The value of Doppler ultrasound in cirrhosis and portal hypertension

Prediction of Esophageal Varices in Viral Hepatitis C Cirrhosis: Performance of Combined Ultrasonography and Clinical Predictors

Objectives

This study is aimed at evaluating the diagnostic performance of clinical predictors and the Doppler ultrasonography in predicting esophageal varices (EV) in patients with hepatitis C-related cirrhosis and exploring the practical predictors of EV.

Methods

We conducted a prospective study from July 2020 to January 2021, enrolling 65 patients with mild hepatitis C-related cirrhosis. We obtained clinical data and performed grayscale and the Doppler ultrasound to explore the predictors of EV. Esophagogastroduodenoscopy (EGD) was performed as the reference test by the gastroenterologist within a week.

Results

The prevalence of EV in the study was 41.5%. Multivariable regression analysis revealed that gender (female, OR = 4.04, p = 0.02), platelet count (<150000 per ml, OR = 3.13, p = 0.09), splenic length (>11 cm, OR = 3.64, p = 0.02), and absent right hepatic vein (RHV) triphasicity (OR = 3.15, p = 0.03) were significant predictors of EV. However, the diagnostic accuracy indices for isolated predictors were not good (AUROC = 0.63-0.66). A combination of these four predictors increases the diagnostic accuracy in predicting the presence of EV (AUROC = 0.80, 95% CI 0.69-0.91). Furthermore, the Doppler assessment of the right hepatic vein waveform showed good reproducibility (κ = 0.76).

Conclusion

Combining clinical and Doppler ultrasound features can be used as a screening test for predicting the presence of EV in patients with hepatitis C-related cirrhosis. The practical predictors identified in this study could serve as an alternative to invasive EGD in EV diagnosis. Further studies are needed to explore the diagnostic accuracy of additional noninvasive predictors, such as elastography, to improve EV screening.

Incidence, predictive factors and clinical significance of development of portal vein thrombosis in cirrhosis: A prospective study

BACKGROUND AND AIMS

The role of portal vein thrombosis (PVT) in the natural history of cirrhosis is controversial. There are few prospective studies validating risk factors for development of PVT. We analysed the incidence, factors associated with PVT development and its influence on cirrhosis decompensations and orthotopic liver transplant (OLT)-free survival.

METHODS

In this prospective observational study between January 2014 and March 2019, 445 consecutive patients with chronic liver disease were screened and finally 241 with cirrhosis included. Factors associated with PVT development and its influence on cirrhosis decompensations and OLT-free survival by time dependent covariate coding were analysed.

RESULTS

Majority of patients belonged to Child-Pugh class A 184 (76.3%) and the average MELD score was 10 ± 5. Previous cirrhosis decompensations occurred in 125 (52.1%), 63 (26.1%) were on NSBB and 59 (27.2%) had undergone banding for bleeding prophylaxis. Median follow-up was 29 (1-58) months. Cumulative incidence of PVT was 3.7% and 7.6% at 1 and 3 years. Previous decompensation of cirrhosis and low platelet counts but not NSBB independently predicted the development of PVT. During follow-up, 82/236 (34.7%) patients developed cirrhosis decompensations. OLT-free survival was 100% and 82.8% at 3 years, with and without PVT respectively. MELD score, but not PVT, independently predicted cirrhosis decompensations (HR 1.14; 95%CI:1.09-1.19) and OLT-free survival (HR 1.16;95%CI:1.11-1.21).

CONCLUSION

Previous decompensations of cirrhosis and thrombocytopenia predict PVT development in cirrhosis suggesting a pathophysiologic role for severity of portal hypertension. PVT development did not independently predict cirrhosis decompensations or lower OLT-free survival.

Doppler assessment of children with liver cirrhosis and portal hypertension in comparison with a healthy control group: An analytical cross-sectional study

Background:

Doppler ultrasonography (Doppler US) plays an important role in evaluating patients with liver cirrhosis. This study aims to investigate the hemodynamic alterations of hepatic artery and portal vein among children with liver cirrhosis and portal hypertension (esophageal varices).

