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Ferraioli G, Barr RG, Berzigotti A, Sporea I, Wong VWS, Reiberger T, Karlas T, Thiele M, Cardoso AC, Ayonrinde OT, Castera L, Dietrich CF, Iijima H, Lee DH, Kemp W, Oliveira CP, Sarin SK. WFUMB Guideline/Guidance on Liver Multiparametric Ultrasound: Part 1. Update to 2018 Guidelines on Liver Ultrasound Elastography. ULTRASOUND IN MEDICINE & BIOLOGY 2024:S0301-5629(24)00142-X. [PMID: 38762390 DOI: 10.1016/j.ultrasmedbio.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 05/20/2024]
Abstract
The World Federation for Ultrasound in Medicine and Biology (WFUMB) endorsed the development of this document on multiparametric ultrasound. Part 1 is an update to the WFUMB Liver Elastography Guidelines Update released in 2018 and provides new evidence on the role of ultrasound elastography in chronic liver disease. The recommendations in this update were made and graded using the Oxford classification, including level of evidence (LoE), grade of recommendation (GoR) and proportion of agreement (Oxford Centre for Evidence-Based Medicine [OCEBM] 2009). The guidelines are clinically oriented, and the role of shear wave elastography in both fibrosis staging and prognostication in different etiologies of liver disease is discussed, highlighting advantages and limitations. A comprehensive section is devoted to the assessment of portal hypertension, with specific recommendations for the interpretation of liver and spleen stiffness measurements in this setting.
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Affiliation(s)
- Giovanna Ferraioli
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Richard Gary Barr
- Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio, USA; Southwoods Imaging, Youngstown, Ohio, USA
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ioan Sporea
- Division of Gastroenterology and Hepatology, Department of Internal Medicine II, Center for Advanced Research in Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, Timișoara, Romania
| | - Vincent Wai-Sun Wong
- Medical Data Analytics Centre, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China; State Key Laboratory of Digestive Disease, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong, China
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Thomas Karlas
- Division of Gastroenterology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Maja Thiele
- Center for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Department for Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ana Carolina Cardoso
- Hepatology Division, School of Medicine, Federal University of Rio de Janeiro, Clementino, Fraga Filho Hospital, Rua Prof. Rodolpho Paulo Rocco, Cidade Universitária da Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Oyekoya Taiwo Ayonrinde
- Department of Gastroenterology and Hepatology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia; Medical School, University of Western Australia, Crawley, Western Australia, Australia; Curtin Medical School, Curtin University, Kent Street, Bentley, Western Australia, Australia
| | - Laurent Castera
- Université Paris-Cité, Inserm UMR1149, Centre de Recherche sur l'Inflammation, Paris, France; Service d'Hépatologie, Hôpital Beaujon, Assistance-Publique Hôpitaux de Paris, Clichy, France
| | - Christoph Frank Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem and Permancence, Bern, Switzerland
| | - Hiroko Iijima
- Division of Hepatobiliary and Pancreatic Disease, Department of Gastroenterology, Hyogo Medical University, Nishinomiya, Hyogo, Japan; Ultrasound Imaging Center, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - William Kemp
- Department of Gastroenterology, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Claudia P Oliveira
- Gastroenterology Department, Laboratório de Investigação (LIM07), Hospital das Clínicas de São Paulo, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
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Marín-Serrano E, Barbado Cano A, Fernández Martos R, Abadía Barno M, Olveira Martín A, Martín Arranz MD. Protocol for acquisition of images and measurement of transabdominal ultrasound pancreatic two-dimensional shear wave elastography (2D-SWE). GASTROENTEROLOGIA Y HEPATOLOGIA 2024:S0210-5705(24)00156-0. [PMID: 38723774 DOI: 10.1016/j.gastrohep.2024.502198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/24/2024] [Accepted: 02/27/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Transabdominal ultrasound (TU) pancreatic 2D-SWE elastography is a developing technique that needs to be protocolized. OBJECTIVES Establish a protocol for image acquisition and measurement of TU pancreatic - 2D-SWE elastography and estimate the minimum number of measurements to be performed. MATERIALS AND METHODS Ten measurements of pancreatic elasticity were taken in healthy volunteers using TU-2D-SWE, following a strict protocol for image acquisition and measurement. RESULTS The 70% of the participants were women, with an average age, weight, and BMI of 49.5±15.7 years, 65.9±11.9kg, and 24.5±4.2kg/m2, respectively. Measurements were taken from the body (70%), tail (16.7%), and pancreatic head (13.3%). The median mean velocity and elasticity were 1.46±0.25cm/sec and 6.46±2.87KPa, respectively. The ROI depth was 4.12±1cm and the SP-ROI distance was 5.2mm on average. There were no statistically significant differences between the 10 measurements. The reliability analysis of the measurements showed high internal consistency and repeatability. Taking 5-6 measurements ensured high concordance with the ten reference measurements. The measurements were significantly lower when the SP-ROI values were intermediate (0.3-0.6cm). The measurement accuracy was higher when performed at a depth less than 4.8cm. CONCLUSION To measure pancreatic elasticity using TU-2D-SWE, we propose a strict protocol for image acquisition and measurement, taking a minimum of 5 measurements in the best visualized and accessible pancreatic portion, and preferably at a depth of less than 4.8cm.
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Anton-Păduraru DT, Azoicăi AN, Trofin F, Murgu AM, Mîndru DE, Bocec AS, Halițchi COI, Zota GR, Păduraru D, Nastase EV. Diagnosis, Management, and Prognosis of Cystic Fibrosis-Related Liver Disease in Children. Diagnostics (Basel) 2024; 14:538. [PMID: 38473009 DOI: 10.3390/diagnostics14050538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/28/2024] [Accepted: 03/01/2024] [Indexed: 03/14/2024] Open
Abstract
Cystic fibrosis (CF) is a multifaceted disorder predominantly investigated for its pulmonary manifestations, yet patients with CF also exhibit a spectrum of extrapulmonary manifestations, notably those involving the hepatobiliary system. The latter constitutes the third leading cause of morbidity and mortality in individuals with CF. Cystic fibrosis-related liver disease (CFLD), with an escalating prevalence, manifests diverse clinical presentations ranging from hepatomegaly to cirrhosis and hepatopulmonary syndrome. Consequently, early detection and appropriate management are imperative for sustaining the health and influencing the quality of life of CF patients afflicted with CFLD. This review aims to consolidate existing knowledge by providing a comprehensive overview of hepatobiliary manifestations associated with CF. It delineates the clinical hepatobiliary manifestations, diagnostic methodologies, incorporating minimally invasive markers, and therapeutic approaches, encompassing the impact of novel CFTR modulators on CFLD. Given the exigency of early diagnosis and the intricate management of CFLD, a multidisciplinary team approach is essential to optimize care and enhance the quality of life for this subset of patients. In conclusion, recognizing CF as more than solely a pulmonary ailment, the authors underscore the imperative for further clinical investigations to establish a more robust evidence base for CFLD management within the continuum of this chronic disease.
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Affiliation(s)
- Dana-Teodora Anton-Păduraru
- Department of Mother and Child Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
- "Sf. Maria" Children Emergency Hospital, 700309 Iasi, Romania
| | - Alice Nicoleta Azoicăi
- Department of Mother and Child Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
- "Sf. Maria" Children Emergency Hospital, 700309 Iasi, Romania
| | - Felicia Trofin
- Department of Preventive Medicine and Interdisciplinarity-Microbiology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
| | - Alina Mariela Murgu
- Department of Mother and Child Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
- "Sf. Maria" Children Emergency Hospital, 700309 Iasi, Romania
| | - Dana Elena Mîndru
- Department of Mother and Child Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
- "Sf. Maria" Children Emergency Hospital, 700309 Iasi, Romania
| | - Ana Simona Bocec
- Department of Mother and Child Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
| | | | - Gabriela Rusu Zota
- Department of Pharmacology, Clinical Pharmacology and Algesiology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Diana Păduraru
- "Dr. C. I. Parhon" Clinical Hospital, 700503 Iaṣi, Romania
| | - Eduard Vasile Nastase
- Department of Internal Medicine II-Infectious Diseases, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Clinical Hospital of Infectious Diseases "Sf. Parascheva", 700116 Iasi, Romania
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Bodewes FAJA, Freeman AJ, Weymann A, Debray D, Scheers I, Verkade HJ, Narkewicz MR. Towards a Standardized Classification of the Hepatobiliary Manifestations in Cystic Fibrosis (CFHBI): A Joint ESPGHAN/NASPGHAN Position Paper. J Pediatr Gastroenterol Nutr 2024; 78:153-165. [PMID: 38291686 DOI: 10.1097/mpg.0000000000003944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/08/2023] [Indexed: 02/01/2024]
Abstract
The broad spectrum of hepatobiliary involvement in cystic fibrosis (CF) has been commonly referred to as cystic fibrosis liver disease (CFLD). However, differences in the definitions of CFLD have led to variations in reported prevalence, incidence rates, and standardized recommendations for diagnosis and therapies. Harmonizing the description of the spectrum of hepatobiliary involvement in all people with CF (pwCF) is deemed essential for providing a reliable account of the natural history, which in turn supports the development of meaningful clinical outcomes in patient care and research. Recognizing this necessity, The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) commissioned and tasked a committee to develop and propose a systematic classification of the CF hepatobiliary manifestations to increase uniformity, accuracy, and comparability for clinical, registry, and research purposes. This report describes the committee's combined expert position statement on hepatobiliary involvement in CF, which has been endorsed by NASPGHAN and ESPGHAN. We recommend using CFHBI (Cystic Fibrosis Hepato-Biliary Involvement) as the updated term to describe and classify all hepatobiliary manifestations in all pwCF. CFHBI encompasses the current extensive spectrum of phenotypical, clinical, or diagnostic expressions of liver involvement observed in pwCF. We present a schematic categorization of CFHBI, which may also be used to track and classify the changes and development of CFHBI in pwCF over time. The proposed classification for CFHBI is based on expert consensus and has not been validated for clinical practice and research purposes. Achieving validation should be an important aim for future research.
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Affiliation(s)
- Frank A J A Bodewes
- Division of Pediatric Gastroenterology/Hepatology, Beatrix Children's Hospital/University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Alvin Jay Freeman
- Division of Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Alexander Weymann
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH
| | - Dominique Debray
- Pediatric Hepatology Unit, Assistance Publique-Hôpitaux de Paris (APHP)-Hôpital Necker-Enfants maladies, Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Paris, France
| | - Isabelle Scheers
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Henkjan J Verkade
- Division of Pediatric Gastroenterology/Hepatology, Beatrix Children's Hospital/University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Michael R Narkewicz
- Digestive Health Institute, Children's Hospital Colorado and Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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Towbin AJ, Ye W, Huang S, Karmazyn BW, Molleston JP, Masand P, Leung DH, Chang S, Narkewicz MR, Alazraki AL, Freeman AJ, Otto RK, Green N, Kamel IR, Karnsakul WW, Magee JC, Tkach J, Palermo JJ. Prospective study of quantitative liver MRI in cystic fibrosis: feasibility and comparison to PUSH cohort ultrasound. Pediatr Radiol 2023; 53:2210-2220. [PMID: 37500799 DOI: 10.1007/s00247-023-05706-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 06/08/2023] [Accepted: 06/17/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Pediatric radiologists can identify a liver ultrasound (US) pattern predictive of progression to advanced liver disease. However, reliably discriminating these US patterns remains difficult. Quantitative magnetic resonance imaging (MRI) may provide an objective measure of liver disease in cystic fibrosis (CF). OBJECTIVE The purpose of this study was to determine if quantitative MRI, including MR elastography, is feasible in children with CF and to determine how quantitative MRI-derived metrics compared to a research US. MATERIALS AND METHODS A prospective, multi-institutional trial was performed evaluating CF participants who underwent a standardized MRI. At central review, liver stiffness, fat fraction, liver volume, and spleen volume were obtained. Participants whose MRI was performed within 1 year of US were classified by US pattern as normal, homogeneous hyperechoic, heterogeneous, or nodular. Each MRI measure was compared among US grade groups using the Kruskal-Wallis test. RESULTS Ninety-three participants (51 females [54.8%]; mean 15.6 years [range 8.1-21.7 years]) underwent MRI. MR elastography was feasible in 87 participants (93.5%). Fifty-eight participants had an US within 1 year of MRI. In these participants, a nodular liver had significantly higher stiffness (P<0.01) than normal or homogeneous hyperechoic livers. Participants with a homogeneous hyperechoic liver had a higher fat fraction (P<0.005) than others. CONCLUSION MR elastography is feasible in children with CF. Participants with a nodular pattern had higher liver stiffness supporting the US determination of advanced liver disease. Participants with a homogeneous hyperechoic pattern had higher fat fractions supporting the diagnosis of steatosis.
