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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.

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.

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.

Background and Aims: Ombitasvir/Paritaprevir/ritonavir/Dasabuvir (OBV/PTV/r+DSV) is one of the elective direct-acting antivirals (DAAs) recommended by international guidelines and the only one covered by the National Insurance System in Romania until November 2016. Our aim was to present the first prospective Romanian cohort evaluating the effectiveness and safety in clinical practice of this 3DAA combination in patients with HCV genotype-1b Child A liver cirrhosis., Methods: 681 patients received OBV/PTV/r+DSV+RBV for 12 weeks and were assessed clinically and biologically at baseline, week 4, 8, 12 (end of treatment, EOT), and 12 weeks after therapy (sustained viral response, SVR)., Results: Per protocol, EOT virological response was 99.8% and SVR12 rate was 99.4%. Adverse events were present in 36.4% of patients. Permanent discontinuation of 3DAA regimen due to side effects was reported in 11 patients (1.6%). In 47.6% (185/389) of patients, Transient Elastography values were >20kPa (defined as clinically significant portal hypertension, CSPH) at baseline. Independent variables associated with CSPH were: baseline cholesterol level (p=0.003), platelet count <120,000/mm³ (p=0.02), MELD score (p=0.01). Liver stiffness measurement has significantly improved between baseline (26.6+/-12.7kPa) and SVR12 (21.6+/-11.8kPa) (p<0.0001). The same was true for APRI score (2.66+/-0.15 at baseline vs 0.85+/-0.02 at SVR12, p<0.0001) and FIB4 score (5.53+/-0.28 vs 3.24+/-0.08, p<0.0001), but not for Lok score (0.57+/-0.01 vs 0.63+/-0.01, p<0.0001)., Conclusions: We report a high efficacy of the 3DAA regimen in a homogeneous compensated HCV genotype-1b liver cirrhosis population, in a real-life setting. Noninvasive fibrosis scores significantly improved at SVR12.

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.

Background and Aims: Nonalcoholic fatty liver disease (NAFLD) is one of the most common chronic liver diseases worldwide. The aim of our study was to evaluate a population of diabetic patients regarding the severity of liver steatosis and liver fibrosis., Methods: The study included 392 type 2 diabetic patients prospectively randomized, evaluated in the same session by transabdominal ultrasound to assess steatosis and by liver elastography to assess fibrosis (Transient Elastography - TE, FibroScan, EchoSens). Steatosis severity was graded using a semi-quantitative scale (S0-no steatosis; S1-mild steatosis; S2-moderate steatosis; S3-severe steatosis). For differentiation between stages of liver fibrosis, the following cut-off values were used (Wong et al., 2010): F2-F3: 7-10.2kPa, F4>/=10.3 kPa., Results: Reliable elastographic measurements were obtained in 76% (298/392) patients. By using the proposed cut-off values, significant fibrosis (F2-F3) was found in 18.8% (56) patients with steatosis, while 13.8% (41) had cirrhosis (F4). Significant fibrosis (F2-F3) was found in 20.4% (20/98) of the patients with S1, in 18.6% (22/118) of those with S2 and in 31.8% (14/44) of those with S3, while cirrhosis (F4) was diagnosed in 7.1% (7/98) patients with S1, in 20.3% (24/118) of those with S2 and in 22.7% (10/44) of those with S3., Conclusions: Liver steatosis diagnosed by ultrasound is very frequently found in type 2 diabetes mellitus patients, more than half of them having moderate/severe steatosis. A significant liver stiffness increase was found in more than 30% of these patients. Liver stiffness assessment in type 2 diabetic patients should be performed systematically to identify those with significant liver fibrosis.