Materials and Methods:

We conducted an analytical cross-sectional study in Imam Hossein Children's Hospital, Isfahan, Iran, in 2016. A number of 33 cirrhotic children with or without esophageal varices were selected through convenience sampling method to be compared with 19 healthy children as controls using color and spectral Doppler US.

Results:

Portal vein mean velocities were 15.03 ± 7.3 cm/s in cirrhotics, 16.47 ± 6.4 cm/s in controls (P = 0.51), 11.6 ± 4.7 cm/s in patients with varices, and 17.9 ± 7.3 cm/s in patients without varices (P = 0.015). Mean diameters of caudate lobe, portal vein, and splenic vein, as well as the mean values of liver and spleen span, were significantly higher in cirrhotic children. The frequency of flow reversal (hepatofugal flow) was not detected significantly different in cirrhotics. Peak systolic velocity, end diastolic velocity, pulsatility index, and resistive index for hepatic artery as well as liver vascular index were not significantly different in cirrhotics in comparison with controls.

Conclusion:

Alterations in Doppler parameters of portal vein including diameter and velocity may be the helpful indicators of liver cirrhosis and esophageal varices in children, respectively. Parameters of hepatic artery may not differentiate children with liver cirrhosis.

Noninvasive Assessment of Portal Hypertension in Advanced Chronic Liver Disease: An Update

The assessment of portal hypertension is a relevant step in the evaluation of newly diagnosed advanced chronic liver disease (ACLD). The current gold standard includes the invasive evaluation of hepatic venous pressure gradient (HVPG) and endoscopy. However, noninvasive or minimally invasive techniques to assess portal hypertension have been proposed and well established. In the present manuscript, we review clinical studies on the use of noninvasive or minimally invasive techniques to assess portal hypertension in ACLD patients.

The Clinical Importance of Cystatin C and Hepatic Artery Resistive Index in Liver Cirrhosis

Background: Data suggest cystatin C (CysC) levels and hepatic artery resistive index (HARI) correspond to the progression of chronic liver disease. We aimed to evaluate the clinical significance of these parameters in assessment of fibrosis in patients with liver cirrhosis. Methods: The cross-sectional study included 63 patients with liver cirrhosis. A control group consisted of 30 age- and gender-matched healthy persons. Results: We confirmed significantly higher values of CysC in patients with cirrhosis compared to control group (p = 0.036). Average value of HARI in the examined group was increased (0.72 ± 0.06) and there was the statistically significant difference compared to controls (0.66 ± 0.03) (p < 0.001). We found statistically significant correlation between HARI and CysC in the study group. Analyzing the possibility of distinguishing healthy subjects from patients with fibrosis, we have found that the area under the curve is far greater in the HARI index than CysC. Comparison of CysC among Child–Pugh stages and correlation with a model for end-stage liver disease (MELD) score showed statistically significant results. Conclusion: We confirmed HARI is a more accurate parameter than CysC in discriminating healthy subjects from patients with fibrosis, while CysC could be a better indicator of the stage of liver cirrhosis.

Pulsed-wave Doppler ultrasonographic evaluation of hepatic vein in dogs with tricuspid regurgitation

This study was performed to identify the relationships between hepatic vein (HV) measurements, including flow velocity and waveform, using pulsed-wave (PW) Doppler ultrasonography, and the severity of tricuspid regurgitation (TR) in dogs. The study included 22 dogs with TR and 7 healthy dogs. The TR group was subdivided into 3 groups according to TR jet profile obtained by echocardiography. The hepatic venous waveform was obtained and classified into 3 types. A variety of HV measurements, including the maximal velocities of the atrial systolic, systolic (S), end ventricular systolic, and diastolic (D) waves and the ratio of the S- and D- wave velocities (S/D ratio), were acquired. TR severity was significantly correlated with the S- (r = −0.380, p = 0.042) and D- (r = 0.468, p = 0.011) wave velocities and the S/D ratio (r = −0.747, p < 0.001). Receiver operating characteristic curve analysis revealed the highest sensitivity and specificity for the S/D ratio (89% and 75%, respectively) at a threshold of 0.97 with excellent accuracy (AUC = 0.911, p < 0.001). In conclusion, PW Doppler ultrasonography of the HV can be used to identify the presence of significant TR and to classify TR severity in dogs.