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Affiliation(s)
- Alexander J Towbin
- Department of Radiology, Cincinnati Children's Hospital, 3333 Burnet Avenue, MLC 5031, Cincinnati, OH, 45229, USA.
- Department of Radiology, University of Cincinnati School of Medicine, Cincinnati, OH, USA.
| | - Wen Ye
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Suiyuan Huang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Boaz W Karmazyn
- Pediatric Radiology, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jean P Molleston
- Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Prakash Masand
- Division of Radiology, Texas Children's Hospital, Houston, TX, USA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's, Baylor College of Medicine, Houston, TX, USA
| | - Samuel Chang
- Department of Radiology, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - Michael R Narkewicz
- Digestive Health Institute, Children's Hospital Colorado and Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adina L Alazraki
- Department of Radiology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Randolph K Otto
- Department of Radiology, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Nicole Green
- Division of Gastroenterology and Hepatology, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Ihab R Kamel
- Department of Radiology, John Hopkins School of Medicine, Baltimore, MD, USA
| | - Wikrom W Karnsakul
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, John Hopkins School of Medicine, Baltimore, MD, USA
| | - John C Magee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jean Tkach
- Department of Radiology, Cincinnati Children's Hospital, 3333 Burnet Avenue, MLC 5031, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Joseph J Palermo
- Division of Pediatric, Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Sakhuja S, Staples HM, Minard CG, Ramm LE, Lewindon PJ, Ramm GA, Leung DH. Risk factors for more rapid progression of severe liver fibrosis in children with cystic fibrosis-related liver disease: A multi-center study validated by liver biopsy. Liver Int 2023; 43:1277-1286. [PMID: 37035868 DOI: 10.1111/liv.15572] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/15/2023] [Accepted: 03/18/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND AND AIMS Early identification of risk factors for the development of severe fibrosis in children with cystic fibrosis-related liver disease (CFLD) is crucial as promising therapies emerge. METHODS This multi-center cohort study of children with a priori defined CFLD from 1999 to 2016, was designed to evaluate the clinical utility of CF-specific characteristics and liver biomarkers assessed years prior to liver biopsy-proven CFLD to predict risk of developing severe fibrosis (F3-4) over time. Fibrosis was staged by Metavir classification. RESULTS The overall study cohort of 42 patients (F0-2 (n = 22) and F3-4 (n = 20)) was 57% male (n = 24) with median age of 7.6 years at baseline visit versus 10.3 years at biopsy. Median FEV1 % predicted was lower in F3-4 participants at baseline versus F0-2 (59% vs. 85%; p = .002), while baseline FIB-4, APRI and GGT were higher in F3-4. Median splits for FIB-4 (≥.13), APRI (≥.36), GPR (≥.09), GGT (≥25.5), and FEV1 % (<64%) were associated with more rapid progression to F3-4 (p < .01 for all). Using a combination of change/year in FIB-4, APRI, and GPR to predict F3-4, the AUROC was .81 (95% CI, .66, .96; p < .0001). For up to 5.8 years prior, thresholds for GPR were met 6.5-fold more rapidly, and those for APRI and FIB-4 were met 2.5-fold more rapidly, in those who progressed to F3-4 than those that did not. CONCLUSIONS This study suggests mild-moderate pulmonary dysfunction and higher liver biomarker indices at baseline may be associated with faster progression of CFLD.
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Affiliation(s)
- Shruti Sakhuja
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Gastroenterology, Hepatology, Nutrition, Texas Children's Hospital, Houston, Texas, USA
| | - Heather M Staples
- Department of Pediatrics, University of South Carolina School of Medicine, Columbia, South Carolina, USA
- Division of Pediatric Pulmonology, Prisma Health Children's Hospital-Midlands, Columbia, South Carolina, USA
| | - Charles G Minard
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas, USA
| | - Louise E Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Peter J Lewindon
- Department of Gastroenterology, Queensland Children's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Grant A Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Daniel H Leung
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Gastroenterology, Hepatology, Nutrition, Texas Children's Hospital, Houston, Texas, USA
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Schnell A, Jüngert J, Klett D, Hober H, Kaiser N, Ruppel R, Geppert A, Tremel C, Sobel J, Plattner E, Schmitt-Grohé S, Zirlik S, Strobel D, Neurath MF, Knieling F, Rauh M, Woelfle J, Hoerning A, Regensburger AP. Increase of liver stiffness and altered bile acid metabolism after triple CFTR modulator initiation in children and young adults with cystic fibrosis. Liver Int 2023; 43:878-887. [PMID: 36797990 DOI: 10.1111/liv.15544] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/30/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Novel cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies (elexacaftor/tezacaftor/ivacaftor-ETI) promise clinically significant and sustained improvements for patients with cystic fibrosis (CF). In this study, we investigated the impact of ETI therapy on liver stiffness and bile acid metabolism in a cohort of children and young adults with CF. METHODS A prospective observational study (NCT05576324) was conducted from September 2020 to November 2021 enrolling CF patients naive to ETI. Standard laboratory chemistry, sweat test, lung function, share wave velocity (SWV) derived by acoustic radiation force impulse imaging (ARFI) and serum bile acid profiles were assessed before and 6 months after induction of ETI therapy. RESULTS A total of 20 patients (10 aged <20 years) completed the study. While lung function and BMI improved after ETI therapy, ARFI SWV increased in CF patients <20 years of age (from 1.27 to 1.43 m/s, p = 0.023). Bile acid (BA) profiles revealed a decrease in unconjugated (5.75 vs 1.46, p = 0.007) and increase in glycine-conjugated derivatives (GCDCA) (4.79 vs 6.64 p = 0.016). There was a positive correlation between ARFI SWV values and GCDCA (r = 0.80, p < 0.0001). Glycine-conjugated BA provided high diagnostic accuracy to predict increased ARFI measurements (AUC 0.90) and clinical (Colombo) CFLD grading (AUC 0.97). CONCLUSIONS ARFI SWV and bile acid profiles provide evidence for early increase in liver stiffness and altered bile acid metabolism in young CF patients after initiation of ETI and may serve as synergistic measures for detection of hepatic complications during ETI therapy.
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Affiliation(s)
- Alexander Schnell
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Jörg Jüngert
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Daniel Klett
- Department of Medicine 1 and German Center Immunotherapy (DZI), University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Hannah Hober
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Natalie Kaiser
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Renate Ruppel
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Annika Geppert
- Department of Medicine 1 and German Center Immunotherapy (DZI), University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Christina Tremel
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Julia Sobel
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Erika Plattner
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Sabina Schmitt-Grohé
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Sabine Zirlik
- Department of Medicine 1 and German Center Immunotherapy (DZI), University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Deike Strobel
- Department of Medicine 1 and German Center Immunotherapy (DZI), University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Markus F Neurath
- Department of Medicine 1 and German Center Immunotherapy (DZI), University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Ferdinand Knieling
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
- Translational Experimental and Molecular Imaging Laboratory (PETI_Lab), Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Manfred Rauh
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Joachim Woelfle
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - André Hoerning
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Adrian P Regensburger
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
- Translational Experimental and Molecular Imaging Laboratory (PETI_Lab), Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
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H E, CR H, S D, EA E. 2D Shear Wave Elastography, a promising screening tool for Cystic Fibrosis liver disease, shows a correlation between vitamin D and liver stiffness. J Cyst Fibros 2022; 21:873-877. [DOI: 10.1016/j.jcf.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 05/24/2022] [Accepted: 06/17/2022] [Indexed: 11/25/2022]
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9
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Assessment of Liver Fibrosis with the Use of Elastography in Paediatric Patients with Diagnosed Cystic Fibrosis. DISEASE MARKERS 2022; 2022:4798136. [PMID: 35345868 PMCID: PMC8957431 DOI: 10.1155/2022/4798136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 03/02/2022] [Indexed: 11/18/2022]
Abstract
Background Complications of cystic fibrosis-associated liver disease (CFLD) are a leading nonpulmonary cause of death. Noninvasive tests enabling early detection of liver changes, especially in children are sought. The aim of the study was to assess the scale of liver fibrosis with the use of elastography in paediatric patients with diagnosed cystic fibrosis (CF) and its comparison with other tests (APRI and Fibrotest). Methods We examined 41 children, in the age range 2-21 years, with diagnosed CF. The analysis a included clinical picture, laboratory parameters of liver damage, and cholestasis. Aspartate aminotransferase-to-platelet ratio index (APRI) and Fibrotest were done in all patients. Liver stiffness measurements were acquired using shear-wave elastography (SWE). Results CFLD was diagnosed in 16/41 patients (39%). Abnormal elastography was observed in 19/41 patients (46.3%), and in 5/41 (12.2%), the changes were advanced (F4). Abnormal elastography was observed in 12/16 (75%) of the patients with CFLD, and in 7/25 (28%), there were no lesions observed in the liver in the course of cystic fibrosis. In all patients with F4, we observed abnormal results of the APRI and Fibrotest. In most patients with small changes in elastography, we found normal results of the APRI and Fibrotest. Conclusion Elastography seems to be a noninvasive examination useful in everyday clinical work in detecting early liver changes and monitoring of progression in paediatric patients with diagnosed cystic fibrosis, ahead of changes in laboratory tests. The cost-effectiveness of this test, the possibility of its repetition, and its availability are additional benefits.
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10
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Yavuz S, Pişkin FC, Oktay C, Tümgör G. Assessment of hepatic involvement by two-dimensional shear wave elastography in paediatric patients with cystic fibrosis. J Paediatr Child Health 2022; 58:459-462. [PMID: 34519139 DOI: 10.1111/jpc.15741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/16/2021] [Accepted: 08/28/2021] [Indexed: 11/28/2022]
Abstract
AIM This study aimed to investigate parenchymal changes in the liver in paediatric patients with cystic fibrosis (CF) and to analyse diagnostic performance of two-dimensional shear wave elastography (2D-SWE) for the detection of hepatic involvement. METHODS Patients with CF treated and followed at our centre were evaluated prospectively. All patients underwent liver tissue stiffness (TS) measurements by 2D-SWE, in addition to routine clinical assessments, laboratory work-up and abdominal ultrasound imaging. Data from patients with CF were compared with healthy control subjects. RESULTS This study included 39 patients with CF and 37 healthy controls. Patients had a mean body weight of 29.9 (16.6-55) kg, mean age of 9 (5-17) years, mean height of 130 (107-172) cm and a mean body mass index of 16.1 (12.8-21.4) kg/m2 . Average SWE values of the liver were 1.02 (0.70-1.60) m/s in patients with CF (n = 39) and 0.89 (0.60-1.35) m/s in healthy controls (n = 37). Cystic fibrosis patients had significantly increased tissue stifness by liver elastography compared to controls (P = 0.005). CONCLUSION Parenchymal liver changes may occur early in cystic fibrosis, which cannot be detected by conventional ultrasonography but may be demonstrated by 2D-SWE. Based on this cross-sectional study, 2D-SWE may be a promising, simple and non-invasive modality for objective monitoring of patients with cystic fibrosis who require lifelong follow-up, by providing numerical data for tissue stiffness early in the disease.
