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Tagliamonte G, Santagata F, Fraquelli M. Current Developments and Role of Intestinal Ultrasound including the Advent of AI. Diagnostics (Basel) 2024; 14:759. [PMID: 38611672 PMCID: PMC11011653 DOI: 10.3390/diagnostics14070759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/18/2024] [Accepted: 03/29/2024] [Indexed: 04/14/2024] Open
Abstract
Intestinal ultrasound is a non-invasive, safe, and cost-effective technique to study the small and large intestines. In addition to conventional B-mode and color doppler imaging, new US tools have been developed in more recent years that provide auxiliary data on many GI conditions, improving the diagnosis and assessment of relevant outcomes. We have reviewed the more recent literature (from 2010 onwards) on auxiliary tools in bowel ultrasound such as elastography techniques, CEUS, SICUS, and the potential contribution by artificial intelligence (AI) to overcome current intestinal ultrasound limitations. For this scoping review, we performed an extensive literature search on PubMed and EMBASE to identify studies published until December 2023 and investigating the application of elastography techniques, CEUS, SICUS, and AI in the ultrasonographic assessment of the small and large intestines. Multiparametric intestinal ultrasound shows promising capabilities in Crohn's disease, while less is known about the role in ulcerative colitis. Despite some evidence, the CEUS role as a point-of-care examination tool for rare conditions such as intestinal GvHD and ischemic small bowel disease seems promising, possibly avoiding the need to perform further cross-sectional imaging. The use of AI in intestinal ultrasound is still anecdotical and limited to acute appendicitis.
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Affiliation(s)
- Gennaro Tagliamonte
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy; (G.T.); (F.S.)
| | - Fabrizio Santagata
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy; (G.T.); (F.S.)
| | - Mirella Fraquelli
- Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
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Bianco C, Pelusi S, Margarita S, Tavaglione F, Jamialahmadi O, Malvestiti F, Periti G, Rondena J, Tomasi M, Carpani R, Ronzoni L, Vidali M, Ceriotti F, Fraquelli M, Vespasiani‐Gentilucci U, Romeo S, Prati D, Valenti L. Predictors of controlled attenuation parameter in metabolic dysfunction. United European Gastroenterol J 2024; 12:364-373. [PMID: 38141028 PMCID: PMC11017762 DOI: 10.1002/ueg2.12513] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/26/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND & AIMS Hepatic fat content can be non-invasively estimated by controlled attenuation parameter (CAP) during transient elastography. The aim of this study was to examine the determinants and predictors of CAP values in individuals with metabolic dysfunction. METHODS We enrolled 1230 consecutive apparently healthy individuals (Liver-Bible-2022 cohort) with ≥3 metabolic dysfunction features. CAP was measured by Fibroscan. CAP determinants and predictors were identified using backward stepwise analysis and introduced in generalized linear models. RESULTS Participants were predominantly males (82.9%), mean age was 53.8 ± 6.4 years, 600 (48.8%) had steatosis (CAP ≥ 275 dB/m), and 27 had liver stiffness measurement (LSM) ≥ 8 kPa. CAP values correlated with LSM (p < 10-22). In multivariable analysis, fasting insulin and abdominal circumference (AC) were the main determinants of CAP (p < 10-6), together with body mass index (BMI; p < 10-4), age, diabetes, triglycerides, ferritin, and lower HDL and thyroid stimulating hormone (TSH; p < 0.05 for all). In a subset of 592 participants with thyroid hormone measurement, we found an association between higher free triiodothyronine levels, correlating with lower TSH, and CAP values, independent of TSH and of levothyroxine treatment (p = 0.0025). A clinical CAP score based on age, BMI, AC, HbA1c, ALT, and HDL predicted CAP ≥ 275 dB/m with moderate accuracy (AUROC = 0.73), which was better than that of the Fatty Liver Index and of ALT (AUROC = 0.70/0.61, respectively) and validated it in multiple cohorts. CONCLUSION Abdominal adiposity and insulin resistance severity were the main determinants of CAP in individuals with metabolic dysfunction and may improve steatotic liver disease risk stratification. CAP values were modulated by the hypophysis-thyroid axis.