Aim: To evaluate how often do we "miss" chronic hepatitis C patients with at least significant fibrosis (F&gt;/=2) and those with compensated cirrhosis, by using Acoustic Radiation Force Impulse (ARFI) elastography cut-off values proposed by meta-analysis., Material and Methods: Our study included 132 patients with chronic hepatitis C, evaluated by means of ARFI and liver biopsy (LB), in the same session. Reliable measurements were defined as: median value of 10 liver stiffness (LS) measurements with a success rate&gt;/=60% and an interquartile range interval&lt;30%. For predicting F&gt;/=2 and F=4 we used the LS cut-offs proposed in the last published meta-analysis: 1.35 m/s and 1.87 m/s, respectively., Results: Reliable LS measurements by means of ARFI were obtained in 117 patients (87.9%). In our study, 58 patients (49.6%) had LS values &lt;1.35 m/s; from these 75.8% had F&gt;/=2 in LB. From the 59 patients (50.4%) with LS values&gt;/=1.35 m/s, only 6.8% had F0 or F1 in LB. Also, in our study, 88 patients (75.3%) had LS values &lt;1.87 m/s; from these only 2.2 % had F4 in LB. From the 29 patients (24.7%) with LS values&gt;/=1.87 m/s, 41.3% had F4 in LB. Both for prediction of at least significant fibrosis and liver cirrhosis, higher aminotransferases levels were associated with wrongly classified patients, in univariate and multivariate analysis., Conclusions: ARFI elastography had a very good positive predictive value (93.2%) for predicting the presence of significant fibrosis and excellent negative predictive value (97.8%) for excluding the presence of compensated liver cirrhosis.

