Cirrhosis echocardiography or ultrasound: Difference between revisions

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{{Cirrhosis}}
{{Cirrhosis}}
{{CMG}} {{AE}} {{AN}}
{{CMG}} {{AE}} {{AN}}
{{PleaseHelp}}


==Overview==
==Overview==
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**[[Doppler ultrasound]] may show spontaneous [[shunts]]
**[[Doppler ultrasound]] may show spontaneous [[shunts]]
*[[Splenomegaly]] and collaterals from [[portal hypertension]] may be noted.
*[[Splenomegaly]] and collaterals from [[portal hypertension]] may be noted.
{{#ev:youtube|AYb9NrZoSLs}}
*  (typically ultrasound) helps:  
 
*Evaluate the liver parenchyma
==Transient Elastography==
*Detects extrahepatic manifestations of cirrhosis
A new type of device, the '''FibroScan (transient elastography)''', uses elastic waves to determine liver stiffness which theoretically can be converted into a liver score based on the METAVIR scale.  The FibroScan produces an ultrasound image of the liver (from 20-80mm) along with a pressure reading (in kPa).  The test is much faster than a biopsy (usually lasts 2.5-5 minutes) and is completely painless.  It shows reasonable correlation with the severity of cirrhosis.<ref>{{cite journal |author=Foucher J, Chanteloup E, Vergniol J, ''et al'' |title=Diagnosis of cirrhosis by transient elastography (FibroScan): a prospective study |journal=Gut |volume=55|issue=3 |pages=403-8 |year=2006 |pmid=16020491 |doi=10.1136/gut.2005.069153}}</ref> <ref name="pmid22733854">{{cite journal |author=Xie L, Chen X, Guo Q, Dong Y, Guang Y, Zhang X |title=Real-time elastography for diagnosis of liver fibrosis in chronic hepatitis B |journal=[[Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine]] |volume=31 |issue=7 |pages=1053–60 |year=2012 |month=July |pmid=22733854 |doi= |url=}}</ref>
*Findings may include:<ref name="pmid22357834">{{cite journal |vauthors=Udell JA, Wang CS, Tinmouth J, FitzGerald JM, Ayas NT, Simel DL, Schulzer M, Mak E, Yoshida EM |title=Does this patient with liver disease have cirrhosis? |journal=JAMA |volume=307 |issue=8 |pages=832–42 |year=2012 |pmid=22357834 |doi=10.1001/jama.2012.186 |url=}}</ref><ref name="pmid3533689">{{cite journal |vauthors=Becker CD, Scheidegger J, Marincek B |title=Hepatic vein occlusion: morphologic features on computed tomography and ultrasonography |journal=Gastrointest Radiol |volume=11 |issue=4 |pages=305–11 |year=1986 |pmid=3533689 |doi= |url=}}</ref><ref name="pmid2526349">{{cite journal |vauthors=Di Lelio A, Cestari C, Lomazzi A, Beretta L |title=Cirrhosis: diagnosis with sonographic study of the liver surface |journal=Radiology |volume=172 |issue=2 |pages=389–92 |year=1989 |pmid=2526349 |doi=10.1148/radiology.172.2.2526349 |url=}}</ref><ref name="pmid3891495">{{cite journal |vauthors=Sanford NL, Walsh P, Matis C, Baddeley H, Powell LW |title=Is ultrasonography useful in the assessment of diffuse parenchymal liver disease? |journal=Gastroenterology |volume=89 |issue=1 |pages=186–91 |year=1985 |pmid=3891495 |doi= |url=}}</ref><ref name="pmid3532188">{{cite journal |vauthors=Giorgio A, Amoroso P, Lettieri G, Fico P, de Stefano G, Finelli L, Scala V, Tarantino L, Pierri P, Pesce G |title=Cirrhosis: value of caudate to right lobe ratio in diagnosis with US |journal=Radiology |volume=161 |issue=2 |pages=443–5 |year=1986 |pmid=3532188 |doi=10.1148/radiology.161.2.3532188 |url=}}</ref><ref name="pmid10341686">{{cite journal |vauthors=Simonovský V |title=The diagnosis of cirrhosis by high resolution ultrasound of the liver surface |journal=Br J Radiol |volume=72 |issue=853 |pages=29–34 |year=1999 |pmid=10341686 |doi=10.1259/bjr.72.853.10341686 |url=}}</ref><ref name="pmid22144108">{{cite journal |vauthors=Trinchet JC, Chaffaut C, Bourcier V, Degos F, Henrion J, Fontaine H, Roulot D, Mallat A, Hillaire S, Cales P, Ollivier I, Vinel JP, Mathurin P, Bronowicki JP, Vilgrain V, N'Kontchou G, Beaugrand M, Chevret S |title=Ultrasonographic surveillance of hepatocellular carcinoma in cirrhosis: a randomized trial comparing 3- and 6-month periodicities |journal=Hepatology |volume=54 |issue=6 |pages=1987–97 |year=2011 |pmid=22144108 |doi=10.1002/hep.24545 |url=}}</ref><ref name="pmid22424438">{{cite journal |vauthors= |title=EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma |journal=J. Hepatol. |volume=56 |issue=4 |pages=908–43 |year=2012 |pmid=22424438 |doi=10.1016/j.jhep.2011.12.001 |url=}}</ref>
 