A novel technique for the assessment of total liver blood flow in pregnancy: interrater and intrarater agreements

OBJECTIVE

To improve the technique for hepatic blood flow examination, with the objective of investigating the role for Doppler flowmetry of the liver in monitoring pregnant females with pre-eclampsia.

METHODS

Two physicians independently examined a group of 50 healthy pregnant females. The main difference in the proposed technique is the measurement of the vessel cross-sectional area and the adjustment of the Doppler samples according to the diameter of each vessel. The portal vein was studied by using two approaches: in the epigastrium, to measure the diameter, and in the intercostal, for Doppler sample collection. The common hepatic artery was studied by using the epigastric approach. The average of three measurements of each vessel, in each subject, with intrarater and interrater agreements, was compared.

RESULTS

The intraclass correlation coefficient for the intrarater flow measurements of the hepatic artery and portal vein ranged from 0.98 to 0.99 (p < 0.0001). The intraclass correlation coefficients for the interrater flow measurements was 0.93 for the flow of the portal vein (p < 0.0001), 0.94 for the flow of the hepatic artery (p < 0.0001) and 0.96 for the measurement of the portal vein diameter (p < 0.0001).

CONCLUSION

The new technique for evaluation of blood flow to the liver displayed excellent reproducibility, possibly because of the adjustment of the Doppler samples according to the diameter of each vessel. Advances in knowledge: This approach will add reliability to the method. It opens a vast field of investigation given the importance of liver vascular lesions in pre-eclampsia.

Hepatic vein transit time of second-generation ultrasound contrast agent: new tool in the assessment of portal hypertension

PURPOSE

It has been demonstrated that Doppler waveform of the hepatic vein (normally triphasic) is transformed into a biphasic or monophasic waveform in cirrhotic patients. The compressive mechanism of liver tissue has been considered up till now the cause of this change. Moreover, cirrhotics show, after USCA injection, a much earlier HVTT due to intrahepatic shunts. Our aim was to prospectively evaluate the correlation between Doppler pattern of hepatic vein and HVTT of a second-generation USCA; we also correlated HVTT with the most common indexes of portal hypertension.

METHODS

We enrolled 38 participants: 33 cirrhotics and 5 healthy controls. Doppler shift signals were obtained from the right hepatic vein. To characterize the hepatic vein pattern, we used the hepatic vein waveform index (HVWI). This index becomes >1 with the appearance of the triphasic waveform. We recorded a clip from 20 s before to 2 min after a peripheral intravenous bolus injection of 2.4 ml of USCA (sulfur hexafluoride).The time employed by USCA to cross the liver from the hepatic artery and portal vein to the hepatic vein was defined as HA-HVTT and PV-HVTT, respectively.

RESULTS

Cirrhotics with low HVWI showed an earlier transit time; participants with higher HVWI had a longer transit time (p < 0.001). HVTT was earlier as MELD, Child-Pugh score and spleen diameter increased. Patients with ascites and varices of large size had significantly shorter transit times.

CONCLUSIONS

Abnormal hepatic vein Doppler waveform in cirrhotic patients could be due to intrahepatic shunts. HVTT could be useful in the non-invasive evaluation of portal hypertension.