Introduction: To identify liver stiffness (LS) cut-off values assessed by means of 2D-Shear Wave Elastography (2D-SWE) for predicting different stages of liver fibrosis, considering Transient Elastography (TE) as the reference method., Methods: Our prospective study included 383 consecutive subjects, with or without hepatopathies, in which LS was evaluated by means of TE and 2D-SWE. To discriminate between various stages of fibrosis by TE we used the following LS cut-offs (kPa): F1-6, F2-7.2, F3-9.6 and F4-14.5., Results: The rate of reliable LS measurements was similar for TE and 2D-SWE: 73.9% vs. 79.9%, p=0.06. Older age and higher BMI were associated for both TE and 2D-SWE with the impossibility to obtain reliable LS measurements. Reliable LS measurements by both elastographic methods were obtained in 65.2% of patients. A significant correlation was found between TE and 2D-SWE measurements (r=0.68). The best LS cut-off values assessed by 2D-SWE for predicting different stages of liver fibrosis were: F≥1: >7.1 kPa (AUROC=0.825); F≥2: >7.8 kPa (AUROC=0.859); F≥3: >8 kPa (AUROC=0.897) and for F=4: >11.5 kPa (AUROC=0.914)., Conclusions: 2D-SWE is a reliable method for the non-invasive evaluation of liver fibrosis, considering TE as the reference method. The accuracy of 2D-SWE measurements increased with the severity of liver fibrosis., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Our study compared three elastographic methods--transient elastography (TE), acoustic radiation force impulse (ARFI) imaging and supersonic shear imaging (SSI)--with respect to the feasibility of their use in liver fibrosis evaluation. We also compared the performance of ARFI imaging and SSI, with TE as the reference method. The study included 332 patients, with or without hepatopathies, in which liver stiffness was evaluated using TE, ARFI and SSI. Reliable measurements were defined as a median value of 10 (TE, ARFI imaging) or 5 (SSI) liver stiffness measurements with a success rate ≥60% and an interquartile range interval <30%. A significantly higher percentage of reliable measurements were obtained using ARFI than by using TE and SSI: 92.1% versus 72.2% (p < 0.0001) and 92.1% versus 71.3% (p < 0.0001). Higher body mass index and older age were significantly associated with inability to obtain reliable measurements of liver stiffness using TE and SSI. In 55.4% of patients, reliable liver stiffness measurements were obtained using all three elastographic methods, and ARFI imaging and TE were similarly accurate in diagnosing significant fibrosis and cirrhosis, with TE as the reference method., (Copyright © 2013 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Background: Acoustic Radiation Force Impulse Elastography is a new method for non-invasive evaluation of liver fibrosis., Aim: To evaluate the impact of elevated alanine aminotransferase levels on liver stiffness assessment by Acoustic Radiation Force Impulse Elastography., Methods: A multicentre retrospective study including 1242 patients with chronic liver disease, who underwent liver biopsy and Acoustic Radiation Force Impulse. Transient Elastography was also performed in 512 patients., Results: The best Acoustic Radiation Force Impulse cut-off for predicting significant fibrosis was 1.29 m/s in cases with normal alanine aminotransferase levels and 1.44 m/s in patients with alanine aminotransferase levels>5 × the upper limit of normal. The best cut-off for predicting liver cirrhosis were 1.59 and 1.75 m/s, respectively. Acoustic Radiation Force Impulse cut-off for predicting significant fibrosis and cirrhosis were relatively similar in patients with normal alanine aminotransferase and in those with alanine aminotransferase levels between 1.1 and 5 × the upper limit of normal: 1.29 m/s vs. 1.36 m/s and 1.59 m/s vs. 1.57 m/s, respectively. For predicting cirrhosis, the Transient Elastography cut-offs were significantly higher in patients with alanine aminotransferase levels between 1.1 and 5 × the upper limit of normal compared to those with normal alanine aminotransferase: 12.3 kPa vs. 9.1 kPa., Conclusion: Liver stiffness values assessed by Acoustic Radiation Force Impulse and Transient Elastography are influenced by high aminotransferase levels. Transient Elastography was also influenced by moderately elevated aminotransferase levels., (Copyright © 2013 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Aims: This meta-analysis aims to compare the diagnostic performance of acoustic radiation force impulse (ARFI) elastography and transient elastography (TE) in the assessment of liver fibrosis using liver biopsy (LB) as 'gold-standard'., Methods: PubMed, Medline, Lilacs, Scopus, Ovid, EMBASE, Cochrane and Medscape databases were searched for all studies published until 31 May 2012 that evaluated the liver stiffness by means of ARFI, TE and LB. Information abstracted from each study according to a fixed protocol included study design and methodological characteristics, patient characteristics, interventions, outcomes and missing outcome data., Results: Thirteen studies (11 full-length articles and 2 abstracts) including 1163 patients with chronic hepatopathies were included in the analysis. Inability to obtain reliable measurements was more than thrice as high for TE as that of ARFI (6.6% vs. 2.1%, P < 0.001). For detection of significant fibrosis, (F ≥ 2) the summary sensitivity (Se) was 0.74 (95% CI: 0.66-0.80) and specificity (Sp) was 0.83 (95% CI: 0.75-0.89) for ARFI, while for TE the Se was 0.78 (95% CI: 0.72-0.83) and Sp was 0.84 (95% CI: 0.75-0.90). For the diagnosis of cirrhosis, the summary Se was 0.87 (95% CI: 0.79-0.92) and Sp was 0.87 (95% CI: 0.81-0.91) for ARFI elastography, and, respectively, 0.89 (95% CI: 0.80-0.94) and 0.87 (95% CI: 0.82-0.91) for TE. The diagnostic odds ratio of ARFI and TE did