'''Elastography:''' <ref name="pmid18395077">{{cite journal |vauthors=Friedrich-Rust M, Ong MF, Martens S, Sarrazin C, Bojunga J, Zeuzem S, Herrmann E |title=Performance of transient elastography for the staging of liver fibrosis: a meta-analysis |journal=Gastroenterology |volume=134 |issue=4 |pages=960–74 |year=2008 |pmid=18395077 |doi=10.1053/j.gastro.2008.01.034 |url=}}</ref><ref name="pmid15690481">{{cite journal |vauthors=Ziol M, Handra-Luca A, Kettaneh A, Christidis C, Mal F, Kazemi F, de Lédinghen V, Marcellin P, Dhumeaux D, Trinchet JC, Beaugrand M |title=Noninvasive assessment of liver fibrosis by measurement of stiffness in patients with chronic hepatitis C |journal=Hepatology |volume=41 |issue=1 |pages=48–54 |year=2005 |pmid=15690481 |doi=10.1002/hep.20506 |url=}}</ref><ref name="pmid14698338">{{cite journal |vauthors=Sandrin L, Fourquet B, Hasquenoph JM, Yon S, Fournier C, Mal F, Christidis C, Ziol M, Poulet B, Kazemi F, Beaugrand M, Palau R |title=Transient elastography: a new noninvasive method for assessment of hepatic fibrosis |journal=Ultrasound Med Biol |volume=29 |issue=12 |pages=1705–13 |year=2003 |pmid=14698338 |doi= |url=}}</ref><ref name="pmid23558397">{{cite journal |vauthors=Bamber J, Cosgrove D, Dietrich CF, Fromageau J, Bojunga J, Calliada F, Cantisani V, Correas JM, D'Onofrio M, Drakonaki EE, Fink M, Friedrich-Rust M, Gilja OH, Havre RF, Jenssen C, Klauser AS, Ohlinger R, Saftoiu A, Schaefer F, Sporea I, Piscaglia F |title=EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: Basic principles and technology |journal=Ultraschall Med |volume=34 |issue=2 |pages=169–84 |year=2013 |pmid=23558397 |doi=10.1055/s-0033-1335205 |url=}}</ref><ref name="pmid25911335">{{cite journal |vauthors= |title=EASL-ALEH Clinical Practice Guidelines: Non-invasive tests for evaluation of liver disease severity and prognosis |journal=J. Hepatol. |volume=63 |issue=1 |pages=237–64 |year=2015 |pmid=25911335 |doi=10.1016/j.jhep.2015.04.006 |url=}}</ref><ref name="pmid21205132">{{cite journal |vauthors=Castera L, Bedossa P |title=How to assess liver fibrosis in chronic hepatitis C: serum markers or transient elastography vs. liver biopsy? |journal=Liver Int. |volume=31 Suppl 1 |issue= |pages=13–7 |year=2011 |pmid=21205132 |doi=10.1111/j.1478-3231.2010.02380.x |url=}}</ref><ref name="pmid23732714">{{cite journal |vauthors=Chou R, Wasson N |title=Blood tests to diagnose fibrosis or cirrhosis in patients with chronic hepatitis C virus infection: a systematic review |journal=Ann. Intern. Med. |volume=158 |issue=11 |pages=807–20 |year=2013 |pmid=23732714 |doi=10.7326/0003-4819-158-11-201306040-00005 |url=}}</ref><ref name="pmid26779260">{{cite journal |vauthors=Khallafi H, Qureshi K |title=Imaging Based Methods of Liver Fibrosis Assessment in Viral Hepatitis: A Practical Approach |journal=Interdiscip Perspect Infect Dis |volume=2015 |issue= |pages=809289 |year=2015 |pmid=26779260 |pmc=4686715 |doi=10.1155/2015/809289 |url=}}</ref><ref name="pmid23954643">{{cite journal |vauthors=Singh S, Fujii LL, Murad MH, Wang Z, Asrani SK, Ehman RL, Kamath PS, Talwalkar JA |title=Liver stiffness is associated with risk of decompensation, liver cancer, and death in patients with chronic liver diseases: a systematic review and meta-analysis |journal=Clin. Gastroenterol. Hepatol. |volume=11 |issue=12 |pages=1573–84.e1–2; quiz e88–9 |year=2013 |pmid=23954643 |pmc=3900882 |doi=10.1016/j.cgh.2013.07.034 |url=}}</ref>
*Increasing scarring of the liver is associated with increasing "stiffness" of the tissue.
*Transient elastography and the acoustic radiation force impulse (ARFI) technique are now well-established methods for the staging of fibrosis in various liver diseases <ref name="pmid20581229">{{cite journal |vauthors=Castera L, Pinzani M |title=Biopsy and non-invasive methods for the diagnosis of liver fibrosis: does it take two to tango? |journal=Gut |volume=59 |issue=7 |pages=861–6 |year=2010 |pmid=20581229 |doi=10.1136/gut.2010.214650 |url=}}</ref><ref name="pmid22239521">{{cite journal |vauthors=Friedrich-Rust M, Nierhoff J, Lupsor M, Sporea I, Fierbinteanu-Braticevici C, Strobel D, Takahashi H, Yoneda M, Suda T, Zeuzem S, Herrmann E |title=Performance of Acoustic Radiation Force Impulse imaging for the staging of liver fibrosis: a pooled meta-analysis |journal=J. Viral Hepat. |volume=19 |issue=2 |pages=e212–9 |year=2012 |pmid=22239521 |doi=10.1111/j.1365-2893.2011.01537.x |url=}}</ref> 
'''Radiologic findings:'''
*Radiologic studies include:<ref name="pmid22357834">{{cite journal |vauthors=Udell JA, Wang CS, Tinmouth J, FitzGerald JM, Ayas NT, Simel DL, Schulzer M, Mak E, Yoshida EM |title=Does this patient with liver disease have cirrhosis? |journal=JAMA |volume=307 |issue=8 |pages=832–42 |year=2012 |pmid=22357834 |doi=10.1001/jama.2012.186 |url=}}</ref>
**Abdominal ultrasound
**Computed tomography scan 
**Magnetic resonance imaging
 
