few years; the introduction of novel elastographic methods (Transient Elastography, point Shear Wave Elastography, Real Time Shear Wave Elastography, Strain Elastography) has changed the perspective in the evaluation of liver disease. The ongoing research in this area is mainly focused on diffuse liver diseases and for predicting liver cirrhosis complication. This guideline created under the auspice of Romanian Society of Ultrasound in Medicine and Biology is intended to accustomize the clinician with the current practical use of liver elastography and has been issued to help in maximizing the clinical benefit for the patients with chronic liver diseases. [ABSTRACT FROM AUTHOR]

Aim: To analyze how many measurements are needed for non-invasive assessment of liver stiffness (LS) by means of 2D-Shear Wave Elastography (2D-SWE) and if the use of mean of median values of 2D-SWE measurements is needed.Methods: We evaluated 449 consecutive subjects (with or without chronic liver disease) by means of Transient Elastography (TE) and 2D-SWE. We compared the correlation of LS assessed by TE with 2D-SWE measurements when using either the median of 5 valid 2D-SWE measurements or the mean of 3 or 5 valid 2D-SWE measurements.Results: We obtained reliable LS measurements by TE in 330/449 subjects (73.5%). From these, in 281 subjects we obtained 5 valid 2D-SWE measurements. The correlation of LS assessed by TE with 2D-SWE values was similar when we used the median value of 5 valid 2D-SWE measurements, the mean value of 5 valid 2D-SWE measurements or the mean value of 3 valid 2D-SWE measurements: r =0.683, r=0.711 and r=0.691, respectively. There were no significant differences between the median value of 5 valid 2D-SWE measurements; the mean value of 5 valid 2D-SWE measurements; or the mean value of 3 valid 2D-SWE measurements: 7.6 kPa, 7.7 kPa and 7.6 kPa, respectively.Conclusions: Our study showed that it is enough to perform 3 valid 2D-SWE measurements and to use the mean value of these measurements. [ABSTRACT FROM AUTHOR]

Introduction: Contrast-enhanced ultrasound (CEUS) uses second generation microbubble contrast agents and is considered to be a useful imaging method for focal liver lesions (FLLs) characterization. Aim: To observe if CEUS increases the diagnostic performance of benign FLLs as compared with standard ultrasonography examination (US). Patients and Methods: This is a single centre study developed during September 2009- December 2011 in the Department of Gastroenterology and Hepatology, in Timisoara. We evaluated 386 benign FLLs diagnosed by means of CEUS. Before performing CEUS, all FLLs were examined by US and Power Doppler techniques. At CEUS, the benign nature of a lesion was established by the absence of washout in the portal and late phase. The typical features observed using contrast, allowed their classification in a particular type of pathology, according to the 2008 EFSUMB Guidelines. Results: From 386 benign FLLs, 81 (20.9%) of them were diagnosed in patients with chronic liver disease, while 305 (79.1%) were in patients without chronic hepatopathy. In 355 (92%) cases CEUS established a particular type of pathology. The most frequent lesions were: hemangiomas (37.5%), focal fatty alterations (24.8%), complex cysts (10.7%) and regenerative nodules (11.8%). Based on US we correctly estimated the positive diagnosis in 55.7% cases and using CEUS, the diagnostic performance increased up to 92%. Conclusions: In our study, by means of US the estimate positive diagnosis was made in 55.7% of cases. CEUS properly characterized 92% of benign FLLs and increased the diagnostic performance of these lesions, as compared with US. [ABSTRACT FROM AUTHOR]

Aim: The aim of our study was to assess the influence of liver residual mass in cirrhotic patients on the liver stiffness (LS), measured by ARFI elastography. Methods: Two hundreds eleven cirrhotic patients were enrolled. To evaluate the liver residual mass, the Child-Pugh and MELD scores were used and 10 valid ARFI measurements were performed. The correlation between Child-Pugh, MELD scores and the LS were evaluated. Results: Valid ARFI measurements were not obtained in 3 patients. A direct, very low correlation between the LS values and the Child-Pugh (r=0.264, p<0.001) and MELD scores (r=0.194, p=0.005) was found. A direct, low correlation between LS measurements and total bilirubin (r=0.271, p<0.001) and an inverse, low correlation with albumin (r=-0.270, p<0.001), prothrombin time (r=-0.196, p=0.006), cholinesterase (r=-0.241, p=0.003) was obtained. The LS mean values were statistically significant higher in patients with Child-Pugh class B vs. A (p=0.002) and in Child-Pugh C vs. A (p<0.001). The values were not significantly different in patients with Child-Pugh B vs. C (p=0.06). Conclusions: Higher values of LS measurements by means of ARFI could be an indicator of decreased liver functional reserve, evaluated by means of Child Pugh or Meld scores. [ABSTRACT FROM AUTHOR]