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Affiliation(s)
- Sibel Yavuz
- Department of Pediatric Gastroenterology, Cukurova University Medical Faculty, Adana, Turkey
| | - Ferhat C Pişkin
- Department of Radiology, Cukurova University Medical Faculty, Adana, Turkey
| | - Cemil Oktay
- Department of Radiology, Adıyaman University Education and Research Hospital, Adıyaman, Turkey
| | - Gökhan Tümgör
- Department of Pediatric Gastroenterology, Cukurova University Medical Faculty, Adana, Turkey
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11
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Cystic fibrosis-related liver disease: Clinical presentations, diagnostic and monitoring approaches in the era of CFTR modulator therapies. J Hepatol 2022; 76:420-434. [PMID: 34678405 DOI: 10.1016/j.jhep.2021.09.042] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/09/2021] [Accepted: 09/30/2021] [Indexed: 12/11/2022]
Abstract
Cystic fibrosis (CF) is the most common autosomal recessive disease in the Caucasian population. Cystic fibrosis-related liver disease (CFLD) is defined as the pathogenesis related to the underlying CFTR defect in biliary epithelial cells. CFLD needs to be distinguished from other liver manifestations that may not have any pathological significance. The clinical/histological presentation and severity of CFLD vary. The main histological presentation of CFLD is focal biliary fibrosis, which is usually asymptomatic. Portal hypertension develops in a minority of cases (about 10%) and may require specific management including liver transplantation for end-stage liver disease. Portal hypertension is usually the result of the progression of focal biliary fibrosis to multilobular cirrhosis during childhood. Nevertheless, non-cirrhotic portal hypertension as a result of porto-sinusoidal vascular disease is now identified increasingly more frequently, mainly in young adults. To evaluate the effect of new CFTR modulator therapies on the liver, the spectrum of hepatobiliary involvement must first be precisely classified. This paper discusses the phenotypic features of CFLD, its underlying physiopathology and relevant diagnostic and follow-up approaches, with a special focus on imaging.
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12
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Pancreatic Steatosis Is Associated with Both Metabolic Syndrome and Pancreatic Stiffness Detected by Ultrasound Elastography. Dig Dis Sci 2022; 67:293-304. [PMID: 33651254 DOI: 10.1007/s10620-021-06844-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 01/10/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION There is increasing evidence that pancreatic steatosis (PS) is associated with metabolic syndrome (MS). However, it is not known whether it is associated with PS grade and pancreatic stiffness, or not. We aimed to evaluate the relationship between PS and its grade detected by transabdominal ultrasound, and pancreatic stiffness determined by two-dimensional shearwave elastography (2D-SWE), whether it has clinical significance and its relationship with MS. METHODS Patients with and without PS were evaluated prospectively. RESULTS Patients with PS had higher odds ratio for MS (OR 5.49). Also, ultrasonographic grade of PS was associated with MS parameters and hepatosteatosis. Pancreatic SWE value was significantly higher in PS group and positively correlated with PS grade, liver fat, MS, number of MS criteria. DISCUSSION/CONCLUSION PS and its grade were associated with MS. In this first comprehensive PS-SWE study, we found that pancreas stiffness increased in the presence of PS, in correlation with PS grade and MS.
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13
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Yılmaz K, Hattapoğlu S, Şen V, Karabel M, Kan A, Yılmaz ED, Selimoglu Sen H, Yılmaz S. Evaluation of children and adolescent with cystic fibrosis by pancreatic elastography. Pediatr Int 2022; 64:e14951. [PMID: 34390069 DOI: 10.1111/ped.14951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 07/28/2021] [Accepted: 08/11/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) is an autosomal recessively inherited disease. Clinical findings vary by age of the patient, the organ systems involved, and the severity of the CFTR gene mutation. Pancreatic and liver involvement is prominent and exocrine pancreatic insufficiency is observed in the majority of patients. Point shear wave elastography (pSWE) is a non-invasive method that can quantitatively determine tissue elasticity and stiffness. In this study, the morphological evaluation of the pancreas was performed using the pSWE technique in pediatric patients diagnosed with CF. The effectiveness of this method for the early detection of pancreatic insufficiency was investigated. METHODS Fifty-five patients with CF (24 girls, 31 boys) and 60 healthy children (29 girls, 31 boys) without any chronic diseases and who were suitable for the pSWE examination were included in the study. RESULTS The mean value of pSWE was 1.12 ± 0.16 in the healthy group and 0.97 ± 0.16 in the patients with cystic fibrosis. There was a statistically significant difference between the two groups (P < 0.001). Significant negative correlations were found between pSWE and age (r = -0.319; P = 0.018), height (r = -0.293; P = 0.03), serum glucose (r = -0.346; P = 0.01), HbA1C (r = -0.592; P = 0.02), and duration of the disease (r = -0.806; P < 0.001). CONCLUSIONS Investigating pancreatic elasticity and detecting pancreatic insufficiency using pSWE (a simple, inexpensive, and non-invasive method) in the early period before overt laboratory and clinical symptoms of EPI appear can contribute positively to long-term results in young patients with CF.
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Affiliation(s)
- Kamil Yılmaz
- Department of Pediatric Infectious Diseases, Diyarbakir, Turkey
| | | | - Velat Şen
- Department of Pediatric Pulmonology, Diyarbakir, Turkey
| | | | - Ahmet Kan
- Department of Pediatric Allergy, Diyarbakir, Turkey
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14
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Enaud R, Frison E, Missonnier S, Fischer A, de Ledinghen V, Perez P, Bui S, Fayon M, Chateil JF, Lamireau T. Cystic fibrosis and noninvasive liver fibrosis assessment methods in children. Pediatr Res 2022; 91:223-229. [PMID: 33731812 DOI: 10.1038/s41390-021-01427-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 01/27/2021] [Accepted: 02/08/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Noninvasive assessments of liver fibrosis are currently used to evaluate cystic fibrosis (CF)-related liver disease. However, there is scarce data regarding their repeatability and reproducibility, especially in children with CF. The present study aimed to evaluate the repeatability and reproducibility of transient elastography (TE) (FibroScan®) and point shear-wave elastography using virtual touch quantification (pSWE VTQ) in children with CF. METHODS TE and pSWE VTQ were performed in 56 children with CF by two different operators. Analysis of repeatability and reproducibility was available in 33 patients for TE and 46 patients for pSWE VTQ. Intra- and interobserver agreement were assessed using the intraclass correlation coefficient (ICC) and their 95% confidence interval (CI), and Bland and Altman graphs. RESULTS For TE, ICC was 0.91 (0.83-0.95) for intraobserver agreement and 0.92 (95% CI: 0.86-0.96) for interobserver agreement. For pSWE VTQ, ICC was 0.83 (0.72-0.90) for intraobserver agreement and 0.67 (0.48-0.80) for interobserver agreement. CONCLUSIONS Both technics can be proposed in the follow-up of patients, according to their availability in CF centers. IMPACT This study shows that TE and pSWE VTQ are reliable methods to evaluate liver fibrosis in children with CF. This study shows for the first time that TE and pSWE VTQ are both repeatable and reproducible in children with CF. These data indicate that both TE and pSWE VTQ can be proposed for the follow-up of patients with CF, according to their availability in each CF center.
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Affiliation(s)
- Raphael Enaud
- Pediatric Hepatology and Gastroenterology Unit, Bordeaux University Hospital, Pellegrin-Enfants Hospital, Bordeaux, France.,Bordeaux University Hospital, Pellegrin-Enfants Hospital, Pediatric Cystic Fibrosis-Center (CRCM), Bordeaux, France.,INSERM, Centre de Recherche Cardio-thoracique de Bordeaux (U1045), University of Bordeaux, Bordeaux, France
| | - Eric Frison
- Unité de soutien méthodologique à la recherche clinique et épidémiologique, Service d'information médicale, Pôle Santé Publique, Bordeaux University Hospital, Bordeaux, France.,Clinical Investigation Centre (CIC 1401), Bordeaux University Hospital, Bordeaux, France
| | - Sophie Missonnier
- Pediatric Imaging Unit, Bordeaux University Hospital, Pellegrin-Enfants Hospital, Bordeaux, France
| | - Aude Fischer
- Pediatric Hepatology and Gastroenterology Unit, Bordeaux University Hospital, Pellegrin-Enfants Hospital, Bordeaux, France
| | - Victor de Ledinghen
- Hepatology Unit, Bordeaux University Hospital, Haut-Lévêque Hospital, Pessac, France
| | - Paul Perez
- Unité de soutien méthodologique à la recherche clinique et épidémiologique, Service d'information médicale, Pôle Santé Publique, Bordeaux University Hospital, Bordeaux, France.,Clinical Investigation Centre (CIC 1401), Bordeaux University Hospital, Bordeaux, France
| | - Stéphanie Bui
- Bordeaux University Hospital, Pellegrin-Enfants Hospital, Pediatric Cystic Fibrosis-Center (CRCM), Bordeaux, France
| | - Michael Fayon
- Bordeaux University Hospital, Pellegrin-Enfants Hospital, Pediatric Cystic Fibrosis-Center (CRCM), Bordeaux, France.,INSERM, Centre de Recherche Cardio-thoracique de Bordeaux (U1045), University of Bordeaux, Bordeaux, France.,Clinical Investigation Centre (CIC 1401), Bordeaux University Hospital, Bordeaux, France
| | - Jean-François Chateil
- Pediatric Imaging Unit, Bordeaux University Hospital, Pellegrin-Enfants Hospital, Bordeaux, France.,CRMSB (UMR 5536), University of Bordeaux/CNRS, Bordeaux, France
| | - Thierry Lamireau
- Pediatric Hepatology and Gastroenterology Unit, Bordeaux University Hospital, Pellegrin-Enfants Hospital, Bordeaux, France. .,Clinical Investigation Centre (CIC 1401), Bordeaux University Hospital, Bordeaux, France.
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15
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Abstract
PURPOSE OF REVIEW Liver disease (CFLD) as a complication of cystic fibrosis is recognized as a more severe disease phenotype in both children and adults. We review recent advances in understanding the disease mechanism and consider the implications of new strategies for the diagnosis and management of cystic fibrosis in those with evidence of clinically significant liver disease. RECENT FINDINGS Evidence suggests that the prevalence of CFLD has not declined with the introduction of newborn screening. Furthermore, children with CFLD, who have been diagnosed with cystic fibrosis following newborn screening continue to have a much higher mortality rate compared with those with no liver disease. There is further data suggesting noncirrhotic obliterative portal venopathy as the predominant pathological mechanism in the majority of children and young adults receiving a liver transplantation. Little progress has been made in developing an accurate noninvasive test for early diagnosis or monitoring disease progression in CFLD. The benefit of new modulator therapies is not well understood in those with established CFLD, whereas the risk of hepatotoxicity as a complication of treatment must be carefully monitored. SUMMARY Better understanding of the pathophysiology of CFLD would allow a standardized approach to diagnosis, with the potential to improve outcomes for those with CFLD.