*Findings may include:<ref name="pmid3533689">{{cite journal |vauthors=Becker CD, Scheidegger J, Marincek B |title=Hepatic vein occlusion: morphologic features on computed tomography and ultrasonography |journal=Gastrointest Radiol |volume=11 |issue=4 |pages=305–11 |year=1986 |pmid=3533689 |doi= |url=}}</ref><ref name="pmid2526349">{{cite journal |vauthors=Di Lelio A, Cestari C, Lomazzi A, Beretta L |title=Cirrhosis: diagnosis with sonographic study of the liver surface |journal=Radiology |volume=172 |issue=2 |pages=389–92 |year=1989 |pmid=2526349 |doi=10.1148/radiology.172.2.2526349 |url=}}</ref><ref name="pmid3891495">{{cite journal |vauthors=Sanford NL, Walsh P, Matis C, Baddeley H, Powell LW |title=Is ultrasonography useful in the assessment of diffuse parenchymal liver disease? |journal=Gastroenterology |volume=89 |issue=1 |pages=186–91 |year=1985 |pmid=3891495 |doi= |url=}}</ref><ref name="pmid3532188">{{cite journal |vauthors=Giorgio A, Amoroso P, Lettieri G, Fico P, de Stefano G, Finelli L, Scala V, Tarantino L, Pierri P, Pesce G |title=Cirrhosis: value of caudate to right lobe ratio in diagnosis with US |journal=Radiology |volume=161 |issue=2 |pages=443–5 |year=1986 |pmid=3532188 |doi=10.1148/radiology.161.2.3532188 |url=}}</ref><ref name="pmid10341686">{{cite journal |vauthors=Simonovský V |title=The diagnosis of cirrhosis by high resolution ultrasound of the liver surface |journal=Br J Radiol |volume=72 |issue=853 |pages=29–34 |year=1999 |pmid=10341686 |doi=10.1259/bjr.72.853.10341686 |url=}}</ref><ref name="pmid22144108">{{cite journal |vauthors=Trinchet JC, Chaffaut C, Bourcier V, Degos F, Henrion J, Fontaine H, Roulot D, Mallat A, Hillaire S, Cales P, Ollivier I, Vinel JP, Mathurin P, Bronowicki JP, Vilgrain V, N'Kontchou G, Beaugrand M, Chevret S |title=Ultrasonographic surveillance of hepatocellular carcinoma in cirrhosis: a randomized trial comparing 3- and 6-month periodicities |journal=Hepatology |volume=54 |issue=6 |pages=1987–97 |year=2011 |pmid=22144108 |doi=10.1002/hep.24545 |url=}}</ref><ref name="pmid22424438">{{cite journal |vauthors= |title=EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma |journal=J. Hepatol. |volume=56 |issue=4 |pages=908–43 |year=2012 |pmid=22424438 |doi=10.1016/j.jhep.2011.12.001 |url=}}</ref>
**A liver that appears shrunken, irregular, and nodular.
**A liver that appears shrunken, irregular, and nodular.


Line 46: Line 33:
**varices
**varices
**Ascites
**Ascites
'''DIAGNOSIS''' — 
**  Findings on abdominal imaging are viewed in light of other signs of cirrhosis, such as physical examination or laboratory test findings.
*Abdominal imaging (typically ultrasound) helps:
**In addition to evaluating the liver, abdominal imaging may reveal:
**Evaluate the liver parenchyma
***Hepatocellular carcinoma
**Detects extrahepatic manifestations of cirrhosis
***Extrahepatic findings suggestive of cirrhosis:
'''Laboratory tests:'''
****Ascites
* AST to platelet ratio index
****Varices
*FibroTest/FibroSure
****Splenomegaly
'''Imaging studies:'''
****Hepatic or portal vein thrombosis
* Findings on abdominal imaging are viewed in light of other signs of cirrhosis, such as physical examination or laboratory test findings.
****  '''Ultrasonography:'''  routinely used during the evaluation of cirrhosis
*In addition to evaluating the liver, abdominal imaging may reveal:
*****First-line investigation of choice.
**Hepatocellular carcinoma
*****The first radiologic study obtained due to easy availability.
**Extrahepatic findings suggestive of cirrhosis:
***Ascites
***Varices
***Splenomegaly
***Hepatic or portal vein thrombosis
***  '''Ultrasonography:'''  routinely used during the evaluation of cirrhosis
****First-line investigation of choice.
****The first radiologic study obtained due to easy availability.


