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Introduction: Acoustic Radiation Force Impulse (ARFI) elastography is a non-invasive technique for liver fibrosis assessment., Aim: To assess the feasibility of ARFI elastography in a large cohort of subjects and to identify factors associated with impossibility to obtain reliable liver stiffness (LS) measurements by means of this technique., Methods: Our retrospective study included 1031 adult subjects with or without chronic liver disease. In each subject LS was assessed by means of ARFI elastography. Failure of ARFI measurements was defined if no valid measurement was obtained after at least 10 shots and unreliable in the following situations: fewer than 10 valid shots; or median value of 10 valid measurements with a success rate (SR)<60% and/or an interquartile range interval (IQR) ≥ 30%., Results: Failure of LS measurements by means of ARFI was observed in 4 subjects (0.3%), unreliable measurements in 66 subjects (6.4%), so reliable measurements were obtained in 961 subjects (93.3%). In univariant analysis, the following risk factors were associated with failed and unreliable measurements: age over 58 years (OR=0.49; 95% CI 0.30-0.80, p=0.005), male gender (OR=0.58; 95% CI 0.34-0.94, p=0.04), BMI>27.7 kg/m(2) (OR=0.23, 95% CI 0.13-0.41, p<0.0001). In multivariate analysis all the factors mentioned above were independently associated with the risk of failed and unreliable measurements., Conclusions: Reliable LS measurements by means of ARFI elastography were obtained in 93.3% of cases. Older age, higher BMI and male gender were associated with the risk of failed and unreliable measurements, but their influence is limited as compared with Transient Elastography., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

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.

Aim: Liver biopsy (LB) is often essential for the diagnosis and staging of chronic viral hepatitis. The aim of our paper was to establish if the size of the biopsy needle influences the number of portal tracts obtained through LB., Material and Methods: We conducted a retrospective study on 596 echoassisted percutaneous LBs performed in the Department of Gastroenterology and Hepatology Timisoara during a 4 years period. We included only those biopsy results that had mentioned both the type of needle and the number of portal tracts. All LBs were echoassisted and performed with Menghini modified needles 1.4 and 1.6 mm in diameter (technique with two passages into the liver). The liver fragments were analyzed by a senior pathologist and Knodell score was used to describe necroinflammatory activity as well as fibrosis. We compared the number of portal tracts obtained with 1.4 vs. 1.6 Menghini needles., Results: Type 1.4 mm Menghini needles were used for 80 LBs, while 1.6 mm type were used in 516 LBs. Liver fragments obtained with 1.6 mm Menghini needles had a significantly higher mean number of portal tracts as compared to those obtained with 1.4 needles (24.5 ± 10.6 vs. 20.8 ± 8.6, p = 0.003)., Conclusion: The 1.6 mm Menghini needles provide better liver biopsy specimens, with higher number of portal tracts, as compared to 1.4 mm Menghini needles.

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.

Unlabelled: Contrast enhanced ultrasound (CEUS) has a well established role for the evaluation of focal liver lesions (FLL). The AIM of our paper was to evaluate if CEUS is a cost-efficient method for the first line evaluation of FLL., Material and Method: We performed a prospective study that included all the CEUS evaluations performed in our Department during a 6 months period (September 2009-March 2010). CEUS evaluation was performed with a Siemens Acuson S2000TM Ultrasound System following an intravenous bolus injection of 2.4 ml SonoVue(R) (Bracco). A CEUS examination was considered conclusive if, following contrast, the FLL had a typical enhancement pattern(after EFSUMB Guidelines 2008), allowing its classification as hemangioma, FNH, adenoma, hepatocellular carcinoma, metastasis, fatty-free area, focal fatty infiltration. We compared the costs of a CEUS positive diagnosis, to the cost of contrast CT and/or contrast MRI positive diagnosis. We also included the additional costs of CT and/or MRI, if CEUS was not conclusive. The cost of CEUS was calculated as the cost of 1/2 vial of SonoVue + the cost of abdominal ultrasound (150 + 30 = 180 RON). The costs of contrast CT scan and MRI were 285 and 650 RON respectively (mean costs practiced in Timisoara)., Results: In our study were included 316 FLL: 163 (51.6 %) in patients without hepatitis and 153 (48.4 %) in patients with chronic hepatopathies (in 133 cases liver cirrhosis and in 20 cases chronic hepatitis). CEUS was conclusive in 250 (79.1%) of the 316 cases, the cost for the evaluation of these patients being 45,000 RON. For the other 66 patients, the diagnosis cost will include the cost of CEUS + the cost of contrast CT: 30,690 RON. If contrast MRI was used for the differential diagnosis, the cost would be 54,780 RON. So the total cost of diagnosing 316 FLL would be 75,690 RON or 99,780 RON. If contrast CT would be used as the first line diagnosis for the 316 FLL, the cost would be 90,060 RON, by CEUS saving 14,370 RON, or 45.5 RON/lesion (using contrast CT for the differential diagnosis). If contrast MRI would be used as the first line diagnosis, the cost would be 205,400 RON, by CEUS saving 105,620 RON, or 334.2 RON/lesion (using contrast MRI for the differential diagnosis)., Conclusion: CEUS is a cost-efficient method as a first line diagnosis of FLL as compared to first line contrast-CT or first-line MRI.