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16
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Martonosi ÁR, Soós A, Rumbus Z, Hegyi P, Izsák V, Pázmány P, Imrei M, Váncsa S, Szakács Z, Párniczky A. Non-invasive Diagnostic Tests in Cystic Fibrosis-Related Liver Disease: A Diagnostic Test Accuracy Network Meta-Analysis. Front Med (Lausanne) 2021; 8:598382. [PMID: 34386504 PMCID: PMC8353091 DOI: 10.3389/fmed.2021.598382] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 06/25/2021] [Indexed: 11/28/2022] Open
Abstract
Background and Aims: Cystic fibrosis-related liver disease (CFLD) is one of the leading causes of morbidity and mortality in cystic fibrosis (CF). Several non-invasive diagnostic methods have been proposed as screening tools for CFLD. Our aim was to rank all available non-invasive modalities for diagnostic performance. Methods: A systematic search was performed in five medical databases to find studies which reported on any single or composite non-invasive diagnostic test (as an index test) compared to the Debray, the EuroCare or the Colombo criteria (as a reference standard). Ranking was carried out with a Bayesian diagnostic test accuracy network meta-analysis based on superiority indices, calculated for pooled sensitivity (Se) and specificity (Sp) with a 95% confidence interval (CI). The study was registered under CRD42020155846 in PROSPERO. Results: Fifteen studies with 15 index tests and a combination of them were included. The New criteria proposed by Koh et al. – which represent a composite diagnostic definition for CFLD including liver biochemistry, ultrasonography, transient elastography and fibrosis markers—had the best performance for detecting CFLD (Se:94%[CI:58–100], Sp:72%[CI:52–84]); while transient elastography (Se:65%[CI:56–74], Sp:88%[CI:84–91]) and a combination of it with a tissue inhibitor of metalloproteinase-4 measurement (Se:78%[CI:30–100], Sp:64%[CI:18–95%]) proved to be the second and third best options, respectively. In the imaging techniques subgroup, transient elastography (Se:66%[CI:57–72], Sp:88%[CI:85–91%]), acoustic radiation force impulse in the right lobe (Se:54%[CI:33–74], Sp:88%[CI:66–96]) and that in the left lobe (Se:55%[CI:23–81], Sp:82%[CI:50–95]) were ranked the highest. Comparing biochemical markers/fibrosis indices, the measurement of the Forns index (Se:72%[CI:25–99], Sp:63%[CI:16–94]), the aspartate aminotransferase-to-platelet ratio (Se:55%[CI:41–68], Sp:83%[CI:66–89]) and alkaline phosphatase (Se:63%[CI:18–93], Sp:64%[CI:19–95]) were ranked the highest. Conclusion: The New criteria show the best diagnostic performance. In clinical practice, transient elastography seems to be a simple, cheap and non-invasive tool, outperforming imaging, biochemical and fibrosis tests for detecting CFLD. Further studies are needed to validate our findings.
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Affiliation(s)
- Ágnes Rita Martonosi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Alexandra Soós
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zoltán Rumbus
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Vera Izsák
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Piroska Pázmány
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Marcell Imrei
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Szilárd Váncsa
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Andrea Párniczky
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
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17
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Repeatability of transient elastography in children. Pediatr Res 2020; 88:587-592. [PMID: 32357363 DOI: 10.1038/s41390-020-0916-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Poorly performing diagnostic tests can impact patient safety. Clinical investigations must have good precision and diagnostic accuracy before widespread use in clinical practice. Transient elastography (TE) measures liver stiffness, a surrogate marker of liver fibrosis in adults and children. Studies to evaluate its repeatability and reproducibility (precision) in children are limited. Our aim was to determine (i) the normal range of TE measurements and (ii) the repeatability and reproducibility of TE in healthy children. METHODS TE was performed in 257 healthy children, of whom 235 (91%, mean age 11.7 years, standard deviation (SD) 2.51, 107 were males (45.5%)) had two valid TE measurements performed, at least 24 h apart, by two operators under similar circumstances. High-quality TE images were obtained for each examination. RESULTS The normal range of TE was 2.88-6.52 kPa. The mean difference between paired measurements was 0.044 (SD 0.4). The 95% limits of agreement ranged from -0.8 to +0.76 kPa for repeat measurements. There was a difference of >1 kPa between measurements in 61/235 (25.9%) children. The lack of precision was similar across all age groups. CONCLUSIONS This study demonstrates that TE does not have acceptable precision in healthy children, because random measurement variation results in the lack of agreement between paired measurements. IMPACT The precision and diagnostic accuracy of a new technology must be determined before it is deployed in children in order to ensure that appropriate clinical decisions are made, and healthcare resources are not wasted. TE is widely used to diagnose liver disease in children without adequate evaluation of the precision (repeatability) of TE either in healthy children or children with liver disease. This study demonstrates that TE does not have adequate precision in children. This study was performed in accordance with methods previously published for children. Refinements to the test protocol, such as duration of fasting or probe size, will have to be evaluated for their impact on precision and accuracy before the test is deployed in research studies or clinical practice.
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18
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Abstract
CLINICAL ISSUE Abdominal complications are often the first indications for cystic fibrosis (CF), a multiorgan disease. A broad range of abdominal manifestations are associated with the disease, including gastrointestinal abnormalities (such as meconium ileus in newborns and distal intestinal obstruction syndrome in older children) and hepatobiliary alterations (e.g., cholelithiasis, microgallbladder, hepatosteatosis, biliary cirrhosis). A characteristic finding is pancreatic involvement, which leads to exocrine and over the course of time to endocrine insufficiency. STANDARD RADIOLOGICAL METHODS Ultrasonography is the preferred and often sole modality for a precise diagnosis of abdominal CF manifestations. However, all imaging modalities can be used, depending on the pathology: X‑ray, fluoroscopic examinations, computed tomography, magnetic resonance imaging (also with application of magnetic resonance cholangiopancreatography). METHODICAL INNOVATIONS/PERFORMANCE Scoring systems are useful for standardized diagnostics. Sonographic findings, described using a scoring system, correlate with clinical symptoms, such as pancreatic lipomatosis with abdominal pain (p = 0.018), flatulence (p = 0.006), and gastroesophageal reflux (p = 0.006). EVALUATION/PRACTICAL RECOMMENDATIONS A standardized approach with structured reporting is important due to the numerous abdominal CF manifestations. To enable precise follow-up analyses, scoring systems based on sonographic findings are excellent.
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19
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Sağlam D, Demirbaş F, Bilgici MC, Yücel S, Çaltepe G, Eren E. Can Point Shear Wave Elastography Be Used as an Early Indicator of Involvement?: Evaluation of the Pancreas and Liver in Children With Cystic Fibrosis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1769-1776. [PMID: 32309883 DOI: 10.1002/jum.15281] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 02/28/2020] [Accepted: 03/05/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The aim of this study was to determine the effect of cystic fibrosis (CF) on pancreas and liver elasticity in young children using point shear wave elastography and to determine the relationship with clinical findings. METHODS Twenty-two patients with genetically proven CF, who were admitted to our pediatric gastroenterology clinic, and 22 healthy control participants were enrolled in the study. The shear wave velocity (SWV) of the liver and pancreas were measured with point shear wave elastography. RESULTS The 22 patients with CF included 45.5% girls with a mean age ± SD of 35 ± 35.8 months (range, 5-123 months). The 22 healthy control participants included 41.2% girls with a mean age of 58.9 ± 44.4 months (range, 2-159 months). The mean SWV of the pancreas in the patients with CF (1.06 ± 0.26 m/s) was significantly higher than that of the healthy control participants (0.85 ± 0.23 m/s; P = .01). The mean SWV of the liver in the patients with CF (1.46 ± 0.24 m/s) was significantly higher than that of the healthy control participants (1.12 ± 0.21 m/s; P = .001). The SWV of the pancreas and liver did not show any significant differences depending on ursodeoxycholic acid use, malnutrition status, and the presence of the F508 deletion mutation. CONCLUSIONS This study showed an increased SWV of the pancreas in children with CF, contrary to the literature. We also found an increased liver SWV even in the absence of CF-related liver disease. Ultrasound elastography may be a useful method of evaluating early changes in the pancreas and liver before the obvious clinical, laboratory, and B-mode ultrasound signs of CF-related involvement.
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Affiliation(s)
- Dilek Sağlam
- Department of Pediatric Radiology, Malatya Education and Research Hospital, Yeşilyurt, Turkey
| | - Fatma Demirbaş
- Diyarbakır Education and Research Hospital, Diyarbakır, Turkey
| | - Meltem Ceyhan Bilgici
- Departments of Pediatric Radiology, Ondokuz Mayıs University, School of Medicine, Kurupelit, Turkey
| | | | - Gönül Çaltepe
- Pediatric Gastroenterology, Ondokuz Mayıs University, School of Medicine, Kurupelit, Turkey
| | - Esra Eren
- Kayseri Education and Research Hospital, Kayseri, Turkey
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20
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Calvopina DA, Noble C, Weis A, Hartel GF, Ramm LE, Balouch F, Fernandez-Rojo MA, Coleman MA, Lewindon PJ, Ramm GA. Supersonic shear-wave elastography and APRI for the detection and staging of liver disease in pediatric cystic fibrosis. J Cyst Fibros 2020; 19:449-454. [DOI: 10.1016/j.jcf.2019.06.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 06/28/2019] [Accepted: 06/30/2019] [Indexed: 12/18/2022]
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21
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Assessment of Selected Parameters of Liver Fibrosis and Inflammation in Patients with Diagnosed Cystic Fibrosis. Mediators Inflamm 2020; 2020:5696185. [PMID: 32308556 PMCID: PMC7132586 DOI: 10.1155/2020/5696185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/23/2020] [Accepted: 03/14/2020] [Indexed: 11/17/2022] Open
Abstract
Changes in the liver and bile ducts observed in patients diagnosed with cystic fibrosis result from inflammatory processes as well as fibrosis, remodeling, apoptosis, and cholestasis. As a consequence, portal hypertension, cirrhosis, and hepatic failure may develop. So far, the complexity of these processes has not been elucidated. Study Objectives. The aim of the study was to evaluate the selected parameters of hepatitis and fibrosis (Fibrotest, Actitest, and APRI) in patients diagnosed with cystic fibrosis. Material and Methods. The study included 79 patients with cystic fibrosis, aged 1 to 20 years (mean age 9.8 years), 49 girls (62%) and 30 boys (38%). The analysis involved the following: age, sex, clinical manifestations, laboratory tests evaluating pancreas function, parameters of liver damage, and cholestasis. Fibrotest, Actitest, and APRI were performed in all subjects. Results. Elevated parameters of hepatic cell damage (hypertransaminasemia) were found in 31/79 (39.2%) patients, while abnormal cholestasis parameters in 21/79 (26.6%). The abnormal results of Fibrotest were reported in 15% of patients (12/79), while of Actitest in 10% (8/79). In contrast, elevated APRI values were found in only 7.6% (6/79) of subjects. There was a statistically significant correlation between APRI and age (higher values were observed in younger children) and between Fibrotest and Actitest and pancreatic insufficiency (higher values were found in subjects without this abnormality). Moreover, Fibrotest values were significantly higher in girls. There was no correlation between Fibrotest, Actitest, and APRI values and the type of mutation. Conclusion. It appears that Fibrotest may be used as an early marker of liver fibrosis in patients with cystic fibrosis. Increased APRI values were only found in subjects with advanced hepatic lesions, most often in the form of portal hypertension.