****Provides information about :
*****Provides information about :
*****appearance of the liver
******appearance of the liver
*****blood flow within the portal circulation
******blood flow within the portal circulation


****less expensive than other imaging modalities
*****less expensive than other imaging modalities


****No exposure to intravenous contrast or radiation
*****No exposure to intravenous contrast or radiation


****Noninvasive
*****Noninvasive
****cheap
*****cheap
****safe
*****safe


****well tolerated
*****well tolerated


****widely available
*****widely available
**** Ultrasound, particularly with colour Doppler imaging : <ref name="pmid7718281">{{cite journal |vauthors=Zwiebel WJ |title=Sonographic diagnosis of hepatic vascular disorders |journal=Semin. Ultrasound CT MR |volume=16 |issue=1 |pages=34–48 |year=1995 |pmid=7718281 |doi= |url=}}</ref>
***** Ultrasound, particularly with colour Doppler imaging : <ref name="pmid7718281">{{cite journal |vauthors=Zwiebel WJ |title=Sonographic diagnosis of hepatic vascular disorders |journal=Semin. Ultrasound CT MR |volume=16 |issue=1 |pages=34–48 |year=1995 |pmid=7718281 |doi= |url=}}</ref>
*****measures changes in blood flow in the presence of portal hypertension
******measures changes in blood flow in the presence of portal hypertension
*****excludes biliary obstruction in patients who present with jaundice
******excludes biliary obstruction in patients who present with jaundice


****Early signs of cirrhosis in B-ultrasonography include:
*****Early signs of cirrhosis in B-ultrasonography include:
*****inhomogeneity of the hepatic tissue
******inhomogeneity of the hepatic tissue
*****Irregularity of the hepatic surface 
******Irregularity of the hepatic surface 
*****enlargement of the caudate lobe 
******enlargement of the caudate lobe 
*****Splenomegaly due to portal HTN
******Splenomegaly due to portal HTN


****The diagnostic evaluation of cirrhosis with ultrasonography is based on the direct relation between the extent of fibrosis and the ultrasonographically determined degree of liver stiffness.
*****The diagnostic evaluation of cirrhosis with ultrasonography is based on the direct relation between the extent of fibrosis and the ultrasonographically determined degree of liver stiffness.


**** ultrasonography can rule cirrhosis in or out in over 90% of cases , its findings are less than 100% specific because of occasional in -correct measurements and false-positive findings
***** ultrasonography can rule cirrhosis in or out in over 90% of cases , its findings are less than 100% specific because of occasional in -correct measurements and false-positive findings


****Findings:<ref name="pmid25263492">{{cite journal |vauthors=Di Lelio A, Cestari C, Lomazzi A, Beretta L |title=Cirrhosis: diagnosis with sonographic study of the liver surface |journal=Radiology |volume=172 |issue=2 |pages=389–92 |year=1989 |pmid=2526349 |doi=10.1148/radiology.172.2.2526349 |url=}}</ref><ref name="pmid11866220">{{cite journal |vauthors=Martínez-Noguera A, Montserrat E, Torrubia S, Villalba J |title=Doppler in hepatic cirrhosis and chronic hepatitis |journal=Semin. Ultrasound CT MR |volume=23 |issue=1 |pages=19–36 |year=2002 |pmid=11866220 |doi= |url=}}</ref><ref name="pmid12216750">{{cite journal |vauthors=Tchelepi H, Ralls PW, Radin R, Grant E |title=Sonography of diffuse liver disease |journal=J Ultrasound Med |volume=21 |issue=9 |pages=1023–32; quiz 1033–4 |year=2002 |pmid=12216750 |doi= |url=}}</ref><ref name="pmid12202712">{{cite journal |vauthors=Awaya H, Mitchell DG, Kamishima T, Holland G, Ito K, Matsumoto T |title=Cirrhosis: modified caudate-right lobe ratio |journal=Radiology |volume=224 |issue=3 |pages=769–74 |year=2002 |pmid=12202712 |doi=10.1148/radiol.2243011495 |url=}}</ref><ref name="pmid10334257">{{cite journal |vauthors=Albrecht T, Blomley MJ, Cosgrove DO, Taylor-Robinson SD, Jayaram V, Eckersley R, Urbank A, Butler-Barnes J, Patel N |title=Non-invasive diagnosis of hepatic cirrhosis by transit-time analysis of an ultrasound contrast agent |journal=Lancet |volume=353 |issue=9164 |pages=1579–83 |year=1999 |pmid=10334257 |doi=10.1016/S0140-6736(98)06373-9 |url=}}</ref>
*****Findings:<ref name="pmid25263492">{{cite journal |vauthors=Di Lelio A, Cestari C, Lomazzi A, Beretta L |title=Cirrhosis: diagnosis with sonographic study of the liver surface |journal=Radiology |volume=172 |issue=2 |pages=389–92 |year=1989 |pmid=2526349 |doi=10.1148/radiology.172.2.2526349 |url=}}</ref><ref name="pmid11866220">{{cite journal |vauthors=Martínez-Noguera A, Montserrat E, Torrubia S, Villalba J |title=Doppler in hepatic cirrhosis and chronic hepatitis |journal=Semin. Ultrasound CT MR |volume=23 |issue=1 |pages=19–36 |year=2002 |pmid=11866220 |doi= |url=}}</ref><ref name="pmid12216750">{{cite journal |vauthors=Tchelepi H, Ralls PW, Radin R, Grant E |title=Sonography of diffuse liver disease |journal=J Ultrasound Med |volume=21 |issue=9 |pages=1023–32; quiz 1033–4 |year=2002 |pmid=12216750 |doi= |url=}}</ref><ref name="pmid12202712">{{cite journal |vauthors=Awaya H, Mitchell DG, Kamishima T, Holland G, Ito K, Matsumoto T |title=Cirrhosis: modified caudate-right lobe ratio |journal=Radiology |volume=224 |issue=3 |pages=769–74 |year=2002 |pmid=12202712 |doi=10.1148/radiol.2243011495 |url=}}</ref><ref name="pmid10334257">{{cite journal |vauthors=Albrecht T, Blomley MJ, Cosgrove DO, Taylor-Robinson SD, Jayaram V, Eckersley R, Urbank A, Butler-Barnes J, Patel N |title=Non-invasive diagnosis of hepatic cirrhosis by transit-time analysis of an ultrasound contrast agent |journal=Lancet |volume=353 |issue=9164 |pages=1579–83 |year=1999 |pmid=10334257 |doi=10.1016/S0140-6736(98)06373-9 |url=}}</ref>
*****Advanced cirrhosis: liver may appear small and nodular
******Advanced cirrhosis: liver may appear small and nodular
*****Surface nodularity and increased echogenicity with irregular appearing areas are consistent with cirrhosis
******Surface nodularity and increased echogenicity with irregular appearing areas are consistent with cirrhosis
*****Usually atrophy of the right lobe and hypertrophy of the caudate or left lobes.
******Usually atrophy of the right lobe and hypertrophy of the caudate or left lobes.