Ascites in the Puerperium in the Context of a Woman with Turner Syndrome Who Conceived through Assisted Reproductive Technology

The case is about a young female who delivered twins by caesarean section (CS). On the 4th postoperative day, she presented with ascites which was resistant to empirical antibiotic and diuretic treatment. The woman was affected by Turner syndrome (TS); she had a medical background of chronic use of hormonal medication since puberty and conceived through ART- (assisted reproduction techniques-) IVF-oocyte donation. It is important to exhibit high suspicion for clot formation in the hepatic vasculature during the puerperium, especially in the case of history of chronic hormone treatment. Ascites albumin gradient and Doppler values lead to the diagnosis of thrombosis and the administration of high doses of anticoagulants is considered to be fundamental.

Value of portal venous system radiological indices in predicting esophageal varices

Introduction

Portal hypertension results from increased resistance to portal blood flow and has the potential complications of variceal bleeding and ascites. The splenoportal veins increase in caliber with worsening portal hypertension, and partially decompress by opening a shunt with systemic circulation, ie, a varix. In the event of portosystemic shunting, there is a differential decompression across the portal vein and splenic vein (portal vein > splenic vein), with a resultant decrease in the ratio of portal vein diameter to that of splenic vein. Portal vein to splenic vein diameter ratio and gradient could be valuable tools in predicting the presence of portosystemic shunting.

Methods

We retrospectively reviewed patients with cirrhosis who underwent esophagogastroduodenoscopy (EGD) for variceal screening and had a computerized tomogram (CT) of the abdomen within 6 months of the index endoscopic study, between January 2009 and December 2013. Patients on nonselective beta blockers, patients with presinusoidal portal hypertension (portal vein thrombosis or extrinsic compression), and patients who had undergone portosystemic shunting procedures (transjugular intrahepatic portosystemic shunt [TIPS]) or balloon-occluded retrograde transvenous obliteration (BRTO) were excluded from the study. Splenic and portal vein diameters were measured (in mm) just proximal and distal to the splenomesenteric venous confluence, respectively.

Results

A total of 164 patients were included in the study; of these, 60% (n=98) were male and 40% (n=66) were female. The mean age of the study population was 58.7 years. A total of 126 patients (77%) had varices, while 38 patients (33%) did not. The mean Model for End-Stage Liver Disease (MELD) score was 5.9 for those who had varices as compared with 7.03 for those who did not. The mean of ratios of portal vein to splenic vein diameters in patients with varices was 1.27 (±0.2), while it was 1.5 (±0.23) in those without varices. This difference was statistically significant (P<0.001). The mean of the gradients between the portal vein and splenic vein diameters was 2.7 (±2) mm for patients with varices as compared with 5 (±1.8) mm in those without varices. This difference was also statistically different (P<0.001). These correlations were statistically significant even after controlling for age, sex, and MELD. These radiological indices also had statistically significant correlations with the presence of gastric varices (P=0.018 for the ratio and P=0.01 for the gradient). A discriminant function analysis was performed that generated the equation: D = 2.68 (ratio of portal vein to splenic vein diameters) + 0.187 (gradient of portal vein to splenic vein diameters, in mm) − 4.152. This equation had a very high sensitivity, of 95%, but low specificity, of 26.3%, in predicting the presence of esophageal varices.

Conclusion

Both venous diameter ratio (portal vein size/splenic vein size) and venous diameter gradient in mm (portal vein size – splenic vein size) calculated from CTs of the abdomen were good predictors of presence of esophageal varices. These parameters might be useful in stratifying patients at risk of developing esophageal varices who are poor candidates for endoscopic evaluation.

