Search

Hepatic Epitheloid Hemangioendothelioma (HEH) is considered a rare tumor with vascular origins that has an overexpression of vascular endothelial growth factor (VEGF) and its receptors VEGFR (Weiss SW, Enzinger FM. Cancer 1982 Sept; 50(5): 970–981). Until now, there has been no standardized treatment for this pathology, the only suitable treatment being surgery, including liver resection, liver transplantation, or considering recent studies, transcatheter arterial chemoembolization (Mehrabi A et al. Cancer 2006 Nov; 107: 2108-2121; Cardinal J et al. Arch Surg. 2009; 144: 1035–1039). The evolution of a HEH is unpredictable. Sometimes the tumor has a quiet and stable course but it can also evolve aggressively and become metastatic (Sangro B et al. Rare Tumors 2012 Apr; 4(2): e34). The diagnosis of HEH is established first through imaging methods; it is shown as an hypoechoic tumor on ultrasonography (Lyburn ID et al. American Journal of Roentgenology 2003; 180: 1359-1364), with low density on CT, and on MRI usually exhibits low signal intensity on T1 weighted images and high signal intensity on T2 weighted images (Salech F et al. Ann Hepatol. 2011; 99–102, Ros LH et al. Canadian Association of Radiologists Journal. 1999; 387–389; Kehagias DT et al. Hepato-Gastroenterology. 2000; 1711–1713). The imaging findings of HEH have some typical features but have a size-dependent pattern with contrast enhancement, on both CT and MRI images (Lisha Z, et al. BMC Gastroenterol. 2015; DOI: doi: 10.1186/s12876-015-0299-x). HEH exhibits great heterogeneity regarding the imaging findings (Lyburn ID et al. American Journal of Roentgenology. 2003 May; vol.180: 1359–1364). Studies show that it can appear as a single or multiple avascular masses with calcification, and can involve the entire liver (den Bakker MA et al. Pathol Res Pract 1998; 194; Issue 3: 194–198; EH, Rha SE, Lee YJ et al. Abdom Imaging. 2015 Mar; 40(3): 500–509). Some imaging suggestions have been proposed in order to improve diagnostic accuracy, such as the retraction sign (capsule retraction of the liver, near the lesion) (Miller WJ et al. American Journal of Roentgenology. 1992; 159: 53–57). Another is the halo sign, which is related to the i.v administration of contrast medium (a hyperintense layer between the hypointense center and periphery) ( Linand J, Ji Y. Hepatobiliary and Pancreatic Diseases International. 2010; 154–8), even though HEH is often misdiagnosed as being a metastatic tumor. In this report we shall present a case of a young woman diagnosed with multiple liver tumors that proved to be HEH. We shall likewise discuss related imaging aspects.

Point shear wave elastography is a quantitative ultrasound-based imaging method used in the assessment of renal disease. Among point shear wave elastographic options, 2 techniques have been studied considerably: Virtual Touch quantification (VTQ; Siemens AG, Erlangen, Germany) and ElastPQ (EPQ; Philips Healthcare, Bothell, WA). Both rely on the tissue response to an acoustic beam generated by the ultrasound transducer. The data on renal VTQ are more extensive, whereas EPQ has been used less thus far in the assessment of the kidneys. This study aimed to evaluate the performance of EPQ in the kidney and compare it with VTQ.We studied 124 participants using EPQ: 22 with no renal disease and 102 with chronic kidney disease (CKD). Ninety-one were studied with both the EPQ and VTQ methods. We obtained 5 valid measurements in each kidney, expressed in meters per second.The mean kidney stiffness measurements ± SD obtained with EPQ in the healthy control group were as follows: right kidney, 1.23 ± 0.33 m/s; and left kidney, 1.26 ± 0.32 m/s (P = .6). In the patients with CKD (all stages), the mean kidney stiffness measurements obtained were significantly lower: right kidney, 1.09 ± 0.39 m/s; and left kidney, 1.04 ± 0.38 m/s (P = .4). We observed that, similar to VTQ, EPQ values decreased with CKD progression, based on analysis of variance results using different CKD stages. From a receiver operating characteristic curve analysis, the cutoff value for an estimated glomerular filtration rate of less than 45 mL/min was 1.24 m/s, and the value for an estimated glomerular filtration rate of less than 30 mL/min was 1.07 m/s.When using EPQ, the kidney shear wave velocity is decreased in patients with CKD, an observation similar to that obtained by using the VTQ method.