****Ultrasonography may also be used as a screening test for hepatocellular carcinoma :nodules on ultrasonography warrants further evaluation
*****Ultrasonography may also be used as a screening test for hepatocellular carcinoma :nodules on ultrasonography warrants further evaluation
****Findings of portal hypertension:
*****Findings of portal hypertension:
***** increased diameter of the portal vein
****** increased diameter of the portal vein
***** presence of collateral veins
****** presence of collateral veins
***** decreased flow within the portal circulation on Doppler imaging
****** decreased flow within the portal circulation on Doppler imaging
****Ultrasonography is also useful for detecting splenomegaly, ascites, and portal vein thrombosis. 
*****Ultrasonography is also useful for detecting splenomegaly, ascites, and portal vein thrombosis. 
{{#ev:youtube|AYb9NrZoSLs}}
 
==Transient Elastography==
A new type of device, the '''FibroScan (transient elastography)''', uses elastic waves to determine liver stiffness which theoretically can be converted into a liver score based on the METAVIR scale.  The FibroScan produces an ultrasound image of the liver (from 20-80mm) along with a pressure reading (in kPa).  The test is much faster than a biopsy (usually lasts 2.5-5 minutes) and is completely painless.  It shows reasonable correlation with the severity of cirrhosis.<ref>{{cite journal |author=Foucher J, Chanteloup E, Vergniol J, ''et al'' |title=Diagnosis of cirrhosis by transient elastography (FibroScan): a prospective study |journal=Gut |volume=55|issue=3 |pages=403-8 |year=2006 |pmid=16020491 |doi=10.1136/gut.2005.069153}}</ref> <ref name="pmid22733854">{{cite journal |author=Xie L, Chen X, Guo Q, Dong Y, Guang Y, Zhang X |title=Real-time elastography for diagnosis of liver fibrosis in chronic hepatitis B |journal=[[Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine]] |volume=31 |issue=7 |pages=1053–60 |year=2012 |month=July |pmid=22733854 |doi= |url=}}</ref>
 