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A comparative study of the pancreas in pediatric patients with cystic fibrosis and healthy children using two-dimensional shear wave elastography. J Ultrasound 2020; 23:535-542. [PMID: 32034705 DOI: 10.1007/s40477-020-00432-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 01/23/2020] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To compare sonographic parameters of the pancreas between healthy children and pediatric cystic fibrosis (CF) patients with pancreatic involvement using shear wave elastography (SWE) and to investigate the efficacy of SWE in the diagnosis of pancreatic involvement in pediatric CF patients. METHODS The pancreas was evaluated in 38 patients with CF and 38 healthy children using conventional B-mode ultrasonography (US) and two-dimensional (2D)-SWE. RESULTS The pancreatic 2D-SWE values of the CF group were significantly lower than those of the healthy control group (1.01 ± 0.16 vs. 1.31 ± 0.01 m/s for the head, 1.03 ± 0.05 vs. 1.28 ± 0.08 m/s for the pancreatic body, and 1.02 ± 0.05 vs. 1.30 ± 0.10 m/s for the tail; p < 0.005 for all the comparisons). When the threshold values were obtained for the pancreatic head, body, and tail segments for the differentiation of the CF patients and healthy controls, the sensitivity of the test was determined as 81.5%, 76.3%, and 73.3%, respectively, and the specificity as 97.3%, 100%, and 100%, respectively. When the patients were divided into two groups based on the presence of B-mode US characteristics (homogeneity, sharp demarcation, and hyperechoic pancreas), there was a significant difference in the 2D-SWE values of the pancreatic head between the patients with and the patients without these characteristics (p = 0.048 for homogeneity, p = 0.021 for sharp demarcation, and p = 0.006 for hyperechoic pancreas). CONCLUSION The measurement of 2D-SWE values was found to be an easily applicable non-invasive test with high sensitivity and specificity for the demonstration of changes in the pancreas of pediatric CF patients.
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Hercun J, Alvarez F, Vincent C, Bilodeau M. Cystic fibrosis liver disease: A condition in need of structured transition and continuity of care. CANADIAN LIVER JOURNAL 2019; 2:71-83. [PMID: 35990223 PMCID: PMC9202747 DOI: 10.3138/canlivj-2018-0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 09/10/2018] [Indexed: 08/05/2023]
Abstract
Liver disease affects one-third of patients with cystic fibrosis (CF) and it is one of the major causes of morbidity and mortality in these patients. Historically considered a disease of childhood, its impact is now seen more often in adulthood. The heterogeneous pattern of CF liver disease and its rapid progression to cirrhosis remain a diagnostic challenge and new questions pertaining to the nature of liver involvement have recently been raised. Non-invasive measures to stratify the severity of liver involvement are increasingly used to predict clinical outcomes. A single treatment, ursodeoxycholic acid, has been used to slow progression of liver disease while recent advances in the field of CF treatments are promising. Management of portal hypertension remains challenging but outcomes after liver transplantation are encouraging. While many questions remain unanswered, a growing number of CF patients reach adulthood and will require care for CF liver disease.
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Affiliation(s)
- Julian Hercun
- Hepatology Department, Centre Hospitalier de l’Université de Montréal, Montréal, Québec;
| | - Fernando Alvarez
- Gastroenterology, Hepatology and Nutrition Division, CHU Sainte-Justine, Montréal, Québec
| | - Catherine Vincent
- Hepatology Department, Centre Hospitalier de l’Université de Montréal, Montréal, Québec;
| | - Marc Bilodeau
- Hepatology Department, Centre Hospitalier de l’Université de Montréal, Montréal, Québec;
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Abstract
Ultrasound elastography (USE) of the pancreas allows pancreatic tissue stiffness assessment by virtual palpation. Two main types of USE are used. For the pancreas strain elastography applying by endoscopic ultrasound has been established for the characterisation of small solid pancreatic lesions (SPL). In larger SPL >30 mm the results are less convincing mainly due to the heterogenicity of the lesions but also by concomitant changes of the surrounding pancreatic parenchyma. The current role of shear wave elastography has to be determined. This article reviews the current use of elastography of the pancreas.
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Affiliation(s)
- Christoph F Dietrich
- Ultrasound Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Department of Internal Medicine, Caritas Hospital Bad Mergentheim, Bad Mergentheim, Germany
| | - Michael Hocke
- Department of Internal Medicine, HELIOS Klinikum Meiningen, Meiningen, Germany
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Conti CB, Weiler N, Casazza G, Schrecker C, Schneider M, Mücke MM, Queck A, Herrmann E, Conte D, Colombo M, Zeuzem S, Fraquelli M, Friedrich-Rust M. Feasibility and reproducibility of liver and pancreatic stiffness in patients with alcohol-related liver disease. Dig Liver Dis 2019; 51:1023-1029. [PMID: 30658941 DOI: 10.1016/j.dld.2018.12.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 12/11/2018] [Accepted: 12/21/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND To date no studies evaluated liver stiffness and pancreatic stiffness by shear-wave elastography, in alcoholic liver disease setting. AIMS To assess feasibility and reproducibility of Shear-wave elastrography in measuring liver and pancreatic stiffness in alcoholic liver disease and investigate the correlation among liver and pancreatic stiffness and clinical data. METHODS Liver and pancreatic stiffness were measured by elastography (2 examiners) in patients with alcoholic liver disease and in healthy volunteers, for reference values. Effect of clinical data was evaluated on log-transformed pancreatic or liver stiffness, using univariate and multivariate linear regression model. RESULTS 87 patients and 46 healthy volunteers enrolled. Both the stiffness values were higher in patients than healthy volunteers (p < 0.001). For liver stiffness: no failure measurements found, the Intraclass correlation coefficient (between 2 examiners) was 0.72 and the variables significantly correlated at multivariate analysis were cirrhosis (p < 0.0001) and steatosis (p = .007). For pancreatic stiffness: 2 failures found, with ICC 0.40 and the only variable significantly correlated at multivariate analysis was liver cirrhosis (p = .005). CONCLUSIONS Shear-wave elastography feasibility was good for liver and pancreatic stiffness. Reproducibility was good for liver stiffness, whereas fair for pancreatic one. Both the stiffness correlated with alcoholic liver disease severity. Elastography could be a useful tool to detect and monitor alcohol-related liver and pancreatic damage.
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Affiliation(s)
- Clara Benedetta Conti
- Department of Pathophysiology and Organ Transplantation, Maggiore Hospital and IRRCS Foundation, University of Milan, Milan, Italy.
| | - Nina Weiler
- Department of Internal Medicine 1, Hospital of the Goethe University, Frankfurt, Germany
| | - Giovanni Casazza
- Department of Biomedical and Clinical Sciences "L Sacco", University of Milan, Milan, Italy
| | - Christopher Schrecker
- Department of Internal Medicine 1, Hospital of the Goethe University, Frankfurt, Germany
| | - Maximillian Schneider
- Department of Internal Medicine 1, Hospital of the Goethe University, Frankfurt, Germany
| | - Marcus M Mücke
- Department of Internal Medicine 1, Hospital of the Goethe University, Frankfurt, Germany
| | - Alexander Queck
- Department of Internal Medicine 1, Hospital of the Goethe University, Frankfurt, Germany
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, Frankfurt, Germany
| | - Dario Conte
- Department of Pathophysiology and Organ Transplantation, Maggiore Hospital and IRRCS Foundation, University of Milan, Milan, Italy
| | - Massimo Colombo
- Department of Pathophysiology and Organ Transplantation, Maggiore Hospital and IRRCS Foundation, University of Milan, Milan, Italy
| | - Stefan Zeuzem
- Department of Internal Medicine 1, Hospital of the Goethe University, Frankfurt, Germany
| | - Mirella Fraquelli
- Department of Pathophysiology and Organ Transplantation, Maggiore Hospital and IRRCS Foundation, University of Milan, Milan, Italy
| | - Mireen Friedrich-Rust
- Department of Internal Medicine 1, Hospital of the Goethe University, Frankfurt, Germany
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Pfahler MHC, Kratzer W, Leichsenring M, Graeter T, Schmidt SA, Wendlik I, Lormes E, Schmidberger J, Fabricius D. Point shear wave elastography of the pancreas in patients with cystic fibrosis: a comparison with healthy controls. Abdom Radiol (NY) 2018; 43:2384-2390. [PMID: 29460047 DOI: 10.1007/s00261-018-1479-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Manifestations of cystic fibrosis in the pancreas are gaining in clinical importance as patients live longer. Conventional ultrasonography and point shear wave elastography (pSWE) imaging are non-invasive and readily available diagnostic methods that are easy to perform. The aim of this study was to perform conventional ultrasonography and obtain pSWE values in the pancreases of patients with cystic fibrosis and to compare the findings with those of healthy controls. METHODS 27 patients with cystic fibrosis (13 women/14 men; mean age 27.7 ± 13.7 years; range 9-58 years) and 60 healthy control subjects (30 women/30 men; mean age 30.3 ± 10.0 years; range 22-55 years) underwent examinations of the pancreas with conventional ultrasound and pSWE imaging. RESULTS Patients with cystic fibrosis have an echogenic pancreatic parenchyma. We found cystic lesions of the pancreas in six patients. pSWE imaging of the pancreatic parenchyma gave significantly lower shear wave velocities in patients with cystic fibrosis than in the control group (1.01 m/s vs 1.30 m/s; p < 0.001). CONCLUSIONS Using pSWE imaging in vivo, we have shown that the pancreas is considerably softer in patients with cystic fibrosis than in a healthy control population.
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Affiliation(s)
| | - Wolfgang Kratzer
- Department of General Internal Medicine I, Ulm University Hospitals, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
| | - Michael Leichsenring
- Department of Paediatric and Adolescent Medicine, Ulm University Hospitals, Eythstrasse 24, 89075, Ulm, Germany
| | - Tilmann Graeter
- Department of Diagnostic and Interventional Radiology, Ulm University Hospitals, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Stefan Andreas Schmidt
- Department of Diagnostic and Interventional Radiology, Ulm University Hospitals, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Inka Wendlik
- Department of Diagnostic and Interventional Radiology, Ulm University Hospitals, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Elisabeth Lormes
- Department of Diagnostic and Interventional Radiology, Ulm University Hospitals, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Julian Schmidberger
- Department of General Internal Medicine I, Ulm University Hospitals, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Dorit Fabricius
- Department of Paediatric and Adolescent Medicine, Ulm University Hospitals, Eythstrasse 24, 89075, Ulm, Germany
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Engjom T, Kavaliauskiene G, Tjora E, Erchinger F, Wathle G, Lærum BN, Njølstad PR, Frøkjær JB, Gilja OH, Dimcevski G, Haldorsen IS. Sonographic pancreas echogenicity in cystic fibrosis compared to exocrine pancreatic function and pancreas fat content at Dixon-MRI. PLoS One 2018; 13:e0201019. [PMID: 30048483 PMCID: PMC6062060 DOI: 10.1371/journal.pone.0201019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 07/06/2018] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Fatty infiltration of the pancreas is a dominating feature in cystic fibrosis (CF). We evaluate the association between pancreatic fat content assessed by Dixon magnetic resonance imaging (MRI), pancreatic echogenicity at ultrasonography (US) and exocrine function in CF patients and healthy controls (HC). MATERIAL AND METHODS Transabdominal US, pancreatic Dixon-MRI and diffusion-weighted imaging (DWI) were performed in 21 CF patients and 15 HCs. Exocrine function was assessed by endoscopic secretin test and fecal elastase. RESULTS CF patients were grouped according to exocrine pancreatic function as subjects with normal (CFS: n = 11) or reduced (CFI: n = 10) function. Among CFI 90% (9/10) had visual hyperechogenicity. CFI also had increased echo-level values (p<0.05 vs others). All CFI (10/10) had markedly increased pancreatic fat content estimated by MRI compared to sufficient groups, p<0.001). Among CFS patients and HC, 27% (3/11) and 33% (5/15), respectively, had hyperechoic pancreas. However, all these had low pancreatic fat-content at MRI compared to CFI. In CFI, pancreatic fat content was correlated to ADC (r = -0.93, p<0.001). CONCLUSION Pancreas insufficient CF patients exhibit severe pancreatic fatty-infiltration at MRI and hyperechoic pancreas at US. Pancreas hyperechogenicity in pancreatic sufficient subjects does not co-exist with fatty infiltration at MRI. MRI evaluates pancreatic fatty infiltration more accurately than US and fat infiltration estimated by MRI outperforms sonographic hyper-echogenicity as a marker for exocrine pancreatic failure in CF.