not differ significantly in the detection of significant fibrosis [mean difference in rDOR = 0.27 (95% CI: 0.69-0.14)] and cirrhosis [mean difference in rDOR = 0.12 (95% CI: 0.29-0.52)]., Conclusion: Acoustic radiation force impulse elastography seems to be a good method for assessing liver fibrosis, and shows higher rate of reliable measurements and similar predictive value to TE for significant fibrosis and cirrhosis., (© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Our study tried to identify the factors associated with discordance between liver stiffness values assessed by acoustic radiation force impulse (ARFI) elastography and histologic fibrosis in 106 chronic hepatitis C patients. Liver biopsy (LB) and ARFI measurements were performed in the same session. A discordance of at least two stages of fibrosis in the Metavir scoring system between ARFI results and LB was defined as significant. The performance of ARFI elastography was assessed using the following cut-offs: F1-1.19 m/s, F2-1.34 m/s, F3-1.55 m/s and F4-1.80 m/s. Discordance of at least two stages of fibrosis between ARFI results and histologic assessment were observed in 31.7% of the patients. In an univariate analysis, female sex (p = 0.004), interquartile range interval (IQR) ≥30% (p = 0.04), high alanine aminotransferases (p = 0.008) and high aspartate aminotransferases levels (p = 0.003) were associated with discordances. In a multivariate analysis, the female sex (p = 0.006) and IQR ≥30% (p = 0.004) were associated with discordances. Therefore, IQR parameter should be used for ARFI measurements., (Copyright © 2013 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Aim: The aim of this international multicenter study was to evaluate the reliability of Acoustic Radiation Force Impulse (ARFI) elastography for predicting fibrosis severity, in patients with chronic hepatitis C., Patients and Methods: We compared ARFI to liver biopsy (LB) in 914 patients (10 centers, 5 countries) with chronic hepatitis C. In each patient LB (evaluated according to the METAVIR score) and ARFI measurements were performed (median of 5-10 valid measurements, expressed in meters/second - m/s). In 400 from the 914 patients, transient elastography (TE) was also performed (median of 6-10 valid measurements, expressed in kiloPascals - kPa)., Results: Valid ARFI measurements were obtained in 911 (99.6%) of 914 cases. On LB 61 cases (6.7%) had F0, 241 (26.4%) had F1, 202 (22.1%) had F2, 187 (20.4%) had F3, and 223 (24.4%) had F4 fibrosis. A highly significant correlation (r=0.654) was found between ARFI measurements and fibrosis (p<0.0001). The predictive values of ARFI for various stages of fibrosis were: F ≥ 1 - cut-off>1.19 m/s (AUROC=0.779), F ≥ 2 - cut-off>1.33 m/s (AUROC=0.792), F ≥ 3 - cut-off>1.43 m/s (AUROC=0.829), F=4 - cut-off>1.55 m/s (AUROC=0.842). The correlation with histological fibrosis was not significantly different for TE in comparison with ARFI elastography: r=0.728 vs. 0.689, p=0.28. TE was better than ARFI for predicting the presence of liver cirrhosis (p=0.01) and fibrosis (F ≥ 1, METAVIR) (p=0.01)., Conclusion: ARFI elastography is a reliable method for predicting fibrosis severity in chronic hepatitis C patients., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Our aim was to compare liver stiffness (LS) measurements by means of acoustic radiation force impulse (ARFI) elastography and transient elastography (TE) in patients with chronic hepatitis B and C, according to the severity of fibrosis. We also compared the correlation strength of ARFI and TE measurements with liver fibrosis. We included 53 patients with hepatitis B and 107 with hepatitis C in which liver biopsy, ARFI and TE measurements were performed in the same session. The mean LS values measured with ARFI were similar in patients with chronic hepatitis B and C and depended on the stage of fibrosis. The correlation strength of LS measurements by ARFI and by TE with fibrosis was similar in chronic hepatitis B and C patients. In conclusion, for the same stage of fibrosis, the mean LS values by ARFI were similar in patients with chronic hepatitis B and C. ARFI had similar predictive value with TE in both chronic viral hepatitis., (Copyright © 2012 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Aim: To establish an algorithm which includes the liver stiffness (LS) and/or spleen stiffness (SS) assessed by ARFI for the prediction of significant esophageal varices-EV (at least grade 2)., Material and Methods: Our study included 145 newly diagnosed cirrhotic patients admitted in our Department between September 2009-August 2011. 62 patients (42.7%) had significant EV. We performed 10 ARFI measurements in each patient, both in the liver and in the spleen; median values were calculated, expressed in meters/second. In 24 consecutive newly diagnosed cirrhotic patients admitted between September 2011-December 2011, we prospectively analyzed the value of the new score for predicting significant EV., Results: The LS and SS assessed by ARFI elastography, and the percentage of patients with ascites were stastically significant higher in patients with significant EV as compared with those without EV or grade 1 EV. By multiple regression analysis we obtained the following formula for predicting significant EV: prediction of significant EV (Pred EV(2-3)) score: -0.572 + 0.041 x LS (m/s) + 0.122 x SS (m/s) + 0.325 x ascites (1-absent, 2-present). The best Pred EV(2-3) cut-off value for predicting significant EV was > 0.395 (AUROC = 0.721, accuracy = 69.6%). The accuracy in the group of patients in which the value of this score was prospectively analyzed was similar with that obtained in the first cohort of patients (70.8 vs. 69.6%). In conclusion, the proposed Pred EV(2-3) score had a enough good value for predicting significant EV.