Hepatitis B virus may reactivate in patients with chronic hepatitis C treated with direct-acting antivirals. The aim of this study was to investigate the risk of hepatitis B virus (HBV) reactivation in HBV + hepatitis C virus (HCV)-co-infected patients with compensated liver cirrhosis treated with paritaprevir/ombitasvir/ritonavir, dasabuvir with ribavirin. We reviewed prospectively gathered data from a national cohort of 2070 hepatitis C virus patients with compensated liver cirrhosis who received reimbursed paritaprevir/ombitasvir/r, dasabuvir with ribavirin for 12 weeks from the Romanian National Health Agency during 2015-2016. Twenty-five patients in this cohort were HBs antigen positive (1.2%); 15 untreated with nucleotide analogues agreed to enter the study. These patients were followed up: ALT monthly, serology for HBV and DNA viral load at baseline, EOT and SVR at 12 weeks. Hepatitis B virus (HBV)-co-infected patients were all genotype 1b and 52% females, with a median age of 60 years (51 ÷ 74); 76% were pretreated with peginterferon + ribavirin; 72% were with severe necroinflammatory activity on FibroMax assessment; 40% presented comorbidities; and all were HBe antigen negative. Hepatitis C virus (HCV) SVR response rate was 100%. Hepatitis B virus (HBV)-DNA viral load was undetectable in 7/15 (47%) before therapy, and for the other 8 patients, it varied between below 20 and 867 IU/mL. Five patients (33%) presented virological reactivation (>2 log increase in HBV-DNA levels) during therapy. One patient presented with hepatitis associated with HBV reactivation, and two started anti-HBV therapy with entecavir. Hepatitis B virus (HBV) virological reactivation was present in 33% in our patients. Generally, HBV-DNA elevations were mild (

Background & Aims: Hepatitis C virus (HCV) infection is a common condition with endemic prevalence in some areas of the world. In Romania, the mean prevalence is about 3%. New treatments have become available on the market in recent years and new drugs are in the pipeline. A re-evaluation of HCV therapy was considered mandatory. The Romanian Society of Gastroenterology and Hepatology undertook this task for the practitioners of this country.Methodology: A group of recognized experts was created who screened the available literature and the major available guidelines. A list of items requiring attention was created and these were discussed and rated. Decisions were taken by consensus.Recommendations: We present here the second part of the Society’s recommendations for chronic HCV infection treatment. An agreement between experts was reached regarding the therapy of the special categories of patients infected with HCV, complications and monitoring of the therapy, follow-up of the patients who reached sustained virologic response and re-treatment of the patients with therapy failure.Conclusions: This Position Paper represents a guide for the assessment and the therapy of HCV infection. The recommendations are in concordance with other guidelines but are applied to real-life conditions in Romania. Abbreviations: CKD: Chronic kidney disease; DAAs: Direct-acting antivirals; DDIs: Drug-drug interactions; ESDL: End-stage liver disease; FCH: Fibrosing cholestatic hepatitis; GT: Genotype; HCV: Hepatitis C virus; HCC: Hepatocellular carcinoma; LT: Liver transplantation; MELD score: Mayo-Clinic End-Stage Liver Disease score; PDC: Premature discontinuation; PWID: Persons who inject drugs; RASs: Resistance associated substitutions; RBV: Ribavirin; RCT: Randomized controlled trial; SAE: Serious adverse events; SRGH: Romanian Society of Gastroenterology and Hepatology; SVR: Sustained virologic response.

Background & Aims: Hepatitis C Virus (HCV) infection is a common condition with endemic prevalence in some areas of the world. In Romania, the mean prevalence is about 3%. New treatments became available on the market in recent years and new drugs are in the pipeline. A re-evaluation of HCV therapy was considered mandatory. The Romanian Society of Gastroenterology and Hepatology undertook this task for the practitioners of this country.Methodology: A group of recognized experts was created who screened the available literature and the major available guidelines. A list of items requiring attention has been created. These items were discussed and rated. Decisions were taken by consensus.Recommendations: We present here the first of the two parts of our Society’s recommendations for chronic HCV infection treatment. An agreement was reached regarding the diagnostic tools, the assessment of severity and the up-dated therapy schedules.Conclusions: This Position Paper represents a guide for the assessment and the therapy of HCV infection. The recommendations are in concordance with other guidelines but are applied to the real-life conditions in this country.Abbreviations: DAAs: Direct-acting antivirals; DDIs: Drug-drug interactions; ESLD: End-stage liver disease; ESRD: End-stage renal disease; eGFR: Estimated glomerular filtration rate; EASL: European Association for the Study of the Liver; EMA: European Medicines Agency; FDA: US Food and Drug Administration; FDC: Fixed-dose combination; GT: Genotype; GRADE: Grading of Recommendations Assessment, Development and Evaluation; HCV: Hepatitis C virus; HCC: Hepatocellular carcinoma; LT: Liver transplantation; LLD: Lower limit of detection; MELD score: Mayo-Clinic End-Stage Liver Disease score; ANMDM: National Agency of Medicines and Medical Devices; PPIs: Proton pump inhibitors; PWID: People who inject drugs; RCT: Randomized controlled trial; RDT: Rapid diagnostic test; RAS: Resistance-associated substitution; SRGH: Romanian Society of Gastroenterology and Hepatology; SAE: serious adverse events; SPC: Summary of Product Characteristics; SVR: Sustained virologic response.