Vibration-controlled transient elastography (VCTE) was the first non-invasive method used for assessing liver fibrosis in patients with chronic liver disease. Over the years, many studies have evaluated its performance. It is now used globally, and, in some countries, it represents the primary step in evaluating liver fibrosis. The aim of this study is to assess the feasibility of VCTE and highlight the prevalence of liver fibrosis stages assessed by VCTE in a large cohort of patients at a single study center. We also aimed to observe the trends in liver stiffness (LS) values over the years according to each type of hepatopathy. A retrospective study was conducted over a period of 13 years (2007–2019) and included patients who presented to our clinic for LS measurements (LSMs), either with known liver diseases or with suspected liver pathology who were undergoing fibrosis screening. The database contained a total of 23,420 measurements. Valid LSMs were obtained in 90.91% (21,291/23,420) of the cases, while 2129 (9.09%) of the measurements were either failed or unreliable. In untreated patients with chronic viral hepatitis, LS values tended to increase during the years, while in patients undergoing antiviral therapy LS values significantly decreased. Our comprehensive study, one of the largest of its kind spanning 13 years, emphasizes the reliability and significance of VCTE in real-world clinical settings. [ABSTRACT FROM AUTHOR]

Liver fibrosis is the most significant prognostic factor in chronic liver disease (CLD). Clinical practice guidelines recommend the use of non-invasive techniques, such as two-dimensional shear-wave elastography (2D-SWE), to assess liver elasticity as a marker of fibrosis. It is presumed that changes due to necro-inflammation modify the propagation of shear waves [1]. Therefore, new imaging techniques that investigate the dispersion properties of shear waves have been developed, which can serve as an indirect method of measuring liver viscosity (Vi PLUS). This study aims to analyze the performance of SWE to assess viscosity, to analyze factors influencing Vi PLUS measurements in a large cohort of patients with CLD, and to assess the normal ranges of liver viscosity measurements in participants with healthy livers. 867 consecutive adult subjects were enrolled in this prospective study (199 with healthy livers and 668 with CLD). Subjects were first examined using the Supersonic MACH® 30 US system (Hologic® SuperSonic® Imagine, Aix-en-Provence, France). Gray-scale US, as well as 2D-SWE and Vi PLUS measurements were performed. Secondly, TE measurements were performed with a FibroScan® Compact 530 device (EchoSens®, Paris, France). The mean Vi PLUS values in normal, ALD, HBV, HCV, NAFLD patients were: 1.6±0.3 Pa·s, 2.8±0.8 Pa·s, 1.9±0.3 Pa·s, 2.1±0.5 Pa·s and 2±0.4 Pa·s respectively (table 1). The mean Vi PLUS values were significantly higher in subjects with chronic liver disease than in normal subjects, independent of the etiology (p>0.05). Mean Vi PLUS values were significantly higher in subjects with ALD compared to HCV (p<0.0001), HBV (p<0.0001) and NAFLD subjects (p<0.0001); significantly higher in subjects with HCV compared to HBV (p=0.0001) and NAFLD subjects (p=0.011). No significant differences were found between HBV and NAFLD subjects (p=0.0615). In univariate regression analysis, Vi PLUS measurements were independently associated with: BMI (p<0.001), abdominal circumference (p<0.001), age (p<0.001), AST (p<0.001), ALT (p=0.009), the presence of diabetes mellitus (p<0.0001) and the presence of arterial hypertension (p<0.001). In multiple regression analysis the model including: abdominal circumference (p<0.0001), AST (p<0.0001) and ALT values (p=0.0029) was associated with ViPLUS measurements. Vi PLUS and 2D-SWE by SSI are highly feasible methods. The mean liver viscosity determined by Vi PLUS in our cohort of participants with healthy livers was 1.69 Pa·s. CLD patients had significantly higher viscosity values. Increased liver stiffness, high transaminases and obesity were associated with high viscosity values. [ABSTRACT FROM AUTHOR]