Doppler parameters of hepatic and renal hemodynamics in patients with liver cirrhosis

Introduction. There are limited studies on simultaneous evaluation of liver and renal blood flow using Doppler methods. We evaluated and compared the changes of liver and renal Doppler US parameters in patients with liver cirrhosis according to the degree of liver disease. Material and Methods. We assessed a large spectrum of liver and renal Doppler US parameters in 67 patients with liver cirrhosis. Results. Significant differences between Child's classes or score, as well as MELD score, were observed in all investigated intrarenal blood flow Doppler US parameters, except renal artery peak systolic velocity, but only in some of the hepatic ones. The deviations of renal Doppler US parameters were also related with the complications of liver cirrhosis, as well as serum urea and creatinine levels. There was relationship between Doppler US parameters of hepatic artery and the corresponding renal artery Doppler US parameters. The changes of Doppler US parameters were age independent. Conclusion. Our results show, renal Doppler US parameters correlate with the severity and complications of liver cirrhosis. Because of dynamic deviations of renal Doppler US parameters with advance of liver cirrhosis, we recommend Doppler US of renal artery as a part of follow up of these patients.

Liver diffusivity in healthy volunteers and patients with chronic liver disease: comparison of breathhold and free-breathing techniques

PURPOSE

To compare liver ADC obtained with breathhold and free-breathing diffusion weighted imaging (DWI) in healthy volunteers and patients with liver disease.

MATERIALS AND METHODS

Twenty-eight subjects, 12 healthy volunteers and 16 patients (9 NAFLD, 7 chronic active HCV), underwent breathhold (BH) and free-breathing (FB) DWI MRI at 1.5 Tesla. Pearson's correlation coefficient was used to determine correlation while paired t-tests assessed differences between BH and FB ADC. Estimated bias was calculated using the Bland-Altman method.

RESULTS

Liver ADC (×10(-3) mm(2) /s) was lower on BH for all groups (mean difference 0.36 ± 0.20; P < 0.01). ADC was higher in healthy volunteers (BH 1.80 ± 0.18; FB 2.24 ± 0.20) compared with NAFLD patients (BH 1.43 ± 0.27; FB 1.78 ± 0.28) (P < 0.001) and HCV patients (BH 1.63 ± 0.191; FB 1.88 ± 0.12). Overall correlation between BH and FB ADC was (r = 0.75), greatest in NAFLD (r = 0.90) compared with the correlation in HCV (r = 0.24) and healthy subjects (r = 0.34). Bland-Altman plots did not show agreement in mean absolute difference and estimated bias between subjects.

CONCLUSION

Correlation between BH and FB liver ADC is moderate indicating that BH and FB should not be used interchangeably. Additionally, the lower ADC values in BH versus FB should be accounted for when comparing different liver DWI studies.

Doppler assessment of hepatic venous waves for predicting large varices in cirrhotic patients

BACKGROUND/AIM

Color Doppler examination of changes in hepatic venous waveforms is being evaluated as a means of prediction of severity of portal hypertension and presence of esophageal varices. Normal hepatic venous waveform shows a triphasic pattern. In cirrhosis, this pattern changes to a biphasic or monophasic pattern. We aimed to study the sensitivity of loss of normal hepatic venous waveforms in predicting large varices in a cross-sectional analysis.

MATERIALS AND METHODS

All patients, admitted or attending the outpatient department, with a diagnosis of cirrhosis were included in the study. All patients were subjected to oesophagogastroduodenoscopy and Color Doppler examination, and waveform patterns in hepatic vein were recorded. The sensitivity and specificity of changes in waveform in detecting large varices were studied.

RESULTS

A total of 51 cases were examined. Triphasic waves were seen in 4 (7.8%) cases, biphasic in 26 (51%) cases, and monophasic in 21 (41.2%) cases. Small varices were seen in 30 (58.8%) cases and large varices in 21 (41.2%) cases. The sensitivity of loss of the triphasic wave pattern in detecting significant varices (Grade 3 or 4) was very high (95.23%) and negative predictive value was also high (75%). Severity of liver disease as indicated by Child-Pugh and MELD scores did not correlate with changes in hepatic venous waveforms.

CONCLUSION

Loss of triphasic hepatic venous waveform is highly sensitive in predicting significant varices in patients with cirrhosis.

Hepatic artery resistance in children with obesity and fatty liver

OBJECTIVE

The present study assessed whether there is a correlation between hepatic artery resistive index (HARI) and increase of body mass index and hepatosteatosis grading in children with non-alcoholic fatty liver disease (NAFLD) reflecting hemodynamic effects of hepatosteatosis.