Background The evaluation of liver fibrosis is of utmost importance in managing paediatric liver diseases. Currently, liver biopsy remains the golden standard for assessing liver fibrosis in children. Still, new non-invasive tools for liver fibrosis evaluation are emerging. Aim To compare the measurements acquired with the linear and convex probe and to assess the intra-observer reproducibility of a two dimensional shear wave elastography (2D-SWE GE) technique. Material and methods: We conducted a prospective study that included 70 children (age range: 3–17 years, 37.1% girls, mean body mass index 24.73±7.2 kg/m 2 ). Our study population consisted of obese children (n=35) and a control group: normal weight children without liver disease (n=35). Liver stiffness measurements were performed using 2D-SWE.GE (Logiq E9, GE Healthcare, Chalfont St Giles- UK). For each child one examiner performed 10 liver stiffness measurements with both a linear and a convex probe. To assess the intra-observer reproducibility, we calculated, for each probe, the medians for the first five and the last five measurements, respectively. We then calculated the interclass correlation coefficients (ICCs) for the two medians. Results Overall, we found significantly higher measurement values for the linear probe: 7.8±5.1 kPa vs 4.1±0.9 kPa, p=0.001. The measurements were also higher for the linear probe, both in obese and controls: 9.9±6.1 kPa vs 4.2±0.8 kPa, p=0.01 and 6.5±4 kPa vs 3.9±1 kPa, p=0.235. As for the intraobserver reproducibility, we found no differences between the two sets of measurements for both the linear (8.2±5.8 kPa vs 8.1±5.6 kPa, p=0.25) and the convex probe (4.2±0.9 kPa vs 4.3±0.9 kPa, p=0.33). The agreement between measurements was excellent for both probes: ICC=0.956 (95% CI: 0.922–0.975) and ICC=0.927 (95% CI: 0.883–0.955). Conclusion Measurements acquired with the linear and convex probe are not superimposable. 2D-SWE GE is a reproducible method for liver stiffness measurements in children.

The aim of the study described here was to evaluate the reproducibility of a new shear-wave elastography (SWE) technique, 2-D SWE.GE, and the impact of ultrasound experience in acquiring reliable measurements, as no official recommendations are available for this system. Elastographic measurements (EMs) were obtained in 60 patients using 2-D-SWE with the GE Logiq E9. Three examiners with different levels of experience in ultrasound-based elastography performed 10 valid EMs on each subject: a novice (C.P.) who had no experience in liver elastography and had performed fewer than 50 ultrasound examinations; an elastography expert (A.M.S.) who had more than 1 y of liver elastographic experience in four elastographic methods and had performed more than 1000 ultrasonography examinations; and an ultrasound expert (T.M.) who had no experience in liver elastography and had performed more than 1000 ultrasound examinations. Medians and interquartile ranges were calculated (m/s). We used the inter-class correlation coefficient and Bland–Altman plots with 95% lower and upper limits of agreement to assess the inter- and intra-observer reproducibility of 2-D-SWE.GE measurements. The final study group included 60 patients, 56.7% women and 43.3% men, with a mean age of 33.08 ± 13.83 y and mean body mass index of 22.85 ± 4.04 kg/m2. In this group, 73.3% were healthy volunteers and 26.7% had compensated liver cirrhosis. We did not find significant differences between EMs taken by the examiners overall and across study groups. The overall agreement between examiners was excellent: 0.915 (95% confidence interval [CI]: 0.870–0.946). The agreement between the novice and the experienced examiners, respectively, was good to excellent (novice and ultrasound expert: 0.908, 95% CI: 0.846–0.945; novice and elastography expert: 0.885, 95% CI: 0.808–0.931). The intra-observer reproducibility for each of the examiners was excellent; however, the inter-class correlation coefficients were higher for the examiners more experienced in elastography: 0.936 (95% CI: 0.896–0.963) versus 0.966 (95% CI: 0.943–0.980) versus 0.984 (95% CI: 0. 973–0.991). The good ICCs for the median values indicate that 2-D-SWE.GE is a reproducible method. Ultrasound experience did not significantly influence the results.