The aim of this study was to assess the performance and optimal cut-off points of UDFF for the non-invasive assessment of liver steatosis, using transient elastography (TE) with CAP as a reference method. We included 271 consecutive patients, with or without chronic liver disease (43.7% female, mean age 53.3 ± 13.05 years). Liver steatosis was evaluated in the same session by two techniques: UDFF - using a Siemens ACUSON Sequoia system (Deep Abdominal Transducer-DAX) and by CAP – using a FibroScan Compact M 530 device (M and XL probes). The following CAP cut-off values were used to differentiate among different grades of steatosis: 248dB/m for mild steatosis (S1), 268 dB/m for moderate steatosis (S2) and 280 dB/m for severe steatosis (S3). According to BMI, from the 271 patients 41% were obese, 34% were overweight and 25% normal weight. The correlation between UDFF and CAP was good, r=0.75, p<0.0001. We calculated the following UDFF optimal cut-off values to differentiate among steatosis grades: for S1->5% [(with 88.4% Se, 77.5% Sp,73.8% NPV, 90.3% PPV and an AUC of 0.92 (0.89-0.95), p<0.0001];for S2 >10% [(with 69.3% Se, 99% Sp, 99.1% NPV, 67.9% PPV and an AUC of 0.95 (0.92-0.97), p<0.0001]; and for S3 >15% [(with46.9% Se, 100% Sp, 100% NPV, 60.5% PPV and an AUC of 0.93 (0.89-0.96), p<0.0001]. UDFF is a good method for classifying steatosis severity with the following cut-offs:> 5% for mild steatosis,> 10% for moderate steatosis and > 15% for severe steatosis,the specificity increasing with steatosis severity. [ABSTRACT FROM AUTHOR]

The aim of this study was to assess the performance and optimal cut-off points for p-SWE and 2D-SWE for the non-invasive assessment of advanced liver fibrosis, using transient elastography as a reference method. Siemens ACUSON Sequoia (5C-1 convex transducer and Deep Abdominal Transducer-DAX) and FibroScan Compact M 530 (M and XL probes) were used. We included 198 consecutive patients with or without chronic liver disease that had all five LS values available. LS was evaluated in the same session by 3 elastographic techniques: TE, p-SWE and 2D-SWE. Reliable measurements were defined as the median value of 10 measurements and an IQR/M<0.3. For cACLD, the transient elastography cut-off point of 9.5 kPa was used [1]. From the 198 patients, 41.5% were women and 58.5% were men, mean age 54.8 ±13.8 years. The best cut-off values cACLD were: for 2D-SWE- 5C1 probe:>8.8 kPa, Se=97.7%, Sp=38.6%, AUC=0.84, p<0.0001;DAX probe:>7.6 kPa, Se= 40.9%, Sp=99.9%, AUC=0.84, p<0.0001; ForpSWE- 5C1 probe: >9.1 kPa, Se=54.5%, Sp=97.7%, AUC=0.86, p<0.0001; DAXprobe: > 8.8 kPa, Se=50%, Sp=98.5%, AUC=0.88, p<0.0001. The best cut-off value for predicting cACLD in pSWE range between 8.8 kPa and 9.1 kPa and for 2D-SWE raged between 7.6 kPa and 8.8 kPa. [ABSTRACT FROM AUTHOR]

Background: In chronic liver diseases, a correct estimation of the severity of liver fibrosis is important for recommendations regarding the treatment. Nowadays, evaluation of fibrosis is done by noninvasive methods such as biochemical scores and transient elastography instead of liver biopsy. The lack of sensitivity to detect fibrosis, because of its heterogeneity is a drawback of liver biopsy (LB). Objectives: To compare transient elastography (TE) and acoustic radiation force impulse (ARFI) for the evaluation of liver stiffness (LS), against percutaneous LB. Patients and Methods: Our study comprised of 223 subjects; 52 without fibrosis (38 volunteers and 14 patients with F0 on LB), 36 with F1, 40 with F2, 26 with F3 and 69 with liver cirrhosis (46 with LB and 23 with signs of cirrhosis). For each patient we performed in the same session 10 TE and 5 ARFI measurements. The median values were calculated. Results: A strong linear correlation (Spearman rho = 0.870) was found between TE and fibrosis (P < 0.0001); there was also a weaker correlation between ARFI and fibrosis (Spearman rho = 0.646; P < 0.0001). TE measurements were also correlated with ARFI measurements (Spearman rho = 0.733, P < 0.0001). The best test for predicting significant fibrosis (F ≥ 2) was TE with a cut-off value of 7.1 kPa (AUROC 0.953). For ARFI, the cut-off value was 1.27 m/s--area under ROC curve (AUROC): 0.890, sensitivity (Se) of 88.7%, specificity (Sp) of 67.5%, positive predictive value (PPV) of 64.5%, and negative predictive value (NPV) of 90% (P = 0.0044). For predicting cirrhosis (F = 4), the optimum cut-off values were 14.4 kPa for TE (AUROC: 0.985, Se: 95.6%, Sp: 94.7%, PPV: 89.2%, NPV: 98%) and 1.7 m/s for ARFI (AUROC: 0.931, Se: 93%, Sp: 86.7%, PPV: 73.6%, NPV: 96.9%) (P = 0.0102). Conclusions: LS evaluation by means of ARFI is not superior to TE for the assessment of liver fibrosis. ARFI is an accurate test for the diagnosis of cirrhosis. [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]