Our study assessed acoustic radiation force impulse (ARFI) reproducibility and the factors influencing it. The intra- and interoperator reproducibility were studied in 33 and 58 patients, respectively. Intraclass correlation coefficient (ICC) was used to assess ARFI reproducibility. The overall intraoperator agreement was better than the interoperator one: ICC 0.90 vs. ICC 0.81. The correlation of repeated ARFI measurements was higher, but not significantly so, in cases in which intraoperator reproducibility was assessed compared with the ones in which interoperator reproducibility was studied: r = 0.848 vs. r = 0.694 (p = 0.08). For both intra- and interoperator reproducibility, the ICCs were smaller in women vs. men (0.88 vs. 0.91 and 0.67 vs. 0.86, respectively), in patients with high body mass index (BMI) ≥25 kg/m² vs. <25 kg/m² (0.88 vs. 0.91 and 0.79 vs. 0.82, respectively), in patients with ascites vs. no ascites (0.80 vs. 0.93 and 0.78 vs. 0.84, respectively) and in noncirrhotic vs. cirrhotic patients (0.77 vs. 0.82 and 0.70 vs. 0.83, respectively)., (Copyright © 2012 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

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.

Background: Patients with HCV liver cirrhosis are a category difficult to treat. The aim of this study was to establish the sustained virological response (SVR) rates in HCV patients with liver cirrhosis treated with standard of care therapy (Pegylated Interferon and Ribavirin for 48 weeks in genotypes 1 and 4 and 24 weeks in genotypes 2 and 3)., Methods: Searching the PubMed, Medline, Lilacs, Scopus, Ovid and Medscape databases we identified all the articles published until February 2011 that included only HCV cirrhotic patients. These studies evaluated the SVR after standard of care treatment: Pegylated Interferon alpha 2a (doses ranging between 135-180 µg/week) or Pegylated Interferon alpha 2b (1 or 1.5 µg/kg/week) and Ribavirin (doses ranging between 800-1200 mg/day). We used the following key words: HCV, liver cirrhosis, sustained virological response (SVR)., Results: The overall SVR rate was 33.3% (95%CI-confidence interval=30.6-36.2%). SVR was significantly higher in patients with genotypes 2 and 3 (422 patients) as compared to those with genotypes 1 and 4 (692 patients): 55.4% (95%CI=50.7-60.1) versus 21.7% (95%CI=18.7-25), p < 0.0001., Conclusion: The overall SVR rate in cirrhotic patients treated with standard of care therapy is 33.3%, but lower in cases affected by genotypes 1 and 4 (21.6%) which makes them a priority regarding the development of more potent drugs for effective treatment.

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.