Shear wave elastography (SWE) has been developed to non-invasively estimate liver stiffness. Different techniques are available and they are described in detail in the EFSUMB guidelines on elastography. However, there are only a few published studies investigating normal ranges in healthy subjects by comparing different equipment and analysing influencing factors. In the present review, we summarize the impact factors on liver stiffness measurement (LSM) using SWE, report its reproducibility, and define normal range tables of LSM in healthy subjects for clinical practice according to the published literature.

Background and Aims. 2D-shear wave elastography (2D-SWE) is a relatively new elastographic technique. The aim of the present study is to determine the values of the elasticity indexes (EI) measured by 2D-SWE in parathyroid benign lesions (adenomas or hyperplasia) and to establish if this investigation is helpful for the preoperative identification of the parathyroid adenoma. Material and Methods. The study groups were represented by 22 patients with primary or tertiary hyperparathyroidism, diagnosed by specific tests, and 43 healthy controls, in whom the thyroid parenchyma was evaluated, in order to compare the EI of the thyroid tissue with those of the parathyroid lesions. Results. The mean EI measured by 2D-SWE in the parathyroid lesions was 10.2 ± 4.9 kPa, significantly lower than that of the normal thyroid parenchyma (19.5 ± 7.6 kPa; p=0.007), indicating soft tissue. For a cutoff value of 12.5 kPa, the EI assessed by 2D-SWE had a sensitivity of 93% and a specificity of 86% (AUC = 0.949; p<0.001) for predicting parathyroid lesions. Conclusion. A value lower than 12.5 kPa for the mean EI measured by 2D-SWE can be used to confirm that the lesion/nodule is a parathyroid adenoma.

Nonalcoholic fatty liver disease represents an excessive fat accumulation in the liver of patients with no other liver disease and no history of alcohol abuse. It is associated with insulin resistance, being more prevalent in obesity and type 2 diabetes. Our aim was to assess the prevalence of fatty liver and nonalcoholic steatohepatitis in patients with type 2 diabetes and to evaluate the influence of obesity on its prevalence. We included 348 type 2 diabetes patients (age: 18–65 years), without a history of liver disease or alcohol abuse. We assessed demographical data, medical history, physical examination, blood tests, and abdominal ultrasonography. The prevalence of liver steatosis in our group was 87.1 %, with no significant differences between men and women. Patients with steatosis had higher abdominal circumference, body mass index (BMI; p = 0.001), and serum triglyceride (p

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: >7.1kPa (AUROC=0.825); F ≥2: >7.8kPa (AUROC=0.859); F ≥3: >8kPa (AUROC=0.897) and for F =4: >11.5kPa (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.

Aim: To present a large monocentric experience in the characterization of focal liver lesions (FLLs) using Contrast Enhanced Ultrasound (CEUS).Method: A retrospective study was performed in the Gastroenterology and Hepatology Department, Timisoara, including 1100 patients with 1329 FLLs evaluated between September 2009 and January 2013. A CEUS examination was considered conclusive if the FLL respected the typical enhancement pattern as described in the EFSUMB Guidelines.Results: From the 1329 FLLs, CEUS was conclusive for a specific pathology in 1102 cases (82.9%). For the differentiation of benign/malignant lesions, CEUS reached a conclusive diagnosis in 1196 (90%) cases. The percentage of conclusive CEUS examinations was significantly higher in patients without chronic liver disease as compared with those with chronic hepatopathies: 87.3% vs. 74.4% (p

Abdominal ultrasound is one of the most popular imaging methods due to its feasibility, low cost and accessibility. Contrast Enhanced Ultrasound (CEUS) with second generation contrast agents became in the last years a useful tool for the characterization of focal liver lesions (FLL) so that EFSUMB issued guidelines for its use in clinical practice. Several large studies proved that CEUS has similar performance to more expensive imaging methods such as contrast enhanced CT and contrast enhanced MRI for the characterization of FLL. Also, several studies proved that CEUS is cost-effective as a first-line imaging method. Considering all these data, we think that CEUS is ready to be used in daily practice for the evaluation of FLL.