Background and Aim: While the manufacturer recommended the use of 10 liver stiffness measurements (LSM) to quantify liver stiffness by 2D-SWE.GE, it has been demonstrated that 5 LSM are enough to quantify LS by 2D-SWE.GE [1]. The aim of this study was to evaluate the reliability of 3 vs 5 measurements in a cohort of patients with or without chronic liver disease. Material and method: 333 consecutive patients with or without chronic hepatopathies, in whom LS was evaluated by 2D-SWE, using LOGIQ E9 (GE Healthcare), were included in the study. The mean, median, standard deviation (SD) and interquartile range (IQR) of 3 and 5 were collected for each patient and compared to each other. Reliable LSM were defined as the median value of 5 or 3 measurements acquired in a homogenous area of liver parenchyma and an interquartile range/median(IQR/MED) <0.30. Results: Reliable LSM were obtained in 92.5% (308/333) of patients using 5 LSM and in 94.9% (316/33) using 3 LSM (p= 0.26). The mean kPascal (kPa) value of the median, mean, SD and IQR for 5 and 3 measurements were 10.26, 10.30, 1.49, 1.56 and 10.37, 10.75, 2.96, 1.25 respectively. No significant statistical differences were found between 3 LSM and 5 LSM regarding the median, mean and SD (all p > 0.05). Statistical difference was observed only regarding IQR (p= 0.0026). Conclusion: 3 LSM using 2D-SWE.GE seem to be reliable for LS evaluation with an increased feasibility of the method. [ABSTRACT FROM AUTHOR]

The objective of this study is to evaluate how many measurements are needed for the non-invasive assessment of fibrosis by the new elastography technique THED and also to define the normal liver stiffness(LS) values in healthy subjects. Material and Method: We evaluated by THED and transient elastography(TE) a group of 183 patients: 44-healthy subjects(normal abdominal ultrasound, without any known liver disease and with a TE value <6.5kPa) and the rest with chronic hepatopathies. In all patients, 10 valid LS measurements were obtained in the same day, both with THED and with TE, using IQR/M<30% as a quality criterion. The following TE cut-off values were used to stage fibrosis in the chronic hepatopathies group: F1≥6.5kPa, F2≥7kPa, F3≥9.5kPa, F4≥12kPa(1). Results: Reliable LS measurements were obtained in all 183 patients (54.6% male, mean age 56.5±12.4 years) by means of both methods. According to TE, fibrosis severity was:F4-24.5%(45/183p),F3-6%(11/183p),F2-14.7%(27/183p),F1-12%(22/183p), F0-42.6% (78/183). There were no differences between the mean LSM obtained with 5 THED measurements vs. with 10 THED measurements: 1.66±0.26m/s vs. 1.65±0.24m/s, p=0.48. In the subgroup of 44 healthy volunteers (48.8% men, mean age: 37.7±2.38, average BMI=25.6 kg/m2), the mean LS value was 1.49±0.01 m/s. There were no significant differences between the mean LS values in healthy men vs. healthy women, 1.52±0.06m/s vs. 1.47±0.01m/s (p=0.1). Conclusion: Five valid measurements may be enough to quantify the liver fibrosis THED elastography, without significant loss of accuracy, thus reducing the examination time. The mean liver stiffness values by THED in healthy subjects was 1.49±0.01m/s. [ABSTRACT FROM AUTHOR]