METHODS

Thirty three healthy children [body mass index(BMI): mean+/- standart deviation(SD), min-max: 20.1+/-1.14(18.5-23.7), 33 overweight [BMI:25.1+/-2.2 (18.5-23.7)] and 66 obese [BMI:31.1+/-2(25.6-40)] adolescents were enrolled into the study. To search the relation of HARI with fatty liver degree, study subjects subdivided into groups according to their degree of fatty liver at ultrasonography(US).

RESULTS

Increase of HARI was correlated with increase in BMI (p<0.0001, r=0.533). Increase of HARI was well correlated with increase in degree of fatty liver (p<0.0001, r=0.630).

CONCLUSION

The present study results suggest that there are positive correlations of HARI with BMI and hepatosteatosis grade in obese children with NAFLD. HARI may be a candidate parameter to determine early alarming hemodynamic changes in hepatic tissue of obese children with fatty liver before development of severe stages NAFLD.

Performance of Doppler ultrasound in the prediction of severe portal hypertension in hepatitis C virus-related chronic liver disease

PURPOSE

To evaluate the correlation between hepatic vein pressure gradient measurement and Doppler ultrasonography (DUS) in patients with chronic liver disease (CLD).

PATIENTS AND METHODS

Sixty-six patients with fibrotic to cirrhotic hepatitis C virus-related CLD, were consecutively included upon referral to our haemodynamic laboratory. Superior mesenteric artery pulsatility index (SMA-PI), right interlobar renal and intraparenchymal splenic artery resistance indices, were determined, followed by hepatic venous pressure gradient (HVPG) measurement.

RESULTS

A correlation was found between HVPG and intraparenchymal splenic artery resistance index (SA-RI) (r=0.50, P<0.0001), SMA-PI (r=-0,48, P<0.0001), right interlobar renal artery resistance index (RRA-RI) (r=0.51, P<0.0001) in the whole patient population. However, dividing patients according to the presence/absence of severe portal hypertension (i.e. HVPG > or =12 mmHg), a correlation between HVPG and intraparenchymal SA-RI (r=0.70, P<0.0001), SMA-PI (r=-0.49, P=0.02), RRA-RI (r=0.66, P=0.0002) was observed only for HVPG values <12 mmHg. HVPG but not DUS correlated with the presence of esophageal varices (P<0.0001).

CONCLUSIONS

Superior mesenteric artery pulsatility index, intraparenchymal splenic and right interlobar renal artery resistance indices do not adequately predict severe portal hypertension.

Spectral analysing of portal vein Doppler signals in the cirrhosis patients

In this study, we have researched the efficacy of short-time Fourier transformation (STFT) of Doppler signals from the portal veins of healthy volunteers and cirrhosis patients. Sonogram and power spectral distribution for portal vein Doppler spectral waveform changes in the cirrhosis disease were utilized and these graphics compared with healthy volunteers. Five parameters were used to compare power spectrum graphics. Clear differences were detected in the calculated parameters between healthy and cirrhosis patients. It was seen that power spectral graphics and sonograms of portal vein Doppler signals may be used to determine cirrhosis disease.

Recent variceal bleeding: Doppler US hepatic vein waveform in assessment of severity of portal hypertension and vasoactive drug response

PURPOSE

To prospectively evaluate both the correlation between abnormal Doppler ultrasonography (US) hepatic vein waveforms and the hepatic venous pressure gradient (HVPG) and the response to drug treatment in patients with cirrhosis.