Aim: To assess the values of liver stiffness (LS) in patients with hepatitis B virus (HBV) chronic hepatitis and to compare them with those in patients with hepatitis C virus (HCV) chronic hepatitis., Methods: The study included 140 patients with HBV chronic hepatitis, and 317 patients with HCV chronic hepatitis, in which LS was measured (FibroScan®-Echosens®) and liver biopsy was performed in the same session (assessed according to the Metavir score)., Results: According to the Metavir score of the 140 HBV patients: one had F0, 32 had F1, 67 had F2, 33 had F3 and 7 had F4. Of the 317 HCV patients: 5 had F0, 34 had F1, 146 had F2, 93 had F3 and 39 had F4. For the same severity of fibrosis, the mean values of LS in HBV patients were similar to those in HCV patients: F1, 6.5 ± 1.9 kPa vs 5.8 ± 2.1 kPa (P = 0.0889); F2, 7.1 ± 2 kPa vs 6.9 ± 2.5 kPa (P = 0.3369); F3, 9.1 ± 3.6 kPa vs 9.9 ± 5 kPa (P = 0.7038); F4, 19.8 ± 8.6 kPa vs 17.3 ± 6.1 kPa (P = 0.6574). A significant direct correlation between LS measurements and fibrosis was found in HCV patients (Spearman's r = 0.578, P < 0.0001), as well as in HBV patients (r = 0.408, P < 0.0001). The correlation was more significant in HCV than in HBV patients (Fisher's Z-test, Z = 2.210, P = 0.0271)., Conclusion: In our group, the mean values of LS in patients with chronic B hepatitis were similar to those in patients with chronic HCV hepatitis, for the same stage of fibrosis. Also, LS was correlated with the severity of fibrosis both in HBV and HCV chronic hepatitis patients.

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.

Liver cirrhosis is a major risk factor for the development of hepatocellular carcinoma, hence the need to screen those patients by means of liver ultrasound every 6 months. The differential diagnosis between a regenerative nodule, a dysplastic one and hepatocellular carcinoma is made based on a contrast imaging method (CEUS, MRI or CT) as they all have comparative sensitivities.

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.

Background: Patients with mild hepatitis C have a significant risk of disease progression at medium- and long-term follow-up and should be considered for antiviral therapy., Aim: To evaluate the rate of sustained viral response (SVR) and predictive factors of SVR in HCV genotype 1 patients with mild hepatitis C (fibrosis stage F0/F1) treated with combination antiviral therapy., Methods: 260 naïve patients were followed-up during 72 weeks in three referral hepatology centers between 2004 and 2006. Univariate and multivariate logistic regression analysis was conducted., Results: Early virological response was 88.1% and SVR was 74.2%. In the univariate analysis, SVR was associated with young age (p=0.001), very low (< or = 400,000 IU/mL) baseline viremia (p=0.03) and high aminotransferase levels (p=0.04) and was not associated with gender, body mass index, inflammatory activity, steatosis, ribavirin and peginterferon dose changes, premature cessation of therapy. Multivariate analysis identified the following independent predictors of SVR: age <50 years (p=0.0009), viral load < or = 400,000 IU/mL (p=0.03) and aminotransferase level >2 times normal value (p=0.02)., Conclusions: Genotype 1 HCV patients with mild hepatitis have a high rate of SVR, similar to genotype non-1. Young age, very low viremia and significant hepatocytolisis are independent predictors of SVR in patients with mild hepatitis.

Background and Aim: Chronic liver diseases are investigated through invasive (liver biopsy) or non-invasive (FibroScan or FibroTest) methods. Recently the non-invasive methods have become more and more popular. The aim of this paper is to evaluate the liver stiffness (LS) measured by transient elastography in individuals without known hepatic pathology ("normal" subjects) and to see if it is influenced by age., Material and Method: We examined a group of "normal" subjects by means of a FibroScan device (EchoSens, France). In each patient we performed 10 valid measurements and a median value was calculated by the device. The subjects were individuals without known hepatic pathology: healthy volunteers or patients from departments other than Gastroenterology in our hospital., Results: We evaluated 152 "normal" subjects (87 women and 65 men, mean age 45.3 + or - 17.6 years). The mean value of LS in "normal" subjects was 4.8 + or - 1.3 kPa, ranging from 2.3 to 8.8 kPa. The mean values of LS in age subgroups were: 18-29 years - 5 + or - 1.3 kPa; 30-39 years - 4.5 + or - 1.2kPa; 40-49 years - 5 = or - 1.1kPa; 50-59 years - 4.7 + or - 1.2kPa; 60-69 years - 5 + or - 1.3kPa; >70 years - 4.7 + or - 1.4kPa. There were no statistically significant differences between the mean values of LS in various age subgroups (p=0.5263)., Conclusions: The mean value of LS measured by transient elastography in "normal" subjects was lower than 5 kPa. Age does not modify the LS.