Ultrasound-based liver elastography techniques are non-invasive methods used for the assessment of liver stiffness (LS). In addition to Transient Elastography (TE), new methods were developed. to compare the performance of 2D-SWE technique implemented on two different ultrasound probes from different vendors for the assessment of liver stiffness measurements (LSM) using transient elastography (TE) as reference method. A prospective study was conducted in which LSM were performed in 201 consecutive patients with or without chronic liver disease, evaluated in the same session by 2D-SWE and TE implemented on the following systems: Siemens ACUSON Sequoia (5C-1 convex transducer and Deep Abdominal Transducer-DAX), Aixplorer Mach 30 (C2-1X convex transducer) and FibroScan Compact M 530 (M and XL probes). Reliable measurements were defined as the median value of 10 measurements and an IQR/M<0.3. For significant fibrosis a cut-off value for TE of 7 kPa was used, for advanced fibrosis 9.5 kPa and for liver cirrhosis 12 kPa [1] From 201 patients, 198 patients had reliable measurements in all techniques and were included in the final analysis, mean age 54.8±13.3 years, mean BMI28.8 ± 5.0, 58% (116/198)men. 58.5% were without or with mild fibrosis, 14.1% had significant fibrosis, 6.2% had advanced fibrosis and 21.2% had liver cirrhosis. For significant fibrosis the performance was slightly better for 2D-SWE.SSI (AUROC=0.89, p<0.0001, >7.3 kPa, Se=85.1%, Sp=87.9%) followed by 2D-SWE.5C1 (AUROC=0.79, p<0.0001, >6.9 kPa, Se=33.7%, Sp=96.7%) and 2D-SWE.DAX (AUROC=0.78, p<0.0001, >6.3 kPa, Se= 36.4%, Sp=96.7%), p=0.01. For advanced fibrosis the best performance was slightly better by 2D-SWE.SSI (AUROC=0.92, p<0.0001, >8.8 kPa, Se=92.5%, Sp=91.9%), and by 2D-SWE.DAX (AUROC=0.86, p<0.0001, >7.6 kPa, Se= 38.8%, Sp=99.3%), followed by 2D-SWE.5C1 (AUROC=0.84, p<0.0001, >8.6 kPa, Se=38.8%, Sp=96.5%), p=0.02. For liver cirrhosis the performances were similar: 2D-SWE.SSI (AUROC=0.91, p<0.0001, >10.3 kPa, Se=92.8%, Sp=90.3%), followed by 2D-SWE.DAX (AUROC=0.90, p<0.0001, >10 kPa, Se= 23.8%, Sp=98.7%) and 2D-SWE.5C1 (AUROC=0.84, p<0.0001, >9.9 kPa, Se=33.3%, Sp=96.7%), p=0.10.The cut off values for predicting different stages of fibrosis ranged from 6.3-7.3 kPa for F2, 7.6-8.8 kPa for F3 and 9.9-10.3 for F4. The performance of the evaluated 2D SWE techniques for liver fibrosis assessment was similar. [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: 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]

Abstract: 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 &y& Elsevier]

Abstract: 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>1.19m/s (AUROC=0.779), F ≥2 – cut-off>1.33m/s (AUROC=0.792), F ≥3 – cut-off>1.43m/s (AUROC=0.829), F =4 – cut-off>1.55m/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 &y& Elsevier]

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]

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]

To evaluate the feasibility and usefulness of two novel elastographic methods, integrated in the same ultrasound machine (Samsung-Medison RS85), one pSWE and one 2D-SWE, for liver fibrosis (LF) assessment using Transient Elastography (TE) as the reference method. Our study included 115 subjects, with or without chronic liver disease, in which LF was evaluated in the same session by means of Transient Elastograpy (Fibroscan, EchoSens) and by pSWE and 2D-SWE techniques integrated in the same ultrasound machine (Samsung-Medison RS85 Ultrasound Machine). Reliable liver stiffness (LS) measurements were defined as follows: for TE as the median values of 10 measurements with a success rate of more than 60% and an interquartile range/median ratio (IQR/M)<30%; for pSWE as the median value of 10 measurements with a reliability measurement index (RMI)>0.5 and an IQR/M<30%; and for 2D-SWE as the median value of 10 measurements obtained in an homogenous area with the same quality criteria as for pSWE. For classification of liver fibrosis severity we used TE as reference method with the following cut-offs: F2≥7kPa, F3≥9.5 kPa and F4≥12 kPa. Reliable measurements by TE were obtained in 98.2% (113/115), by pSWE in 93.9% (108/115) and by 2D-SWE in 92.1% (106/115) subjects, 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%) and for 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%). The best cut off values calculated for 2d-SWE are: for 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%), and for 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%). The novel pSWE and 2D-SWE are feasible methods for assessing liver fibrosis, both techniques strongly correlating with TE results. [ABSTRACT FROM AUTHOR]