MATERIALS AND METHODS

Ethics committee approval and informed consent of patients and control subjects were obtained. In 78 patients with cirrhosis (70 men, eight women; mean age, 49.4 years +/- 9.7 [standard deviation]) and a history of variceal bleeding, both the hepatic vein waveform--as measured with Doppler US--and the HVPG were measured, and the relationship between them was analyzed. Hepatic vein Doppler waveforms were classified as triphasic, biphasic, or monophasic. Severe portal hypertension was defined as an HVPG of more than 15 mm Hg. In a subgroup of 21 patients, changes in hepatic vein waveform and HVPG were evaluated after intravenous administration of 2 mg of terlipressin. Statistical analyses were performed with Spearman rank correlation, logistic regression analysis, and cross tabulation.

RESULTS

Abnormal hepatic vein waveforms were seen in 72 patients (92%). Forty-four patients (56%) had biphasic waveforms, 28 (36%) had monophasic waveforms, and six (8%) had triphasic waveforms. A positive correlation was found between the extent of abnormalities in hepatic vein waveforms and the increase in HVPG (P < .05). Monophasic waveforms were associated with severe portal hypertension, with a sensitivity of 74% and a specificity of 95%. Twenty patients in the terlipressin subgroup had abnormal baseline waveforms; the baseline waveform improved in 18 patients in association with the HVPG reduction after injection of terlipressin.

CONCLUSION

Doppler US hepatic vein waveform assessment is useful in the noninvasive evaluation of the severity of portal hypertension and the response to vasoactive drugs in patients with portal hypertension and variceal bleeding.

Grading and staging of hepatic fibrosis, and its relationship with noninvasive diagnostic parameters

AIM: To explore the grade and stage of pathology and the relationship between grading and staging of hepatic fibrosis and noninvasive diagnostic parameters.

METHODS: Inflammatory activity and fibrosis of consecutive liver biopsies from 200 patients with chronic liver disease were determined according to the Diagnostic Criteria of Chronic Hepatitis in China, 1995. A comparative analysis was made in these patients comparing serum markers, Doppler ultrasonography, CT and/or MR imaging with the findings of liver biopsy.

RESULTS: With increase of inflammatory activity, the degree of fibrosis also rose. There was a close correlation between liver fibrosis and inflammatory activity. AST, GGT, albumin, albumin/globulin, ALP, AFP, hyaluronic acid, N-terminal procollagen III (P III NP), collagen type IV (Col IV), tissue inhibitors of metalloproteinases-1 (TIMP-1), alpha-2-macroglobulin, natural killer cells (NK), some parameters of Doppler ultrasonography, CT and/or MR imaging were all related to the degree of inflammatory activity. GGT, albumin, albumin/globulin, ALP, AFP, hyaluronic acid, Col IV, TIMP-1, alpha-2- macroglobulin, transforming growth factor-beta 1 (TGFβ1), NK, some parameters of Doppler ultrasonography, CT and/or MR imaging were all related to the staging of fibrosis. By regression analysis, the parameters used in combination to differentiate the presence or absence of fibrosis were age, GGT, the parameter of blood flow of portal vein per minute, the maximum oblique diameter of right liver by B ultrasound, the wavy hepatic surface contour by CT and/or MR. The sensitivity, specificity and accuracy of the above parameters were 80.36%, 86.67%, and 81.10%, respectively.

CONCLUSION: There is close correlation between liver fibrosis and inflammatory activity. The grading and staging of liver fibrosis are related to serum markers, Doppler ultrasonography, CT and/or MR imaging. The combination of the above mentioned noninvasive parameters are quite sensitive and specific in the diagnosis of hepatic fibrosis.

Hepatic flow parameters measured with MR imaging and Doppler US: correlations with degree of cirrhosis and portal hypertension

PURPOSE

To determine the correlations between hemodynamic parameters of hepatic flow measured with magnetic resonance (MR) imaging and Doppler ultrasonography (US) and the severity of cirrhosis and portal hypertension.