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Affiliation(s)
- Trond Engjom
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | | | - Erling Tjora
- Pediatric Department, Haukeland University Hospital,Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Friedemann Erchinger
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Voss Hospital, Voss, Norway
| | - Gaute Wathle
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | | | - Pål Rasmus Njølstad
- Pediatric Department, Haukeland University Hospital,Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Jens Brøndum Frøkjær
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Odd Helge Gilja
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
| | - Georg Dimcevski
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ingfrid Salvesen Haldorsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
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28
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Lam S, Nettel-Aguirre A, Van Biervliet S, Roeb E, Sadler MD, Friedrich-Rust M, Karlas T, Kitson MT, deBruyn JCC. Transient Elastography in the Evaluation of Cystic Fibrosis-Associated Liver Disease: Systematic Review and Meta-analysis. J Can Assoc Gastroenterol 2018; 2:71-80. [PMID: 31294368 PMCID: PMC6507293 DOI: 10.1093/jcag/gwy029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background and aims Complications of cystic fibrosis-associated liver disease (CFLD) are a leading nonpulmonary cause of death. Transient elastography (TE) has recently been investigated to detect CFLD. This study reviews the current literature for TE in the detection CFLD. A meta-analysis was performed to determine the ideal liver stiffness measurement (LSM) cutoff. Methods PubMed, Medline, EMBASE and Web of Science were searched from inception until April 2016 for publications involving the detection of CFLD with TE. Data were extracted using a fixed protocol (a priori design) including study design, population characteristics, probe size and AST Platelet Ratio Index (APRI). Results Diagnostic properties were summarized from six studies of 605 patients. Cutoff for LSM was determined using pooled data submitted by authors. The cutoff for LSM and APRI were ≥5.95 kPa and ≥0.329 respectively, yielding a sensitivity, specificity and area under receiver operator characteristic of 55%, 87%, 0.76, 52%, 93% and 0.84 for LSM and APRI, respectively. When LSM ≥5.95 kPa and APRI ≥0.329, the sensitivity, specificity, positive predictive value and negative predictive value were 43%, 99%, 92% and 87% with a diagnostic odds ratio of 74.9. A bivariate metaregression model showed that pediatric specific cutoffs for liver stiffness and APRI may not be necessary. Conclusion Individually, LSM and APRI have poor sensitivity but good specificity for detecting CFLD. They are most useful when combined. We propose that patients with LSM ≥5.95 kPa and APRI ≥0.329 be investigated thoroughly for the presence of cystic fibrosis-associated liver disease.
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Affiliation(s)
- Simon Lam
- Alberta Children's Hospital, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Alberto Nettel-Aguirre
- Alberta Children's Hospital, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital, Community Health Sciences, Calgary, Alberta, Canada
| | | | - Elke Roeb
- University Hospital, Gastroenterology, Justus-Liebig-University Giessen, Giessen, Germany
| | | | - Mireen Friedrich-Rust
- J.W. Goethe University Hospital, Department of Internal Medicine, Goethe University Hospital, Frankfurt, Germany
| | - Thomas Karlas
- University of Leipzig, Division of Gastroenterology, University Hospital Leipzig, Leipzig, Germany
| | - Matthew T Kitson
- Alfred Hospital, Gastroenterology, Alfred Hospital, Australia and Monash University, Melbourne, Victoria, Australia
| | - Jennifer C C deBruyn
- Alberta Children's Hospital, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
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Sakai NS, Taylor SA, Chouhan MD. Obesity, metabolic disease and the pancreas-Quantitative imaging of pancreatic fat. Br J Radiol 2018; 91:20180267. [PMID: 29869917 DOI: 10.1259/bjr.20180267] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The association between pancreatic fat, obesity and metabolic disease is well-documented, and although a potentially exciting target for novel therapies, remains poorly understood. Non-invasive quantitative imaging-derived biomarkers can provide insights into pathophysiology and potentially provide robust trial endpoints for development of new treatments. In this review, we provide an overview of the pathophysiology of non-alcoholic fatty pancreas disease and associations with metabolic factors, obesity and diabetes. We then explore approaches to pancreatic fat quantification using ultrasound, CT and MRI, reviewing the strengths, limitations and current published evidence in the assessment of pancreatic fat. Finally, we explore the broader challenges of pancreatic fat quantification as we move toward translating these methods into the clinical setting.
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Affiliation(s)
- Naomi S Sakai
- 1 UCL Centre for Medical Imaging, Division of Medicine, University College London , London , UK
| | - Stuart A Taylor
- 1 UCL Centre for Medical Imaging, Division of Medicine, University College London , London , UK
| | - Manil D Chouhan
- 1 UCL Centre for Medical Imaging, Division of Medicine, University College London , London , UK
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Abstract
PURPOSE OF REVIEW To provide an insight and overview of the challenges in the diagnosis, follow-up and treatment of cystic fibrosis-related liver disease (CFLD). RECENT FINDINGS The variable pathophysiology of CFLD complicates its diagnosis and treatment. A 'gold standard' for CFLD diagnosis is lacking. Over the past years, new techniques to diagnose features of CFLD, such as transient elastography, have been investigated. Although most of these tests confirm cystic fibrosis-related liver involvement (CFLI), they are, however, not suitable to distinguish various phenotypical presentations or predict progression to clinically relevant cirrhosis or portal hypertension. A combined initiative from the European and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition has been started, aimed to obtain consensus on CFLD criteria and definitions. Currently, only ursodeoxycholic acid is used in CFLD treatment, although it has not been convincingly demonstrated to change the natural course of the disease. Drugs that directly target cystic fibrosis transmembrane conductance regulator protein dysfunction show promising results; however, more long-term follow-up and validation studies are needed. SUMMARY CFLD is an umbrella term referring to a wide variety of liver manifestations with variable clinical needs and consequences. CFLD with portal hypertension is the most severe form of CFLD due to its significant implications on morbidity and mortality. The clinical relevance of other CFLI is uncertain. Consensus on CFLD definitions is essential to validate new diagnostic tools and therapeutic outcome measures.
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Abstract
OBJECTIVES Cystic fibrosis-related liver disease (CFLD) can develop silently in early life and approximately 10% of children with cystic fibrosis (CF) become cirrhotic before adulthood. Clinical, biological, and ultrasound criteria used to define CFLD often reveal liver involvement at an advanced stage. The aim of this retrospective study was to assess the progression of liver stiffness measurement (LSM) in pediatric patients with CF. METHODS The change of LSM, expressed as kPa/year and %/year, was measured using transient elastography (Fibroscan) in 82 children with CF (median age: 6.8 years, interquartile range [IQR]: 5.8). Mean time interval between the 2 LSM was 3.5 years. RESULTS Median initial liver stiffness was 3.7 kPa (IQR: 1.3), and then progressed by 0.23 kPa/year, that is, 6%/year. The 7 patients who developed CFLD had a higher initial level of alanine aminotransferase (50 [IQR: 15] vs 30 [IQR: 18], P = 0.0001) and presented a more rapid progression of LSM (0.94 vs 0.23 kPa/year, P = 0.02). CONCLUSIONS The present study shows that the slope of worsening of liver stiffness is greater in patients who will develop CFLD, suggesting that annual transient elastography may be useful to detect risk of severe liver disease at an earlier stage.
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Ayoub F, Trillo-Alvarez C, Morelli G, Lascano J. Risk factors for hepatic steatosis in adults with cystic fibrosis: Similarities to non-alcoholic fatty liver disease. World J Hepatol 2018; 10:34-40. [PMID: 29399276 PMCID: PMC5787682 DOI: 10.4254/wjh.v10.i1.34] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/06/2017] [Accepted: 12/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the clinical, biochemical and imaging characteristics of adult cystic fibrosis (CF) patients with hepatic steatosis as compared to normal CF controls.
METHODS We performed a retrospective review of adult CF patients in an academic outpatient setting during 2016. Baseline characteristics, genetic mutation analysis as well as laboratory values were collected. Abdominal imaging (ultrasound, computed tomography, magnetic resonance) was used to determine presence of hepatic steatosis. We compare patients with hepatic steatosis to normal controls.
RESULTS Data was collected on 114 patients meeting inclusion criteria. Seventeen patients (14.9%) were found to have hepatic steatosis on imaging. Being overweight (BMI > 25) (P = 0.019) and having a higher ppFEV1 (75 vs 53, P = 0.037) were significantly associated with hepatic steatosis. Patients with hepatic steatosis had a significantly higher median alanine aminotransferase level (27 vs 19, P = 0.048). None of the hepatic steatosis patients had frank CF liver disease, cirrhosis or portal hypertension. We found no significant association with pancreatic insufficiency or CF related diabetes.
CONCLUSION Hepatic steatosis appears to be a clinically and phenotypically distinct entity from CF liver disease. The lack of association with malnourishment and the significant association with higher BMI and higher ppFEV1 demonstrate similarities with non-alcoholic fatty liver disease. Long term prospective studies are needed to ascertain whether CF hepatic steatosis progresses to fibrosis and cirrhosis.
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Affiliation(s)
- Fares Ayoub
- Department of Medicine, University of Florida, Gainesville, FL 32608, United States
| | - Cesar Trillo-Alvarez
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL 32608, United States
| | - Giuseppe Morelli
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States
| | - Jorge Lascano
- Department of Medicine, Adult Cystic Fibrosis Center, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL 32608, United States
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Relation of Ultrasound Findings and Abdominal Symptoms obtained with the CFAbd-Score in Cystic Fibrosis Patients. Sci Rep 2017; 7:17465. [PMID: 29234058 PMCID: PMC5727223 DOI: 10.1038/s41598-017-17302-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/22/2017] [Indexed: 02/07/2023] Open
Abstract
Abdominal symptoms are a hallmark of Cystic fibrosis (CF). Yet, their association with morphological abnormalities of different abdominal organs is still poorly understood. Aim was therefore to relate these symptoms, assessed with a questionnaire, to findings in abdominal ultrasound (US). In 114 CF patients of all ages, findings in US considering seventeen specific parameters were related to abdominal symptoms compiled with our novel CF-specific 26-modal symptom score (CFAbd-Score). US abnormalities were detected in 95% of the patients. Most frequent findings were pancreatic lipomatosis (88%), liver steatosis (37%), hepatomegaly (31%), and thickened bowel walls (23%). Highest burden of GI-symptoms was clearly associated with pancreatic lipomatosis (p = 0.036). In detail, patients revealing this pathology reported higher rates of abdominal pain (p = 0.018), flatulence (p = 0.006), heartburn (p = 0.04), and reflux of stomach content (p = 0.006). Patients with pancreatic sufficiency had less US-findings (p = 0.033), which in turn was associated with lower rates of abdominal symptoms. The majority of them were carriers of class IV-VI or G551D mutations. Our approach gives new insights regarding the underestimated multi-organ abdominal involvement in CF. The new score can be of high interest e.g. as a complementary tool to assess the gastrointestinal effects of promising novel CF therapeutics.