'''Elastography:''' <ref name="pmid18395077">{{cite journal |vauthors=Friedrich-Rust M, Ong MF, Martens S, Sarrazin C, Bojunga J, Zeuzem S, Herrmann E |title=Performance of transient elastography for the staging of liver fibrosis: a meta-analysis |journal=Gastroenterology |volume=134 |issue=4 |pages=960–74 |year=2008 |pmid=18395077 |doi=10.1053/j.gastro.2008.01.034 |url=}}</ref><ref name="pmid15690481">{{cite journal |vauthors=Ziol M, Handra-Luca A, Kettaneh A, Christidis C, Mal F, Kazemi F, de Lédinghen V, Marcellin P, Dhumeaux D, Trinchet JC, Beaugrand M |title=Noninvasive assessment of liver fibrosis by measurement of stiffness in patients with chronic hepatitis C |journal=Hepatology |volume=41 |issue=1 |pages=48–54 |year=2005 |pmid=15690481 |doi=10.1002/hep.20506 |url=}}</ref><ref name="pmid14698338">{{cite journal |vauthors=Sandrin L, Fourquet B, Hasquenoph JM, Yon S, Fournier C, Mal F, Christidis C, Ziol M, Poulet B, Kazemi F, Beaugrand M, Palau R |title=Transient elastography: a new noninvasive method for assessment of hepatic fibrosis |journal=Ultrasound Med Biol |volume=29 |issue=12 |pages=1705–13 |year=2003 |pmid=14698338 |doi= |url=}}</ref><ref name="pmid23558397">{{cite journal |vauthors=Bamber J, Cosgrove D, Dietrich CF, Fromageau J, Bojunga J, Calliada F, Cantisani V, Correas JM, D'Onofrio M, Drakonaki EE, Fink M, Friedrich-Rust M, Gilja OH, Havre RF, Jenssen C, Klauser AS, Ohlinger R, Saftoiu A, Schaefer F, Sporea I, Piscaglia F |title=EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: Basic principles and technology |journal=Ultraschall Med |volume=34 |issue=2 |pages=169–84 |year=2013 |pmid=23558397 |doi=10.1055/s-0033-1335205 |url=}}</ref><ref name="pmid25911335">{{cite journal |vauthors= |title=EASL-ALEH Clinical Practice Guidelines: Non-invasive tests for evaluation of liver disease severity and prognosis |journal=J. Hepatol. |volume=63 |issue=1 |pages=237–64 |year=2015 |pmid=25911335 |doi=10.1016/j.jhep.2015.04.006 |url=}}</ref><ref name="pmid21205132">{{cite journal |vauthors=Castera L, Bedossa P |title=How to assess liver fibrosis in chronic hepatitis C: serum markers or transient elastography vs. liver biopsy? |journal=Liver Int. |volume=31 Suppl 1 |issue= |pages=13–7 |year=2011 |pmid=21205132 |doi=10.1111/j.1478-3231.2010.02380.x |url=}}</ref><ref name="pmid23732714">{{cite journal |vauthors=Chou R, Wasson N |title=Blood tests to diagnose fibrosis or cirrhosis in patients with chronic hepatitis C virus infection: a systematic review |journal=Ann. Intern. Med. |volume=158 |issue=11 |pages=807–20 |year=2013 |pmid=23732714 |doi=10.7326/0003-4819-158-11-201306040-00005 |url=}}</ref><ref name="pmid26779260">{{cite journal |vauthors=Khallafi H, Qureshi K |title=Imaging Based Methods of Liver Fibrosis Assessment in Viral Hepatitis: A Practical Approach |journal=Interdiscip Perspect Infect Dis |volume=2015 |issue= |pages=809289 |year=2015 |pmid=26779260 |pmc=4686715 |doi=10.1155/2015/809289 |url=}}</ref><ref name="pmid23954643">{{cite journal |vauthors=Singh S, Fujii LL, Murad MH, Wang Z, Asrani SK, Ehman RL, Kamath PS, Talwalkar JA |title=Liver stiffness is associated with risk of decompensation, liver cancer, and death in patients with chronic liver diseases: a systematic review and meta-analysis |journal=Clin. Gastroenterol. Hepatol. |volume=11 |issue=12 |pages=1573–84.e1–2; quiz e88–9 |year=2013 |pmid=23954643 |pmc=3900882 |doi=10.1016/j.cgh.2013.07.034 |url=}}</ref>
*Increasing scarring of the liver is associated with increasing "stiffness" of the tissue.
*Transient elastography and the acoustic radiation force impulse (ARFI) technique are now well-established methods for the staging of fibrosis in various liver diseases <ref name="pmid20581229">{{cite journal |vauthors=Castera L, Pinzani M |title=Biopsy and non-invasive methods for the diagnosis of liver fibrosis: does it take two to tango? |journal=Gut |volume=59 |issue=7 |pages=861–6 |year=2010 |pmid=20581229 |doi=10.1136/gut.2010.214650 |url=}}</ref><ref name="pmid22239521">{{cite journal |vauthors=Friedrich-Rust M, Nierhoff J, Lupsor M, Sporea I, Fierbinteanu-Braticevici C, Strobel D, Takahashi H, Yoneda M, Suda T, Zeuzem S, Herrmann E |title=Performance of Acoustic Radiation Force Impulse imaging for the staging of liver fibrosis: a pooled meta-analysis |journal=J. Viral Hepat. |volume=19 |issue=2 |pages=e212–9 |year=2012 |pmid=22239521 |doi=10.1111/j.1365-2893.2011.01537.x |url=}}</ref> 
==References==
==References==
{{reflist|2}}
{{reflist|2}}

Revision as of 19:46, 13 December 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]

Overview

On ultrasonography, changes in liver contours and nodularity may be evident. The echo texture may appear coarsened along with an increase in echogenecity from focal fatty changes and irregular appearing areas. It can also be used to screen for hepatocellular carcinoma, portal hypertension and Budd-Chiari syndrome.

Echocardiography

Ultrasound

Ultrasound findings are as follows:

  • Changes in liver contour
  • Nodularity
  • Increase in echogenecity from focal fatty infiltration
  • Vascular changes:
    • Flow across both portal and systemic circulation increases
    • Resistive index increases in end stage liver disease
    • Vessels appear elongated and tortuous, called "corkscrewing" of the vessels
    • Doppler ultrasound may show spontaneous shunts
  • Splenomegaly and collaterals from portal hypertension may be noted.
  • (typically ultrasound) helps:
  • Evaluate the liver parenchyma
  • Detects extrahepatic manifestations of cirrhosis
  • Findings may include:[1][2][3][4][5][6][7][8]
    • A liver that appears shrunken, irregular, and nodular.
  • Evidence of Portal HTN:
    • varices
    • Ascites
    •  Findings on abdominal imaging are viewed in light of other signs of cirrhosis, such as physical examination or laboratory test findings.
    • In addition to evaluating the liver, abdominal imaging may reveal:
      • Hepatocellular carcinoma
      • Extrahepatic findings suggestive of cirrhosis:
        • Ascites
        • Varices
        • Splenomegaly
        • Hepatic or portal vein thrombosis
        • Ultrasonography:  routinely used during the evaluation of cirrhosis
          • First-line investigation of choice.
          • The first radiologic study obtained due to easy availability.
          • Provides information about :
            • appearance of the liver
            • blood flow within the portal circulation
          • less expensive than other imaging modalities
          • No exposure to intravenous contrast or radiation
          • Noninvasive
          • cheap
          • safe
          • well tolerated
          • widely available
          •  Ultrasound, particularly with colour Doppler imaging : [9]
            • measures changes in blood flow in the presence of portal hypertension
            • excludes biliary obstruction in patients who present with jaundice
          • Early signs of cirrhosis in B-ultrasonography include:
            • inhomogeneity of the hepatic tissue
            • Irregularity of the hepatic surface 
            • enlargement of the caudate lobe 
            • Splenomegaly due to portal HTN
          • The diagnostic evaluation of cirrhosis with ultrasonography is based on the direct relation between the extent of fibrosis and the ultrasonographically determined degree of liver stiffness.
          •  ultrasonography can rule cirrhosis in or out in over 90% of cases , its findings are less than 100% specific because of occasional in -correct measurements and false-positive findings
          • Findings:[10][11][12][13][14]
            • Advanced cirrhosis: liver may appear small and nodular
            • Surface nodularity and increased echogenicity with irregular appearing areas are consistent with cirrhosis
            • Usually atrophy of the right lobe and hypertrophy of the caudate or left lobes.
          • Ultrasonography may also be used as a screening test for hepatocellular carcinoma :nodules on ultrasonography warrants further evaluation
          • Findings of portal hypertension:
            •  increased diameter of the portal vein
            •  presence of collateral veins
            •  decreased flow within the portal circulation on Doppler imaging
          • Ultrasonography is also useful for detecting splenomegaly, ascites, and portal vein thrombosis. 