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

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

Background and aim The goals of this study were to compare the noninvasive diagnostic performance of two elastography techniques for the diagnosis of liver cirrhosis in a cohort of patients with known hepatitis C virus using Transient Elastography FibroScan as the method of reference since it is a validated tool for the non-invasive assessment of liver fibrosis. Material and Methods The study included 122 patients aged 38-80 (62 ± 7.9), 35% male (43/122), 65% female (79/122) with known hepatitis C virus in whom liver stiffness was evaluated during the same session by means of three elastography Methods: Point Shear Wave Elastography (pSWE) using virtual touch quantification(VTQ) technology Siemens Acuson S2000TM, Two-Dimensional Shear Wave Elastography (2D-SWE) embedded in General Electrics LOGIQ E9 ultrasound machine and Transient Elastography(TE;FibroScan, EchoSens). Reliable LS measurements were defined, for all techniques, as the median value of 10 measurements with an interquartile range/median(IQR/MED) Results Reliable liver stiffness measurements were obtained in 93% (114/122) of cases by means of TE, 88% (107/122) of cases by means of VTQ and 87% (106/122) of cases by means of 2D-SWE.GE. In the final analysis we included 93 patients which had reliable stiffness measurements with all methods.The AUROCS were calculated considering TE as the reference method. The optimal cutoff of VTQ for cirrhosis was 1.77m/s(SE:83%; SP:88%; AUC:0.89) and for 2D-SWE.GE was 10.2 kPa(SE:86%; SP:77%; AUC:0.89). No statistical differences were found between both methods(p Conclusion Both methods have similar performance for diagnosing liver cirrhosis and seem to be a promising alternative to Transient Elastography in evaluating patients with liver fibrosis.

Background In the current literature, there is only a small number of studies that have evaluated the utility of point share wave elastography for pancreatic assessment. Objective To assess the feasibility of Virtual Touch Quantification (VTQ) elastography for pancreas assessment, as well as the mean pancreatic stiffness values in healthy subjects. Material and Method We included 70 subjects (52.8% women, 47.2% men, average BMI = 25.9 ± 4.9 kg/m2, average age 46.8 ± 18.4 years) with a normal pancreatic ultrasound aspect and with no history of pancreatic disease or diabetes, in whom elastography measurements were performed with a Siemens Acuson S2000 Virtual Touch ultrasound system (Siemens AG, Erlangen, Germany) using a 4CI transducer. For each patient, 10 valid VTQ measurements of the pancreatic parenchyma were performed under fasting conditions. Reliable measurements were defined as a median value of ten pancreas stiffness measurements with a success rate ≥ 60% and an interquartile range interval Results Out of 70 subjects, reliable measurements were acquired in 61 subjects (87.1%) by means of VTQ elastography. The mean pancreas stiffness values in healthy subjects was 1.26 m/s ± 0.1 m/s, CI 95% (1.24-1.28). There were no significant differences between the mean pancreas stiffness in men vs. women 1.25 m/s ± 0.09 m/s, CI 95% (1.21-1.28) vs. 1.28 m/s ± 0.1 m/s CI 95% (1.25-1.31) (p = 0.103). Conclusion VTQ can be a useful tool for pancreas quantification characterized by a good feasibility (87.1%) in healthy subjects. The mean pancreas stiffness values in healthy individuals was 1.26 m/s ± 0.1m/s.

Introduction While most ultrasound elastography methods employ transient stimulation methods, the new time harmonic elastography (THED) relies on time-harmonic vibrations in the same manner as magnetic resonance elastography. The aim of our study was to assess the performance of the THED system for ruling in/out liver cirrhosis (LC) considering transient elastography (TE) as the reference method, as well as and the correlation of THED values with TE. Material & Method We evaluated by THED a group of 70 patients. Each subject has been fasting for more than 6 hours before evaluation. 10 valid LS measurements were performed in the same day, both by THED and by TE. We used the TE cut-off values published by Tsochatzis (1): significant fibrosis (F ≥ 2)- 7.0kPa and for LC (F = 4)- 12kPa as reference values. Quality criteria recommended by the manufacturer: SR ≥ 60%, IQR Results From the 70 patients, 34 were women and 36 men. Mean age 55.2 ± 11.7, mean BMI 27.8 ± 6.2 kg/m2. Of the 70 patients, 15.8% (11/70) were F4, 25.7% (18/70) were F2-3, 58.5 % (41/70) were F0-1.We had 100% feasibility for all the patients that were previously evaluated by TE. The cut-off for ruling out LC by THED measurements on our study group was 2 m/s (11.9 kPa). AUROC = 0.83, 95%CI (0.73-0.91), P Conclusions In our study, the cut-of values to rule-out and rule-in LC by LS measurements with THED system were 11.9 kPa, respectively. There was a strong correlation between the LS values obtained by the two elastographic methods.