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Llamoza-Torres CJ, Fuentes-Pardo M, Álvarez-Higueras FJ, Alberca-de-Las-Parras F, Carballo-Álvarez F. Usefulness of percutaneous elastography by acoustic radiation force impulse for the non-invasive diagnosis of chronic pancreatitis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:450-6. [PMID: 27459032 DOI: 10.17235/reed.2016.4103/2015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the accuracy of the acoustic radiation force impulse (ARFI) technique for the diagnosis of chronic pancreatitis. MATERIALS AND METHODS We present an observational, single-center study that included patients with suspected chronic pancreatitis in the period between October 2012 and September 2015 who underwent endoscopic ultrasound (EUS) and were classified according to the standard and Rosemont criteria. The same group of patients was assessed by the ARFI technology using ACUSON S2000™ equipment with Virtual Touch™ Quantification software for the assessment of pancreatic stiffness by obtaining the shear wave velocity (SWV) in the head, body and tail of the pancreas. Data were analyzed using ANOVA and nonparametric correlation methods. Diagnostic accuracy was obtained by analyzing receiver operating characteristic (ROC) curve. RESULTS A total of thirty-three patients were studied (45.5% women); mean age was 58.3 ± 11.8 years. Seventeen with a diagnosis of chronic pancreatitis and sixteen classified as normal according to standard criteria. A significant difference was detected between the means of SWV in pancreatic body of patients without (SWV: 1.27 m/s) and with chronic pancreatitis (SWV 1.57 m/s), p = 0.037. The area under the ROC curve was 71.3% (95% CI 0.532-0.895) and the accuracy of ARFI for diagnosing chronic pancreatitis was 69.7% for a SWV of 1.4 m/s in the pancreatic body. The SWV means in head (r = 0.421, p < 0.05) and body (r = 0.455, p < 0.05) of the pancreas showed a significant correlation with the number of EUS criteria for chronic pancreatitis. CONCLUSION Quantification of pancreatic stiffness with ARFI elastography technique has proven to be useful for the non-invasive diagnosis of chronic pancreatitis.
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Affiliation(s)
| | | | | | - Fernando Alberca-de-Las-Parras
- Servicio de Medicina de Aparato Digestivo., Hospital Clínico Universitario Virgen de la Arrixaca. IMIB-Arrixaca., España
| | - Fernando Carballo-Álvarez
- Servicio de Medicina de Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca. IMIB-Arrixaca , España
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Pozzi R, Parzanese I, Baccarin A, Giunta M, Conti CB, Cantù P, Casazza G, Tenca A, Rosa R, Gridavilla D, Casella G, Conte D, Fraquelli M. Point shear-wave elastography in chronic pancreatitis: A promising tool for staging disease severity. Pancreatology 2017; 17:905-910. [PMID: 29066007 DOI: 10.1016/j.pan.2017.10.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 10/09/2017] [Accepted: 10/11/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Objectives: ElastPQ®-pSWE is an ultrasound technique developed to stage disease severity in patients with chronic liver diseases. Little data is available about its application to the pancreas. We aimed to assess the feasibility and reproducibility of pancreatic stiffness (PS) measurements in patients with chronic pancreatitis and their relationship with clinical and laboratory data. MATERIAL AND METHODS 52 consecutive patients with chronic pancreatitis (CP) (40 males; median age 60 years) underwent hepatic and pancreatic pSWE. Liver stiffness was measured by transient elastography, 42 healthy subjects being controls (25 males; median age 54 years). Pancreatic pSWE inter-observer agreement was analyzed by intraclass correlation coefficient (ICC). The effects of clinical, laboratory and US data on PS measurements were evaluated by linear regression. RESULTS pSWE was feasible in all the CP patients, but one. Pancreatic stiffness was significantly higher in CP patients than healthy controls (4.3 ± SD 2.4 vs. 2.8 ± SD 1.1 kPa, respectively, p = 0.001). Significantly higher values in the CP group were observed in patients with longer disease duration (>10 vs. ≤10 years) (5.8 ± SD 4 vs. 3.9 ± SD 1.5 kPa, respectively, p = 0.01), on chronic analgesic drugs (6.0 vs. 3.5 kPa, p < 0.05) and with lower body weight (p < 0.05, r = -0.38). At multivariate analysis all the three variables resulted independently associated to the pancreatic stiffness value. The ICC for PS was 0.77. CONCLUSIONS ElastPQ®-pSWE is promising and reproducible in assessing pancreatic stiffness, which mainly reflects disease length and severity. Accordingly, its use is of potential value in stratifying CP patients by identifying those with a more serious degree of disease.
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Affiliation(s)
- Roberta Pozzi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Ilaria Parzanese
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Alessandra Baccarin
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Mariangela Giunta
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Clara Benedetta Conti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Paolo Cantù
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Giovanni Casazza
- Department of Biomedical and Clinical Sciences Luigi Sacco, Università degli Studi di Milano, Milano, Italy
| | - Andrea Tenca
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Roberto Rosa
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Daniele Gridavilla
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | | | - Dario Conte
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy.
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Back SJ, Maya CL, Khwaja A. Ultrasound of congenital and inherited disorders of the pediatric hepatobiliary system, pancreas and spleen. Pediatr Radiol 2017; 47:1069-1078. [PMID: 28779194 DOI: 10.1007/s00247-017-3869-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 02/26/2017] [Accepted: 04/11/2017] [Indexed: 12/17/2022]
Abstract
Ultrasound is often the initial imaging examination performed of the solid organs of the pediatric abdomen. The sonographic appearance of the hepatobiliary system, pancreas and spleen changes with growth and development. This article reviews the normal US appearance of these organs in children and illustrates, through case examples, congenital and inherited conditions that affect them.
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Affiliation(s)
- Susan J Back
- Department of Radiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - Carolina L Maya
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Asef Khwaja
- Department of Radiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
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Klotter V, Gunchick C, Siemers E, Rath T, Hudel H, Naehrlich L, Roderfeld M, Roeb E. Assessment of pathologic increase in liver stiffness enables earlier diagnosis of CFLD: Results from a prospective longitudinal cohort study. PLoS One 2017; 12:e0178784. [PMID: 28575039 PMCID: PMC5456384 DOI: 10.1371/journal.pone.0178784] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 05/18/2017] [Indexed: 12/17/2022] Open
Abstract
About 30% of patients with Cystic Fibrosis (CF) develop CF-associated liver disease (CFLD). Recent studies have shown that transient elastography (TE), as a method to quantify liver stiffness, allows non-invasive diagnosis of CFLD in adults and children with CF. Within this study we aimed to prospectively identify patients at risk for development of CFLD by longitudinal analysis of liver stiffness and fibrosis scores in a 5-year follow-up. 36 pediatric and 16 adult patients with initial liver stiffness below the cut-off value indicative of CFLD (6.3 kPa) were examined by transient elastography for 4-5 years. TE, APRI-, and FIB-4-scores were assessed and compared by Kruskal-Wallis test and receiver operating characteristic (ROC)-analysis. Frequencies were compared by Chi2-test. Among the 36 patients participating in this study, a subgroup of 9 patients developed liver stiffness >6.3 kPa after 4-5 years with an increase of ΔTE >0.38 kPa/a (the group with increasing liver stiffness was labelled TEinc). APRI- and FIB-4 scores confirmed the rationale for grouping. The frequency of CFLD assessed by conventional diagnosis was significantly higher in TEinc-group compared to the control group (TEnorm). None of the adult CF patients matched criteria for TEinc-group. For the first time it was shown that the non-invasive longitudinal assessment of TE allows identification of patients with progression of CFLD in a subgroup of juvenile but not in adult CF patients. Comparing TE to conventional fibrosis-scores underlined the strength of the continuous assessment of liver stiffness for the exact diagnosis of progressive CFLD. The newly described cut-off for pathologic increase of liver stiffness, ΔTEcutoff = 0.38kPa/a, might enable to detect developing CFLD using consequent follow up TE measurements before reaching the level of stiffness indicating established CFLD. Nevertheless, the limited size of the analyzed cohort should encourage a prospective, multi-center, long term follow up study to confirm the suggested cut-off for the rise in liver stiffness.
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Affiliation(s)
- Victoria Klotter
- Department of Internal Medicine, Division of Gastroenterology, Justus-Liebig-University, Giessen, Germany
| | - Caroline Gunchick
- Department of Internal Medicine, Division of Gastroenterology, Justus-Liebig-University, Giessen, Germany
| | - Enno Siemers
- Department of Internal Medicine, Division of Gastroenterology, Justus-Liebig-University, Giessen, Germany
| | - Timo Rath
- Department of Medicine 1, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Helge Hudel
- Institute for Medical Informatics, Justus-Liebig-University, Giessen, Germany
| | - Lutz Naehrlich
- Department of Pediatrics, Division of Pulmonology, Justus-Liebig-University, Giessen, Germany
| | - Martin Roderfeld
- Department of Internal Medicine, Division of Gastroenterology, Justus-Liebig-University, Giessen, Germany
| | - Elke Roeb
- Department of Internal Medicine, Division of Gastroenterology, Justus-Liebig-University, Giessen, Germany
- * E-mail:
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Leung DH. Hepatic fibrosis scores and serum biomarkers in pediatric hepatology. Clin Liver Dis (Hoboken) 2017; 9:125-130. [PMID: 30992975 PMCID: PMC6467157 DOI: 10.1002/cld.634] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 02/22/2017] [Accepted: 03/13/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Daniel H. Leung
- Department of PediatricsBaylor College of MedicineHoustonTX,Division of Pediatric Gastroenterology, Hepatology, and NutritionTexas Children's HospitalHoustonTX
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Correlation of Transient Elastography With Severity of Cystic Fibrosis-related Liver Disease. J Pediatr Gastroenterol Nutr 2017; 64:505-511. [PMID: 27782957 DOI: 10.1097/mpg.0000000000001448] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The aim of the study was to evaluate whether liver stiffness measurement (LSM), determined by transient elastography, correlates with presence and severity of liver disease in children and young adults with cystic fibrosis (CF). METHODS Subjects underwent LSM at routine CF visits. Presence and severity of cystic fibrosis liver disease (CFLD) was determined by clinical parameters. Subjects were classified as no CFLD, CFLD without portal hypertension (PHTN), and CFLD with PHTN. LSM was compared with aspartate aminotransferase/platelet ratio index (APRI) as a correlate to severity of CFLD. RESULTS A total of 249 subjects (53% boys; mean age 14 ± 7 years; 7 [3%] <2 years and 74 [30%] 18-25 years) underwent LSM. Subjects were classified as 158 (64%) with no CFLD, 73 (29%) CFLD without PHTN, and 18 (7%) CFLD with PHTN. The median (interquartile range) LSM was different among the 3 groups: 4.4 (3.8-5.4), 5.1 (4.4-6.3), and 14.1 (8.8-24.8) kPa, respectively, with all pairwise comparisons different from one another (P < 0.0001). Similarly, median (interquartile range) APRI was different in groups 1 and 2 compared with CFLD with PHTN: 0.22 (0.17-0.27), 0.24 (0.17-0.33), and 0.53 (0.24-0.84), respectively (P < 0.01). Analysis of receiver operating characteristics for discriminating CFLD with PHTN from the other groups resulted in cut-points at 6.2 kPa (LSM) and 0.35 (APRI). LSM was superior to APRI in discriminating CFLD with PHTN from other groups, with areas under the curve 0.91 (LSM) versus 0.78 (APRI) (P = 0.05). CONCLUSIONS Liver stiffness, as determined by transient elastography, correlates with the presence and severity of CFLD. Although APRI provided some information regarding severity of liver disease, LSM performed better than APRI in this population.