Unlabelled: Portal vein thrombosis (PVT) is a relatively common complication in patients with liver cirrhosis and hepatocellular carcinoma, but might also occur in the absence of liver disease. Ultrasound (US) is the first imaging method used for assessing PVT. the Purpose: To evaluate the utility of contrast-enhanced ultrasound (CEUS) for the differentiation between benign and malignant PVT. Materials and Methods: from October 2009 to October 2010, 38 PVTs were evaluated by means of ultrasound (standard, Doppler and CEUS). 29 PVT were in patients with liver cirrhosis and 9 in subjects without liver cirrhosis. Results: 15 of 38 patients (39.5%) had benign PVT and 23 patients (60.5%) had malignant PVT. Results of CEUS examination were conclusive in 37/38 (97.2%) of the examinations for PVT, allowing the differentiation between benign and malignant thrombosis. When the result was inconclusive, another imaging method was performed (MRI). Conclusion: CEUS is a very good method for the evaluation of benign or malignant nature of portal vein thrombosis. [ABSTRACT FROM AUTHOR]

Aim: To establish the influence of different factors on the correlation between liver stiffness (LS) measurements by ARFI and liver fibrosis, evaluated by liver biopsy (LB). We assessed the following factors: the success rate (SR) and interquartile range (IQR) interval, the place where ARFI was performed, liver steatosis, the quality of the specimen obtained by LB. Methods: We studied 471 patients: 82 with LB, 82 healthy volunteers and 307 with cirrhosis. We performed 10 valid ARFI measurements, a median value was calculated, expressed in meters/second. Results: Valid measurements were not obtained in 11 patients. There was a direct, strong, correlation (r=0.694) between ARFI and fibrosis (p<0.0001). There were no statistically significant differences between the mean ARFI values obtained in segments V vs. VIII (p=0.89). Considering the IQR and SR, the correlation of ARFI with fibrosis was: for IQR<30% and SR ≥ 60%: r=0.722 and for IQR>30% and/or SR ≤ 60%: r=0.268 (p=0.0001). The quality of the liver specimen (2-3 cm long vs. >3 cm) did not influence the correlation of ARFI with fibrosis. Conclusions: To obtain the best correlation between ARFI and fibrosis, IQR must be <30% and SR ≥ 60%. These technical parameters must be introduced to improve the ARFI value for LS evaluation. [ABSTRACT FROM AUTHOR]

Aim: Contrast-Enhanced Ultrasound (CEUS) is an imaging method that can discriminate between hepatocellular carcinoma (HCC) and other liver lesions. The purpose of this study is to present our experience concerning the use of CEUS in the characterization of HCCs. Material and Method: We included in our study all the patients evaluated in our Department from September 2009 to October 2010, with focal liver lesions (FLLs) on abdominal ultrasound (US) that were diagnosed as HCCs after CEUS examination, also patients with chronic liver disease with focal liver lesions highly suspected to be HCCs but with an inconclusive pattern on CEUS. One hundred patients with 148 HCCs were included. The enhancement pattern of the nodules was evaluated according to the 2008 EFSUMB Guidelines. Nodules displaying arterial hyperenhancement with "washout" in the portal/venous phase on CEUS were considered diagnostic for HCC. Nodules considered indeterminate after CEUS were evaluated by contrast-enhanced CT or MRI for diagnosis. Results: Among the 100 patients included, 96 were patients with chronic liver disease and 4 were patients without known liver disease. 71 patients had a solitary nodule, 16 patients had two nodules and 13 patients had three or more nodules. 112 HCCs had a typical enhancement pattern and 36 nodules were considered indeterminate after CEUS and were sent to CT/ MRI for diagnosis. Conclusions: 75.7% of the studied liver nodules were diagnosed by CEUS as HCCs, thus CEUS is an easy method, convenient to perform, avoiding other expensive examinations. [ABSTRACT FROM AUTHOR]

Unlabelled: The AIM of this paper is to establish the values of liver stiffness (LS) assessed by means of ARFI in patients without known liver pathology and considered healthy subjects. Material and Method: the study group was composed of 82 subjects without known liver pathology, healthy volunteers or patients from other departments of our hospital who did not have altered liver laboratory tests. 76 patients had ARFI valid measurements (47 women and 29 men, mean age 34.5 +/-14.3 years). In each subject abdominal ultrasound was performed (patients with steatosis or any other signs of chronic liver pathology were excluded) as well as ARFI (using Siemens Acuson S2000). The median value of 10 measurements was calculated, expressed in m/s; we considered valid only the measurements with IQR<30%, SR>60%, similar to transient elastography. Mean ARFI values and mean values according to age and gender were evaluated. Results: valid ARFI measurements were obtained in 76/82 patients (92.6%). The mean value of ARFI measurements in normal individuals was 1.15+/-0.21 m/s. There were no significant differences between the mean ARFI values in men vs. women (1.16+/-0.21 vs. 1.14+/-0.22m/s, p=0.67), also among different age groups (p>0.05). Conclusion: In our study the mean LS value obtained by ARFI in healthy subjects was 1.15 m/s. [ABSTRACT FROM AUTHOR]