MATERIALS AND METHODS

Forty-six patients referred for measurements of portal venous pressure (three with normal liver, 12 with chronic hepatitis, and 31 with cirrhosis [10 with Child-Pugh class A cirrhosis; 13 with class B cirrhosis; and eight with class C cirrhosis]) were included in the study. Apparent liver perfusion, apparent arterial and portal perfusion, portal fraction, distribution volume, and mean transit time were measured with dynamic contrast material-enhanced MR imaging. Portal velocity, portal flow, congestion index, right hepatic artery resistance index, and modified hepatic index were measured with Doppler US. Results in patients with cirrhosis and those without cirrhosis were compared with the Wilcoxon rank sum test. Correlations were assessed with Spearman rank correlation coefficients.

RESULTS

With MR imaging, all flow parameters except distribution volume were significantly different between patients with and those without cirrhosis (P <.05). There was a significant correlation between all flow parameters measured with MR imaging and portal pressure (P <.02). Apparent arterial (P =.024) and portal (P <.001) perfusion, portal fraction (P <.001), and mean transit time (P =.004) were correlated with Child-Pugh class. Flow parameters measured with Doppler US did not differ significantly between patients with and those without cirrhosis. Only right hepatic arterial resistance (P <.007) and portal flow (P <.043) were weakly (r < 0.7) correlated with portal pressure. No Doppler US parameter was correlated with Child-Pugh class.

CONCLUSION

Hepatic flow parameters measured with MR imaging correlate with the severity of cirrhosis and portal hypertension. Doppler US parameters are only weakly correlated with portal pressure.

Evaluation of liver functional reserve by combining D-sorbitol clearance rate and CT measured liver volume

AIM: Our research attempted to evaluate the overall functional reserve of cirrhotic liver by combination of hepatic functional blood flow, liver volume, and Child-Pugh’s classification, and to discuss its value of clinical application.

METHODS: Ninety two patients with portal hypertension due to hepatic cirrhosis were investigated. All had a history of haematemesis and hematochezia, esophageal and gastric fundus varices, splenomegaly and hypersplenia. A 2-year follow-up was routinely performed and no one was lost. Twenty two healthy volunteers were used as control group. Blood and urine samples were collected 4 times before and after intravenous D-sorbitol infusion. The hepatic clearance (CL_H) of D-sorbitol was then calculated according to enzymatic spectrophotometric method while the total blood flow (Q_TOTAL) and intrahepatic shunt (R_INS) were detected by multicolor Doppler ultrasound, and the liver volume was measured by spiral CT. Data were estimated by t-test, variance calculation and chi-squared test. The relationships between all these parameters and different groups were investigated according to Child-Pugh classification and postoperative complications respectively.

RESULTS: Steady blood concentration was achieved 120 mins after D-sorbitol intravenous infusion, which was (0.358 ± 0.064) mmol·L^-1 in cirrhotic group and (0.189 ± 0.05) mmol·L^-1 in control group (P < 0.01). CL_H = (812.7 ± 112.4) mL·min^-1, Q_TOTAL = (1280.6 ± 131.4) mL·min^-1, and R_INS = (36.54 ± 10.65)% in cirrhotic group and CL_H = (1248.3 ± 210.5) mL·min^-1, Q_TOTAL = (1362.4 ± 126.9) mL·min^-1, and R_INS = (8.37 ± 3.32)% in control group (P < 0.01). The liver volume of cirrhotic group was 1057 ± 249 cm³, 851 ± 148 cm³ and 663 ± 77 cm³ in Child A, B and C group respectively with significant difference (P < 0.001). The average volume of cirrhotic liver in Child B, C group was significantly reduced in comparison with that in control group (P < 0.001). The patient, whose liver volume decreased by 40% with the CL_H below 600 mL·min^-1, would have a higher incidence of postoperative complications. There was no strict correspondent relationship between CL_H, liver volume and Child-Pugh’s classification.

CONCLUSION: The hepatic clearance of D-sorbitol, CT measured liver volume can be reliably used for the evaluation of hepatic functional blood flow and liver metabolic volume. Combined with the Child-Pugh’s classification, it could be very useful for further understanding the liver functional reserve, therefore help determine reasonable therapeutic plan, choose surgical procedures and operating time.