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Imaging the Abdominal Manifestations of Cystic Fibrosis. Int J Hepatol 2017; 2017:5128760. [PMID: 28250993 PMCID: PMC5303593 DOI: 10.1155/2017/5128760] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 12/17/2016] [Accepted: 01/09/2017] [Indexed: 02/07/2023] Open
Abstract
Cystic fibrosis (CF) is a multisystem disease with a range of abdominal manifestations including those involving the liver, pancreas, and kidneys. Recent advances in management of the respiratory complications of the disease has led to a greater life expectancy in patients with CF. Subsequently, there is increasing focus on the impact of abdominal disease on quality of life and survival. Liver cirrhosis is the most important extrapulmonary cause of death in CF, yet significant challenges remain in the diagnosis of CF related liver disease. The capacity to predict those patients at risk of developing cirrhosis remains a significant challenge. We review representative abdominal imaging findings in patients with CF selected from the records of two academic health centres, with a view to increasing familiarity with the abdominal manifestations of the disease. We review their presentation and expected imaging findings, with a focus on the challenges facing diagnosis of the hepatic manifestations of the disease. An increased familiarity with these abdominal manifestations will facilitate timely diagnosis and management, which is paramount to further improving outcomes for patients with cystic fibrosis.
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Ursodeoxycholic acid treatment is associated with improvement of liver stiffness in cystic fibrosis patients. J Cyst Fibros 2016; 15:834-838. [DOI: 10.1016/j.jcf.2016.07.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 07/20/2016] [Accepted: 07/20/2016] [Indexed: 12/11/2022]
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Bruno C, Minniti S, Bucci A, Pozzi Mucelli R. ARFI: from basic principles to clinical applications in diffuse chronic disease-a review. Insights Imaging 2016; 7:735-46. [PMID: 27553006 PMCID: PMC5028343 DOI: 10.1007/s13244-016-0514-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 07/05/2016] [Accepted: 07/19/2016] [Indexed: 12/11/2022] Open
Abstract
Abstract The many factors influencing the shear wave velocity (SWV) measured with Acoustic Radiation Force Impulse (ARFI) are examined in order to define the most correct examination technique. In particular, attention is given to the information achieved by experimental models, such as phantoms and animal studies. This review targets the clinical applications of ARFI in the evaluation of chronic diffuse disease, especially of liver and kidneys. The contribution of ARFI to the clinical workout of these patients and some possible perspectives are described. Teaching Points • Stiffness significantly varies among normal and abnormal biological tissues. • In clinical applications physical, geometrical, anatomical and physiological factors influence the SWV. • Elastographic techniques can quantify fibrosis, which is directly related to stiffness. • ARFI can be useful in chronic diffuse disease of liver and kidney.
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Affiliation(s)
- Costanza Bruno
- Department of Radiology, Verona University, P.le LA Scuro 10, 37134, Verona, Italy.
| | | | - Alessandra Bucci
- Department of Radiology, Verona University, P.le LA Scuro 10, 37134, Verona, Italy
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Stumpf S, Jaeger H, Graeter T, Oeztuerk S, Schmidberger J, Haenle MM, Kratzer W. Influence of age, sex, body mass index, alcohol, and smoking on shear wave velocity (p-SWE) of the pancreas. Abdom Radiol (NY) 2016; 41:1310-6. [PMID: 26880176 PMCID: PMC4912593 DOI: 10.1007/s00261-016-0661-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Purpose A variety of elastographic techniques have been developed to facilitate the non-invasive assessment of tissue properties. The goal of the study was to examine the influence of gender, age, BMI, alcohol consumption, and smoking in healthy volunteers. Methods Of the 263 participants who met all the study inclusion criteria, 234 had successful measurements. The examination was performed with the Siemens Acuson S3000 (Siemens Healthcare, Erlangen, Germany), using the 6C1 curved array transducer with the virtual touch tissue quantification (VTQ) method. Results The values determined with the curved array in the head of the pancreas were 1.44 ± 0.39 m/s for women and 1.19 ± 0.29 m/s for men; in the body, the results were 1.49 ± 0.37 m/s for women and 1.26 ± 0.30 m/s for men; in the tail, the corresponding values were 1.29 ± 0.36 m/s for women and 1.05 ± 0.30 m/s for men. Comparison of gender showed that men have significantly lower mean values than women. There were significantly higher values in all parts of the organ with the increasing age of the participants (p < 0.0001). For BMI, there was a significant correlation with the values only when considering the BMI in continuous form. Alcohol consumption and smoking did not have any significant effects. Conclusions ARFI-VTQ is qualified for use on pancreatic tissue. Further studies are required to examine the influence of other factors in larger populations.
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Hepatic and Splenic Acoustic Radiation Force Impulse Shear Wave Velocity Elastography in Children with Liver Disease Associated with Cystic Fibrosis. BIOMED RESEARCH INTERNATIONAL 2015; 2015:517369. [PMID: 26609528 PMCID: PMC4644813 DOI: 10.1155/2015/517369] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 10/15/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Liver disease associated with cystic fibrosis (CFLD) is the second cause of mortality in these patients. The diagnosis is difficult because none of the available tests are specific enough. Noninvasive elastographic techniques have been proven to be useful to diagnose hepatic fibrosis. Acoustic radiation force impulse (ARFI) imaging is an elastography imaging system. The purpose of the work was to study the utility of liver and spleen ARFI Imaging in the detection of CFLD. Method. 72 patients with cystic fibrosis (CF) were studied and received ARFI imaging in the liver and in the spleen. SWV values were compared with the values of 60 healthy controls. Results. Comparing the SWV values of CFLD with the control healthy group, values in the right lobe were higher in patients with CFLD. We found a SWV RHL cut-off value to detect CFLD of 1.27 m/s with a sensitivity of 56.5% and a specificity of 90.5%. CF patients were found to have higher SWC spleen values than the control group. Conclusions. ARFI shear wave elastography in the right hepatic lobe is a noninvasive technique useful to detect CFLD in our sample of patients. Splenic SWV values are higher in CF patients, without any clinical consequence.
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Management of pancreatic, gastrointestinal and liver complications in adult cystic fibrosis. Rev Mal Respir 2015; 32:566-85. [DOI: 10.1016/j.rmr.2014.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 12/09/2014] [Indexed: 01/27/2023]
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Noninvasive methods, including transient elastography, for the detection of liver disease in adults with cystic fibrosis. Can J Gastroenterol Hepatol 2015; 29:139-44. [PMID: 25855877 PMCID: PMC4399373 DOI: 10.1155/2015/138530] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Liver disease is the third leading cause of mortality in patients with cystic fibrosis (CF). However, detection of CF-associated liver disease (CFLD) is challenging. OBJECTIVE To evaluate the diagnostic performance of noninvasive methods for the detection of CFLD with a focus on transient elastography (TE). METHODS Patients at the Adult CF Clinic of Calgary and Southern Alberta (n=127) underwent liver stiffness measurement (LSM) by TE using the FibroScan (FS, Ecosens, France) M probe; aspartate aminotransferase to platelet ratio index (APRI) and FibroTest (FT) scores were also calculated. The diagnostic performance of these tools for the detection of CFLD (defined as two or more the following criteria: abnormal liver biochemistry, hepatomegaly or sonographic abnormalities other than steatosis) were compared using the area under ROC curves. RESULTS Forty-seven percent of the cohort was male. The median age was 27 years (interquartile range [IQR] 22 to 37 years) and body mass index 21 kg⁄m(2) (IQR 19 kg⁄m(2) to 23 kg⁄m(2)); 25% of patients were on ursodeoxycholic acid and 12% had undergone lung transplantation. The prevalence of CFLD was 14% (n=18). FS was successful in all patients; one (0.8%) patient had poorly reliable results (IQR⁄M >30% and LSM ≥7.1 kPa). Compared with patients without CFLD (n=109), individuals with CFLD had higher median LSM according to FS (3.9 kPa [IQR 3.4 to 4.9 kPa] versus 6.4 kPa [IQR 4.4 to 8.0 kPa]), APRI (0.24 [IQR 0.17 to 0.31] versus 0.50 [IQR 0.22 to 1.18]) and FT scores (0.08 [IQR 0.05 to 1.5] versus 0.18 [IQR 0.11 to 0.35]; all P<0.05). Area under ROC curve for FS, APRI and FT for the detection of CFLD were 0.78 (95% CI 0.65 to 0.92), 0.72 (95% CI 0.56 to 0.87) and 0.76 (95% CI 0.62 to 0.90) (P not significant). At a threshold of >5.2 kPa, the sensitivity, specificity, positive and negative predictive values of LSM according to FS for detecting CFLD were 67%, 83%, 40% and 94%, respectively. CONCLUSIONS FS, APRI and FT were useful noninvasive methods for detecting CFLD in adults.
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JSUM ultrasound elastography practice guidelines: pancreas. J Med Ultrason (2001) 2014; 42:151-74. [PMID: 26576568 DOI: 10.1007/s10396-014-0571-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 08/18/2014] [Indexed: 12/13/2022]
Abstract
Ultrasound elastography is a relatively new diagnostic technique for measuring the elasticity (hardness) of tissue. Eleven years have passed since the debut of elastography. Various elastography devices are currently being marketed by manufacturers under different names. Pancreatic elastography can be used not only with transabdominal ultrasonography but also with endoscopic ultrasonography, but some types of elastography are difficult to perform for the pancreas. These guidelines aim to classify the various types of elastography into two major categories depending on the differences in the physical quantity (strain, shear wave), and to present the evidence for pancreatic elastography and how to use pancreatic elastography in the present day. But the number of reports on ultrasound elastography for the pancreas is still small, and there are no reports on some elastography devices for the pancreas. Therefore, these guidelines do not recommend methods of imaging and analysis by elastography device.
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Staufer K, Halilbasic E, Trauner M, Kazemi-Shirazi L. Cystic fibrosis related liver disease--another black box in hepatology. Int J Mol Sci 2014; 15:13529-49. [PMID: 25093717 PMCID: PMC4159809 DOI: 10.3390/ijms150813529] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/10/2014] [Accepted: 07/16/2014] [Indexed: 02/07/2023] Open
Abstract
Due to improved medical care, life expectancy in patients with cystic fibrosis (CF) has veritably improved over the last decades. Importantly, cystic fibrosis related liver disease (CFLD) has become one of the leading causes of morbidity and mortality in CF patients. However, CFLD might be largely underdiagnosed and diagnostic criteria need to be refined. The underlying pathomechanisms are largely unknown, and treatment strategies with proven efficacy are lacking. This review focuses on current invasive and non-invasive diagnostic standards, the current knowledge on the pathophysiology of CFLD, treatment strategies, and possible future developments.
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Affiliation(s)
- Katharina Staufer
- Division of Transplantation, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
| | - Emina Halilbasic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
| | - Lili Kazemi-Shirazi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
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Abstract
PURPOSE OF REVIEW The article reviews advances in gastrointestinal aspects of cystic fibrosis (CF) published in the literature over the past year, and highlights new and interesting research. RECENT FINDINGS Animal models can be used to understand the pathophysiology of gastrointestinal complications in CF. The CF mouse is useful for studying distal intestinal obstruction, dysmotility and dysbiosis, and the CF pig model has helped us better understand meconium ileus and pancreatic and hepatobiliary secretory problems. Studies in humans help elucidate the evolution of pancreatic insufficiency, how reflux may lead to lung disease, problems with intestinal dysmotility, mechanisms leading to pancreatitis and the increased prevalence of gastrointestinal cancer. Biomarkers are shedding light on CF-related liver disease. Rectal biopsies can help in diagnosis and in studying new drugs for CF. SUMMARY Gastrointestinal complications of CF are likely to be seen with increasing frequency as patients with CF lead longer lives. CF animal models and modern research techniques are providing new insights into extrapulmonary complications. CF clinicians should be familiar with diagnosis and management of common gastrointestinal complications and should build bridges with specialists so that referrals can be made when needed.
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