Aim: to present the practice of two experienced centres concerning the use of contrast enhanced ultrasound (CEUS) in the characterization of focal liver lesions (FLL). Material and Method: A prospective, bicentric study, between 09.2009-09.2010 was undertaken and 729 FLL (506-Center A, 223-Center B) were evaluated. A CEUS examination was considered conclusive, if the FLL had a typical enhancement pattern according to EFSUMB Guidelines. Results: From the 729 cases with FLL, 389 (53.4%) were patients without known and 340 (46.6%) with known chronic liver disease. CEUS was conclusive for the diagnosis in 597/729 cases (82%) and allowed the positive diagnosis of benign vs. malignant lesion in 662/729 (90.8%) FLL. For each center independently (Center A vs. Center B) the situation was as follows: conclusive for the diagnosis 390/506 (77.1%) vs 207/223 (92.8%) (p<0.0001), conclusive for the differentiation benign/malignant 449/506 (88.7%) vs. 213/223 (95.5%) (p=0.0032). Conclusion: In our bicentric study, CEUS was conclusive for diagnosis in 82% of FLL and the benign or malignant character of a lesion was demonstrated in 90.8% of cases. Thus, when faced with an uncharacteristic FLL on standard ultrasound, our local strategy in both centers was to perform CEUS as a first-line investigation thus avoiding other expensive examinations. [ABSTRACT FROM AUTHOR]

Liver metastases are the most frequent malignancies of the liver. The grayscale sonographic appearance of metastases varies: they can be hypoechoic, hyperechoic, they can present a peripheral halo, they can have an infiltrative or cystic appearance. On contrast enhanced ultrasound (CEUS), in the arterial phase, liver metastases can be hyperenhancing (hypervascular ones) or hypoenhancing (hypovascular ones). All liver metastases present wash-out in the portal and late phases, a typical enhancement pattern. CEUS sensitivity is superior to standard ultrasound for the diagnosis of liver metastases being similar to the one of contrast CT. [ABSTRACT FROM AUTHOR]

Aim: To establish the values of spleen stiffness (SS) assessed by Acoustic Radiation Force Impulse (ARFI) in healthy subjects and in cirrhotic patients, and to evaluate its predictive value for the presence of cirrhosis and for the presence and severity of esophageal varices (EV). Patients and Methods: Our study included 82 subjects (15 healthy volunteers, 57 cirrhotic patients, 10 with various grade of liver fibrosis), 38 women and 44 men. Of these, 42 cirrhotic patients had varices, 30 had significant EV and 11 had a history of variceal bleeding. We performed 10 measurements in each patient expressed in meters/second (m/s) and a median value was obtained. Results: The mean SS values (m/s) were: 2.04+/-0.28 in healthy subjects and 3.10+/-0.55 in cirrhotic patients (p<0.001). For a cut-off value of >2.51 m/s of SS, ARFI had 85.2% Se, 91.7% Sp, 95.8% PPV, 73.3% NPV, 87.1% accuracy (AUROC=0.91) for predincting liver cirrhosis. No significant differences regarding SS were observed between patients with and without EV, also between those with and without a history of variceal bleeding. Conclusion: SS evaluated by means of ARFI had a very good predictive value for the presence of cirrhosis (AUROC=0.91, accuracy=87.1%), but could not predict the presence or severity of EV, also the risk of variceal bleeding. [ABSTRACT FROM AUTHOR]

Aim: to assess the accuracy of transient elastography (TE) and Acoustic Radiation Force Impulse (ARFI) for liver fibrosis assessment, as compared to percutaneous liver biopsy (LB) in patients with chronic hepatitis. Patients and Methods: Our study included 71 patients (P) (54 with HCV and 17 with HBV chronic hepatitis) in which we compared TE and ARFI to the LB (evaluated according to the Metavir scoring system). Results: On LB, from the 71P, 6P (8.4%) had F1, 25P (35.2%) had F2, 24P (33.8%) had F3 and 16P (22.5%) had F4. A direct, strong, linear correlation (Spearman r=0.707) was found between TE measurements and fibrosis (p<0.0001) and a weaker one, between ARFI and fibrosis (rho=0.469; p<0.0001). TE measurements were also correlated with ARFI measurements r=0.532, p<0.0001. By comparing the AUROC curves, TE and ARFI had similar predictive values for the presence of significant fibrosis (F greater or equal to 2 Metavir): AUROC ARFI=0.649, AUROC TE=0.731 (p=0.476); and cirrhosis (F=4 Metavir): AUROC ARFI=0.868, AUROC TE= 0.936 (p=0.294) Conclusion: LS measurements assessed by means of TE correlate better than those assessed by means of ARFI to the histological fibrosis in patients with HBV and HCV chronic hepatitis. Both methods have excellent predictive values for the presence of cirrhosis. [ABSTRACT FROM AUTHOR]