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Transient Elastography

A new type of device, the FibroScan (transient elastography), uses elastic waves to determine liver stiffness which theoretically can be converted into a liver score based on the METAVIR scale. The FibroScan produces an ultrasound image of the liver (from 20-80mm) along with a pressure reading (in kPa). The test is much faster than a biopsy (usually lasts 2.5-5 minutes) and is completely painless. It shows reasonable correlation with the severity of cirrhosis.[15] [16]

Elastography: [17][18][19][20][21][22][23][24][25]

  • Increasing scarring of the liver is associated with increasing "stiffness" of the tissue.
  • Transient elastography and the acoustic radiation force impulse (ARFI) technique are now well-established methods for the staging of fibrosis in various liver diseases [26][27] 

References

  1. ↑ Udell JA, Wang CS, Tinmouth J, FitzGerald JM, Ayas NT, Simel DL, Schulzer M, Mak E, Yoshida EM (2012). "Does this patient with liver disease have cirrhosis?". JAMA. 307 (8): 832–42. doi:10.1001/jama.2012.186. PMID 22357834.
  2. ↑ Becker CD, Scheidegger J, Marincek B (1986). "Hepatic vein occlusion: morphologic features on computed tomography and ultrasonography". Gastrointest Radiol. 11 (4): 305–11. PMID 3533689.
  3. ↑ Di Lelio A, Cestari C, Lomazzi A, Beretta L (1989). "Cirrhosis: diagnosis with sonographic study of the liver surface". Radiology. 172 (2): 389–92. doi:10.1148/radiology.172.2.2526349. PMID 2526349.
  4. ↑ Sanford NL, Walsh P, Matis C, Baddeley H, Powell LW (1985). "Is ultrasonography useful in the assessment of diffuse parenchymal liver disease?". Gastroenterology. 89 (1): 186–91. PMID 3891495.
  5. ↑ Giorgio A, Amoroso P, Lettieri G, Fico P, de Stefano G, Finelli L, Scala V, Tarantino L, Pierri P, Pesce G (1986). "Cirrhosis: value of caudate to right lobe ratio in diagnosis with US". Radiology. 161 (2): 443–5. doi:10.1148/radiology.161.2.3532188. PMID 3532188.
  6. ↑ Simonovský V (1999). "The diagnosis of cirrhosis by high resolution ultrasound of the liver surface". Br J Radiol. 72 (853): 29–34. doi:10.1259/bjr.72.853.10341686. PMID 10341686.
  7. ↑ Trinchet JC, Chaffaut C, Bourcier V, Degos F, Henrion J, Fontaine H, Roulot D, Mallat A, Hillaire S, Cales P, Ollivier I, Vinel JP, Mathurin P, Bronowicki JP, Vilgrain V, N'Kontchou G, Beaugrand M, Chevret S (2011). "Ultrasonographic surveillance of hepatocellular carcinoma in cirrhosis: a randomized trial comparing 3- and 6-month periodicities". Hepatology. 54 (6): 1987–97. doi:10.1002/hep.24545. PMID 22144108.
  8. ↑ "EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma". J. Hepatol. 56 (4): 908–43. 2012. doi:10.1016/j.jhep.2011.12.001. PMID 22424438.
  9. ↑ Zwiebel WJ (1995). "Sonographic diagnosis of hepatic vascular disorders". Semin. Ultrasound CT MR. 16 (1): 34–48. PMID 7718281.
  10. ↑ Di Lelio A, Cestari C, Lomazzi A, Beretta L (1989). "Cirrhosis: diagnosis with sonographic study of the liver surface". Radiology. 172 (2): 389–92. doi:10.1148/radiology.172.2.2526349. PMID 2526349.
  11. ↑ Martínez-Noguera A, Montserrat E, Torrubia S, Villalba J (2002). "Doppler in hepatic cirrhosis and chronic hepatitis". Semin. Ultrasound CT MR. 23 (1): 19–36. PMID 11866220.
  12. ↑ Tchelepi H, Ralls PW, Radin R, Grant E (2002). "Sonography of diffuse liver disease". J Ultrasound Med. 21 (9): 1023–32, quiz 1033–4. PMID 12216750.
  13. ↑ Awaya H, Mitchell DG, Kamishima T, Holland G, Ito K, Matsumoto T (2002). "Cirrhosis: modified caudate-right lobe ratio". Radiology. 224 (3): 769–74. doi:10.1148/radiol.2243011495. PMID 12202712.
  14. ↑ Albrecht T, Blomley MJ, Cosgrove DO, Taylor-Robinson SD, Jayaram V, Eckersley R, Urbank A, Butler-Barnes J, Patel N (1999). "Non-invasive diagnosis of hepatic cirrhosis by transit-time analysis of an ultrasound contrast agent". Lancet. 353 (9164): 1579–83. doi:10.1016/S0140-6736(98)06373-9. PMID 10334257.