Introduction and aim Transient Elastography with Controlled Attenuation Parameter(CAP) was recently introduced as a noninvasive method for quantification of liver steatosis.The aim of this study is to assess the performance of ultrasound(US) compared to CAP for the detection and quantification of liver steatosis. Material and Methods 323 patients aged 22-83 (54.7 ± 13.5), 44% male (142/323), 56% female (181/323) with or without different chronic hepatopathies were included in the study.All patients were assessed by US and CAP using Transient Elastography (FibroScan, EchoSense) during the same session in fasting conditions.US examinations were performed by EFSUMB level 1 qualification practitioners using high tech US systems. We used the following cut-offs for quantifying liver steatosis by CAP: 230-275, 275-300 and > 300 db/m for mild, moderate and severe steatosis(S1,S2,S3) following the recommendations of the manufacturer.US classification of liver steatosis was based on the comparison between liver and renal cortex echogenicity; grade 0 – echogenicity equal to the renal cortex, grade 1 – increased echogenicity and no posterior attenuation, grade 2 - increased echogenicity and posterior attenuation without obscuring the diaphragmatic outline, grade 3 - echogenic liver with posterior attenuation that obscures the diaphragmatic outline. Results Based on the cut-off values proposed (CAP) steatosis distribution was 28.8% / 23.2% / 15.8% / 32.2% for S0 / S1 / S2 / S3.By means of US steatosis distribution was 31.6% / 23.5% / 20.4% / 24.5% for S0 / S1 / S2 / S3.Regarding hepatic steatosis US was significantly correlated with CAP score (r = 0.77, p Conclusion US examination is a useful and cheap tool for clinical practice in the screening and quantification of hepatic steatosis, even in the hands of a novice.

Nonalcoholic Liver Disease (NAFLD) is increasing in frequency in daily practice. Evaluation of such patients needs to assess steatosis, fibrosis and inflammation.A new Ultrasound(US) system from Canon noninvasively evaluates these parameters by measuring shear waves speed (2D-SWE) - related to viscoelasticity and fibrosis; dispersion (DI) - related to viscosity and inflammation, and attenuation parameter (ATI) - related to steatosis. Aim: To evaluate the usefulness of 2D-SWE, DI and ATI measurements obtained using Aplio i800 from Canon, for the noninvasive assessment of liver fibrosis, inflammation, and steatosis using Transient Elastography (TE) with Controlled Attenuation Parameter (CAP) as the reference method. Material and Method: 113 consecutive subjects were included in the study group, mostly NAFLD patients, in whom liver stiffness (LS) and steatosis were evaluated in the same session by means of 2 elastography techniques: TE with CAP (FibroScan, EchoSens) and 2D-SWE with ATI(Aplio I800, Canon). Reliable LS measurements were defined for TE as the median value of 10 measurements with an interquartile range/median ratio (IQR/M) To discriminate between TE fibrosis stages we used the following cut-offs [1]: F ≥ 2: 8.4 kPa and F4: 13.2 kPa and to discriminate between steatosis stages we used the following cut-offs recommended by the manufacturer: S1(mild) – 230db/m, S2(moderate) - 275db/m, S3(severe) - 300db/m. Results: Reliable LS measurements were obtained in 99.1% subjects by both 2D-SWE and TE.A very strong positive correlation was found between the LS values obtained by the 2 Methods: r = 0.88, p The best cut-off value for fibrosis, for F0/1 was ≤ 6.2 kPa (AUROC 0.82; Se = 75%; Sp = 85.5%), for F ≥ 2 it was 7.9 kPa (AUROC 0.96; Se = 90.4%; Sp = 95.6%), for F4 it was 11.7 kPa (AUROC 0.99; Se = 100%; Sp = 96%). Regarding steatosis, the best cut-off values were: for S1 = 0.64 dB/cm/mHz (AUROC 0.89; Se = 73.6%; Sp = 88.8%), for S2 = 0.79 dB/cm/mHz (AUROC 0.88; Se = 63.4%; Sp = 96.4%), for S3 = 0.86dB/cm/mHz (AUROC 0.95; Se = 45%; Sp = 100%). When we divided the cohort into healthy vs patients with chronic hepatopathies, we found out that the mean DI values in the pathology group were higher than in the healthy group(12.4 ± 2.7 vs 11.5 ± 1.9, p = 0.03) Conclusion: 2D-SWE and ATI measurements with the new system strongly correlate with TE and CAP results 110.1111/apt.14529

Aim: To analyze how many measurements are needed for non-invasive assessment of liver stiffness (LS) by means of 2DShear 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.