Unlabelled: The AIM of our study was to evaluate the results of transient elastography assessment of liver stiffness (LS) in various categories of patients., Material and Method: We performed transient elastography in 986 patients. We evaluated: the percentage of cases in which valid measurements could be obtained; the values of LS in 40 patients with no history of chronic liver disease ("normal" patients); 44 inactive HBsAg carriers; 173 patients with proven liver cirrhosis; and the correlation between liver biopsy results and LS in 93 patients with chronic HCV hepatitis., Results: We obtained valid measurements of LS in 94.6% of the 986 cases. Male gender, younger age and low BMI were positive predictive factors for obtaining valid measurements. The mean values of LS were: 5.2+/-1.3 kPa in "normal" patients, 5.8+/-2.6 kPa in inactive HBsAg carriers, 37.2+/-20.9 kPa in patients with liver cirrhosis. In patients with chronic HCV hepatitis, we found that the mean value of LS in those with METAVIR F>=2 was 8.5+/-4.2 kPa, higher than in those with F<2: 5.3+/-1.4 kPa (p=0.0017). In patients with F>=3, the mean value of LS was 11.1+/-4.3 kPa, significantly higher than in patients with F<3: 6.1+/-2.5 kPa (p<0.0001)., Conclusions: Liver stiffness, as a marker of fibrosis, can be evaluated by means of transient elastography in a great majority of patients. It is a useful method for the exclusion of significant liver fibrosis and for predicting liver cirrhosis. As compared to liver biopsy, transient elastography can discern significant fibrosis from no or mild fibrosis.

Aim: To compare the liver stiffness (LS) measurement by transient elastography (TE) to the liver biopsy (LB)-considered the "gold standard" in the evaluation of patients with chronic hepatitis C., Methods: During a period of 12 mo, we evaluated 199 consecutive patients with chronic hepatitis due to hepatitis C virus (HCV), in which LB and LS assessments (by means of TE) were performed during the same session., Results: Out of 199 patients, a valid measurement of the LS could not be obtained in 8. The mean value of LS in the cohort of 191 valid measurements was 8.45 +/- 4.96 kPa, ranging from 2.3 to 38 kPa. The mean value of LS in patients with significant fibrosis at biopsy (161 patients with F >= 2 according to Metavir) was 9.02 +/- 5.15 kPa, significantly higher than in patients with no or mild fibrosis (30 patients with F < 2 Metavir): 5.39 +/- 1.81 kPa (P < 0.0001). For a cut-off value of 6.8 kPa, the LS had a PPV of 98%, a NPV of 30.1%, a sensitivity of 59.6% and a specificity of 93.3% for the presence of significant fibrosis (at least F2 Metavir), with a diagnostic performance of 77.3% (AUROC 0.773). Using this cut-off value, we reached the best discrimination between absence of fibrosis/mild fibrosis (F < 2 Metavir) and the presence of moderate to severe fibrosis (F >= 2 Metavir)., Conclusion: In patients with chronic hepatitis due to HCV, a cut-off value of 6.8 kPa measured by TE can differentiate between significant fibrosis and absent or mild fibrosis, with a PPV of 98%, a NPV of 30.1%, a sensitivity of 59.6%, a specificity of 93.3%, and a diagnostic performance of 77.3%.