  15. ↑ Foucher J, Chanteloup E, Vergniol J; et al. (2006). "Diagnosis of cirrhosis by transient elastography (FibroScan): a prospective study". Gut. 55 (3): 403–8. doi:10.1136/gut.2005.069153. PMID 16020491.
  16. ↑ Xie L, Chen X, Guo Q, Dong Y, Guang Y, Zhang X (2012). "Real-time elastography for diagnosis of liver fibrosis in chronic hepatitis B". Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine. 31 (7): 1053–60. PMID 22733854. Unknown parameter |month= ignored (help)
  17. ↑ Friedrich-Rust M, Ong MF, Martens S, Sarrazin C, Bojunga J, Zeuzem S, Herrmann E (2008). "Performance of transient elastography for the staging of liver fibrosis: a meta-analysis". Gastroenterology. 134 (4): 960–74. doi:10.1053/j.gastro.2008.01.034. PMID 18395077.
  18. ↑ Ziol M, Handra-Luca A, Kettaneh A, Christidis C, Mal F, Kazemi F, de Lédinghen V, Marcellin P, Dhumeaux D, Trinchet JC, Beaugrand M (2005). "Noninvasive assessment of liver fibrosis by measurement of stiffness in patients with chronic hepatitis C". Hepatology. 41 (1): 48–54. doi:10.1002/hep.20506. PMID 15690481.
  19. ↑ Sandrin L, Fourquet B, Hasquenoph JM, Yon S, Fournier C, Mal F, Christidis C, Ziol M, Poulet B, Kazemi F, Beaugrand M, Palau R (2003). "Transient elastography: a new noninvasive method for assessment of hepatic fibrosis". Ultrasound Med Biol. 29 (12): 1705–13. PMID 14698338.
  20. ↑ Bamber J, Cosgrove D, Dietrich CF, Fromageau J, Bojunga J, Calliada F, Cantisani V, Correas JM, D'Onofrio M, Drakonaki EE, Fink M, Friedrich-Rust M, Gilja OH, Havre RF, Jenssen C, Klauser AS, Ohlinger R, Saftoiu A, Schaefer F, Sporea I, Piscaglia F (2013). "EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: Basic principles and technology". Ultraschall Med. 34 (2): 169–84. doi:10.1055/s-0033-1335205. PMID 23558397.
  21. ↑ "EASL-ALEH Clinical Practice Guidelines: Non-invasive tests for evaluation of liver disease severity and prognosis". J. Hepatol. 63 (1): 237–64. 2015. doi:10.1016/j.jhep.2015.04.006. PMID 25911335.
  22. ↑ Castera L, Bedossa P (2011). "How to assess liver fibrosis in chronic hepatitis C: serum markers or transient elastography vs. liver biopsy?". Liver Int. 31 Suppl 1: 13–7. doi:10.1111/j.1478-3231.2010.02380.x. PMID 21205132.
  23. ↑ Chou R, Wasson N (2013). "Blood tests to diagnose fibrosis or cirrhosis in patients with chronic hepatitis C virus infection: a systematic review". Ann. Intern. Med. 158 (11): 807–20. doi:10.7326/0003-4819-158-11-201306040-00005. PMID 23732714.
  24. ↑ Khallafi H, Qureshi K (2015). "Imaging Based Methods of Liver Fibrosis Assessment in Viral Hepatitis: A Practical Approach". Interdiscip Perspect Infect Dis. 2015: 809289. doi:10.1155/2015/809289. PMC 4686715. PMID 26779260.
  25. ↑ Singh S, Fujii LL, Murad MH, Wang Z, Asrani SK, Ehman RL, Kamath PS, Talwalkar JA (2013). "Liver stiffness is associated with risk of decompensation, liver cancer, and death in patients with chronic liver diseases: a systematic review and meta-analysis". Clin. Gastroenterol. Hepatol. 11 (12): 1573–84.e1–2, quiz e88–9. doi:10.1016/j.cgh.2013.07.034. PMC 3900882. PMID 23954643.
  26. ↑ Castera L, Pinzani M (2010). "Biopsy and non-invasive methods for the diagnosis of liver fibrosis: does it take two to tango?". Gut. 59 (7): 861–6. doi:10.1136/gut.2010.214650. PMID 20581229.
  27. ↑ Friedrich-Rust M, Nierhoff J, Lupsor M, Sporea I, Fierbinteanu-Braticevici C, Strobel D, Takahashi H, Yoneda M, Suda T, Zeuzem S, Herrmann E (2012). "Performance of Acoustic Radiation Force Impulse imaging for the staging of liver fibrosis: a pooled meta-analysis". J. Viral Hepat. 19 (2): e212–9. doi:10.1111/j.1365-2893.2011.01537.x. PMID 22239521.

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