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

Aim We evaluated the influence of the type of needle and the operator’s experience on the quality of the specimen obtained at liver biopsy (LB).

The aim of this study was to identify if the experience of the examiner does plays a role in the ability to perform liver stiffness (LS) measurements by means of supersonic shear imaging (SSI) due to the lack of recommendation regarding this issue. Material and methods: The study included 371 consecutive subjects (42% men and 58% women, with a median age of 48 years, ranging between 17-85 years) with or without hepatopathies, in which LS was evaluated with an AixplorerTM ultrasound system (SuperSonic Imagine S.A., Aix-en-Provence, France). Reliable LS measurements by means of SSI were defined as the median value of 5 LS measurements expressed in kilopascals (kPa). The SSI measurements were performed by a novice (with less than 300 abdominal ultrasound examinations performed) or by a more experienced operator (with approximately 500 ultrasound examinations performed). The results of both operators were compared. Results: The novice performed 57.4% and the more experienced operator 42.6% of the SSI measurements. The more experienced operator had a higher rate of reliable examinations as compared with the novice: 87.4% vs. 72.8% (p =0.001). The rate of reliable measurements was similar for novice and experienced operator in patients with a normal weight (BMI < 25 kg/m2) and in overweight patients (BMI between 25.1 – 29.9 kg/m2), 92.3% vs. 97.5%, p=0.24, respectively 71.1% vs 80.4%, p=0.39. For obese patients (BMI ≥ 30 kg/m2) the rate of reliable LS measurements was significantly higher for the more experienced operator as compared with the novice: 73.4% vs 45.9%, p=0.03. Conclusions: It seems that experience in liver ultrasonography plays a role in the ability to perform LS measurements by means of SSI and leads to achieving more reliable LS measurements especially in obese subjects.

To retrospectively assess the feasibility of transient elastography (TE) and the factors associated with failed and unreliable liver stiffness measurements (LSMs), in patients with chronic liver diseases.Our retrospective study included 8218 consecutive adult patients with suspected chronic liver diseases. In each patient, LSMs were performed with a FibroScan(®) device (Echosens, France), with the M probe. Failure of TE measurements was defined if no valid measurement was obtained after at least 10 shots and unreliable if fewer than 10 valid shots were obtained, success rate (SR)60% and/or interquartile range interval/median value (IQR/Med) ≥30%.From the 8218 patients, failed and unreliable LSMs were observed in 29.2% of cases. In univariant analysis, the following risk factors were associated with failed and unreliable measurements: age over 50 years (OR 2.04; 95%CI 1.84-2.26), female gender (OR 1.32; 95%CI 1.20-1.45), BMI27.7kg/m(2) (OR 2.89, 95%CI 2.62-3.19), weight77kg (OR 2.17; 95%CI 1.97-2.40) and height162cm (OR 1.26; 95%CI 1.14-1.40). In multivariate analysis all the factors mentioned above were independently associated with the risk of failed and unreliable measurements. If all the negative predictive factors were present (woman, older than 50 years, with BMI27.7kg/m(2), heavier than 77kg and shorter than 162cm), the rate of failed and unreliable measurements was 58.5%. In obese patients (BMI≥30kg/m(2)), the rate of failed and unreliable measurements was 49.5%.Failed and unreliable LSMs were observed in 29.1% of patients. Female gender, older age, higher BMI, higher weight and smaller height were significantly associated with failed and unreliable LSMs.

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

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

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.