Chronic viral hepatitis is a common disease in the general population. During chronic hepatitis, the prognosis and clinical management are highly dependent on the extent of liver fibrosis. The fibrosis evaluation can be performed by FibroTest (using serological markers), by Elastography or FibroScan (a noninvasive percutaneous technique using the elastic properties of the hepatic tissue) and by liver biopsy (LB), considered to be the "gold standard". Currently, there are three techniques for performing LB: percutaneous, transjugular and laparoscopic. The percutaneous LB can be performed blind, ultrasound (US) guided or US assisted. There are two main categories of specialists who perform LB: gastroenterologists (hepatologists) and radiologists, and the specialty of the individual who performs the LB determines if the LB is performed under ultrasound guidance or not. There are two types of biopsy needles used for LB: cutting needles (Tru-Cut, Vim-Silverman) and suction needles (Menghini, Klatzkin, Jamshidi). The rate of major complications after percutaneous LB ranges from 0.09% to 2.3%, but the echo-guided percutaneous liver biopsy is a safe method for the diagnosis of chronic diffuse hepatitis (cost-effective as compared to blind biopsy) and the rate of complications seems to be related to the experience of the physician and the type of the needle used (Menghini type needle seems to be safer). Maybe, in a few years we will use non-invasive markers of fibrosis, but at this time, most authorities in the field consider that the LB is useful and necessary for the evaluation of chronic hepatopathies, despite the fact that it is not a perfect test.

Aim: Focal liver lesions (FLLs) are quite frequently discovered in daily practice at routine ultrasound. The aim of our study is to present a single centre experience concerning the use of contrast enhanced ultrasound (CEUS) in the characterization of FLL and to find when one can avoid using other expensive imaging modalities such as contrast enhanced CT or MRI. Method: We performed a prospective, single centre study during September 2009 - April 2010, and we evaluated 379 FLLs. A CEUS examination was considered conclusive if the FLL had a typical enhancement pattern according to the EFSUMB guidelines. Results: From the 379 cases with FLL, 198 (52.2%) were patients without known liver disease and 181 (47.8%) with known chronic liver disease (156 had cirrhosis, 25 chronic hepatitis); in 296/379 cases (78.1%) CEUS was conclusive. CEUS allowed the positive diagnosis of benign vs. malignant lesion in 261/294 (88.8%) de novo FLLs (CEUS performed for the first time), while in 33 (11.2%) cases it was inconclusive and could not differentiate between benign or malignant lesions. The CEUS results included 129 (49.4%) benign lesions and 132 (50.6%) malignant. Conclusion: CEUS was conclusive in approximately 80% of the FLLs and the benign or malignant character of a lesion was demonstrated in about 90% of cases. Thus, when faced with an uncharacteristic FLL on standard ultrasound examination, our local strategy is to perform CEUS as a first-line investigation, thus avoiding other expensive examinations. [ABSTRACT FROM AUTHOR]

Aim: To assess the efficacy of Percutaneous Ethanol Injection Therapy (PEIT) for the treatment of hepatocarcinoma in a series of Romanian patients, and to compare it with previous studies. Material and method: We retrospectively evaluated 88 patients with liver cirrhosis (LC) and hepatocellular carcinoma (HCC) treated by PElT. Multiple sessions of PELT were performed to treat a single nodule of 2-10 cm in diameter. The Child-Pugh classification was used for evaluating the severity of LC and the Okuda and Barcelona scores for HCC. The efficacy of PElT was assessed by CT or MRI one month after the therapy. The patients' survival after PElT was calculated starting from the first PELT procedure until the moment of death or the end of study (2000-2005). We analyzed the main factors which influenced the survival of the treated patients. Results: The global survival was 38.07±3.97 months, longer in patients with Child-Pugh A class, than in Child-Pugh B class (Log Rank 0.04). Patients with HCC less than 3 cm in diameter survived significantly longer than patients with tumors more than 5 cm (Log Rank 0.007). Also, survival was better in the Barcelona A stage than in the Barcelona B and C stages (Log Rank 0.002) and in patients with alpha-fetoprotein less than 200 ng/l (Log Rank 0.002). Conclusion: The main factors which influenced the survival of patients treated by PELT were: the size of the HCC, the Child-Pugh class, the Barcelona stage and the level of alpha-fetoprotein at the time of initiation of therapy. [ABSTRACT FROM AUTHOR]

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]