Background & Aims: Gastroesophageal reflux disease (GERD) therapy is challenging and suppression of acid secretion or prokinetics do not cure all cases. Some drugs with protective action on the esophageal mucosa have been used alternatively or in association with proton pump inhibitors (PPIs) and/or prokinetics. The Romanian Society of Neurogastroenterology undertook an Evidence-Based analysis, from which this position paper evolved. Methods: We performed a systematic literature search in PubMed until October 2015, using the terms: sucralfate, guaiazulene, gaiazulene, dimethicone, alginate, antacids and gastroesophageal reflux. Forty-seven papers were included and analyzed. Several statements were elaborated regarding the use of these drugs in GERD. The evidence and recommendations were discussed between the authors. Results: There is evidence in the medical literature suggesting the benefit of these drugs in GERD. In patients with persistent or mild reflux symptoms antacids rapidly relieve heartburn. Alginate-antacid combination is superior both over placebo and antacids to treat mild reflux symptoms, and can be used to treat persistent reflux symptoms despite acid suppressant therapy. Sucralfate is superior over placebo in alleviating GERD symptoms and can be used as maintenance therapy. Guaiazulene-dimethicone improves the quality of life in patients with GERD. Conclusions: Drugs used to protect the esophageal mucosa against acid are useful in alleviating chronic heartburn, especially in patients with mild reflux symptoms. Abbreviations: CS: Chondroitin sulfate; DA: Double Action; EE : Erosive esophagitis ; GERD: Gastroesophageal reflux disease; HA: Hyaluronic acid; H2RA: Histamine 2 receptor antagonist; ITT: Intention to treat; IM: Irsogladine maleate; NERD: Non-erosive reflux disease; PPIs: Proton pump inhibitors; RCT: Randomized controlled trial; RDQ: Reflux disease questionnaire; QoL: Quality of life.

In previous studies of acoustic radiation force impulse (ARFI) elastography, using Virtual Touch tissue quantification (VTQ) (Siemens Acuson S2000), it was reported that the measurement of renal shear wave speed in patients with chronic kidney disease (CKD) is not influenced exclusively by renal fibrosis. The purpose of the present study was to analyze the role of VTQ in patients with diabetic kidney disease, considered the main cause of CKD. The study group included 164 patients: 80 patients with diabetic kidney disease (DKD) and 84 without renal disease or diabetes mellitus. In each subject in lateral decubitus, five valid VTQ measurements were performed in each kidney and a median value was calculated, the result being expressed in meters/second. The following means of the median values were obtained In DKD patients, the means of the median values were for VTQ right kidney, 2.21 ± 0.71 m/s, and for VTQ left kidney, 2.13 ± 0.72 m/s, whereas in the normal controls statistically significant higher values were obtained: 2.58 ± 0.78 m/s for VTQ right kidney (p = 0.0017) and 2.46 ± 0.81 m/s for VTQ left kidney (p = 0.006). Patients with an estimated glomerular filtration rate (eGFR)60 mL/min (DKD stages 1 and 2 together with normal controls) had a significantly higher kidney shear wave speed compared with patients with an eGFR60 mL/min (2.53 m/s vs. 2.09 m/s, p 0.05). In the DKD group, there was a significant correlation between eGFR and VTQ levels for the right kidney (r = 0.28, p = 0.04). There was no correlation of VTQ values with proteinuria level, stage of diabetic retinopathy or glycated hemoglobin. Our study indicates that shear wave speed values in patients with diabetic kidney disease and eGFRs60 mL/min are significantly lower compared with those of patients with eGFRs60 mL/min (either normal controls or diabetic patients with DKD stages 1 and 2), and values decrease with the decrease in eGFR. However, proteinuria, diabetic retinopathy and glycated hemoglobin have no influence on VTQ.

In October 2014 the European Federation of Societies for Ultrasound in Medicine and Biology formed a Gastrointestinal Ultrasound (GIUS) task force group to promote the use of GIUS in a clinical setting. One of the main objectives of the task force group was to develop clinical recommendations and guidelines for the use of GIUS under the auspices of EFSUMB. The first part, gives an overview of the examination techniques for GIUS recommended by experts in the field. It also presents the current evidence for the interpretation of normal sonoanatomical and physiological features as examined with different ultrasound modalities.Im Oktober 2014 bildete die „European Federation of Societies for Ultrasound in Medicine and Biology“ einen Arbeitskreis „Gastrointestinaler Ultraschall“ (GIUS), um den Einsatz des GIUS in der klinischen Praxis voranzutreiben. Eines der Hauptziele des Arbeitskreises war die Erarbeitung klinischer Empfehlungen und Leitlinien für den Einsatz des GIUS unter der Schirmherrschaft des EFSUMB. Der erste Teil gibt einen Überblick über die Untersuchungsmethoden des GIUS, wie er von Experten auf diesem Gebiet empfohlen wurde. Außerdem wird die derzeit aktuelle Evidenz für die Interpretation normaler sonoanatomischer und physiologischer Merkmale, wie sie mit unterschiedlichen Ultraschallmethoden untersucht wurden, präsentiert.

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