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Affiliation(s)
- Cristiana Bianco
- Precision Medicine LabBiological Resource Center and Department of Transfusion MedicineFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Serena Pelusi
- Precision Medicine LabBiological Resource Center and Department of Transfusion MedicineFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Sara Margarita
- Precision Medicine LabBiological Resource Center and Department of Transfusion MedicineFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Federica Tavaglione
- Clinical Medicine and Hepatology UnitDepartment of Internal Medicine and GeriatricsFondazione Policlinico Campus Bio‐MedicoRomeItaly
- Department of Medicine and SurgeryUniversità Campus Bio‐Medico di RomaRomeItaly
| | - Oveis Jamialahmadi
- Department of Molecular and Clinical MedicineInstitute of MedicineSahlgrenska AcademyWallenberg LaboratoryUniversity of GothenburgGothenburgSweden
| | - Francesco Malvestiti
- Department of Pathophysiology and TransplantationUniversità degli Studi di MilanoMilanItaly
| | - Giulia Periti
- Precision Medicine LabBiological Resource Center and Department of Transfusion MedicineFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Jessica Rondena
- Precision Medicine LabBiological Resource Center and Department of Transfusion MedicineFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Melissa Tomasi
- Precision Medicine LabBiological Resource Center and Department of Transfusion MedicineFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Rossana Carpani
- Precision Medicine LabBiological Resource Center and Department of Transfusion MedicineFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Luisa Ronzoni
- Precision Medicine LabBiological Resource Center and Department of Transfusion MedicineFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Matteo Vidali
- Clinical Chemistry Unit and Laboratory MedicineFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Ferruccio Ceriotti
- Clinical Chemistry Unit and Laboratory MedicineFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy UnitFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Umberto Vespasiani‐Gentilucci
- Clinical Medicine and Hepatology UnitDepartment of Internal Medicine and GeriatricsFondazione Policlinico Campus Bio‐MedicoRomeItaly
- Department of Medicine and SurgeryUniversità Campus Bio‐Medico di RomaRomeItaly
| | - Stefano Romeo
- Department of Molecular and Clinical MedicineInstitute of MedicineSahlgrenska AcademyWallenberg LaboratoryUniversity of GothenburgGothenburgSweden
- Clinical Nutrition UnitDepartment of Medical and Surgical SciencesUniversity Magna GraeciaCatanzaroItaly
- Cardiology DepartmentSahlgrenska University HospitalGothenburgSweden
| | - Daniele Prati
- Precision Medicine LabBiological Resource Center and Department of Transfusion MedicineFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Luca Valenti
- Precision Medicine LabBiological Resource Center and Department of Transfusion MedicineFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
- Department of Pathophysiology and TransplantationUniversità degli Studi di MilanoMilanItaly
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3
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Piazza O Sed N, Noviello D, Filippi E, Conforti F, Furfaro F, Fraquelli M, Costantino A, Danese S, Vecchi M, Fiorino G, Allocca M, Caprioli F. Superior predictive value of transmural over endoscopic severity for colectomy risk in ulcerative colitis: a multicentre prospective cohort study. J Crohns Colitis 2024; 18:291-299. [PMID: 37632350 PMCID: PMC10896635 DOI: 10.1093/ecco-jcc/jjad152] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND AND AIMS Endoscopic activity is associated with an increased risk of surgery in patients with ulcerative colitis [UC]. Transmural activity, as defined by Milan Ultrasound Criteria [MUC] > 6.2, reliably detects endoscopic activity in patients with UC. The present study aimed to assess in UC patients whether transmural severity is a better predictor of colectomy as compared to endoscopy. METHODS Consecutive adult UC patients were recruited in two IBD Referral Centres and underwent colonoscopy and intestinal ultrasound in a blinded fashion. The need for colectomy was assessed at follow-up. Univariable and multivariable logistic and Cox regression analyses were performed. Receiver operating characteristic [ROC] analysis was used to compare MUC baseline values and Mayo Endoscopic Scores [MES] in predicting colectomy risk. RESULTS Overall, 141 patients were enrolled, and 13 underwent colectomy in the follow-up period. Both MES (hazard ratio [HR]: 3.15, 95% confidence interval [CI]: 1.18-8.37, p = 0.02) and MUC [HR: 1.48, 95% CI: 1.19-1.76, p < 0.001] were associated with colectomy risk, but only MUC was independently associated with this event on multivariable analysis [HR: 1.46, 95% CI: 1.06-2.02, p = 0.02]. MUC was the only independent variable associated with colectomy risk in patients with clinically active disease (odds ratio [OR]: 1.53 [1.03-2.27], p = 0.03). MUC demonstrated higher accuracy than MES (area under ROC curve [AUROC] 0.83, 95% CI: 0.75-0.92 vs 0.71, 95% CI: 0.62-0.80) and better performance for predicting colectomy [p = 0.02]. The optimal MUC score cut-off value for predicting colectomy, as assessed by the Youden index, was 7.7. CONCLUSIONS A superior predictive value was found for transmural vs endoscopic severity for colectomy risk in UC patients.
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Affiliation(s)
- Nicole Piazza O Sed
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Noviello
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Elisabetta Filippi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Francesco Conforti
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Furfaro
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele Milano, Milan, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Costantino
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele Milano, Milan, Italy
- University Vita-Salute San Raffaele Milano, Milan, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Gionata Fiorino
- University Vita-Salute San Raffaele Milano, Milan, Italy
- IBD Unit, Gastroenterology and Digestive Endoscopy, San Camillo-Forlanini Hospital, Rome, Italy
| | - Mariangela Allocca
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele Milano, Milan, Italy
| | - Flavio Caprioli
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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4
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Rossi RE, Busacca A, Brandaleone L, Masoni B, Massironi S, Fraquelli M, Repici A. Small Bowel Imaging in Celiac Disease: Is there a role for Small Bowel Ultrasound? Curr Gastroenterol Rep 2023; 25:430-439. [PMID: 37979097 DOI: 10.1007/s11894-023-00907-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE OF REVIEW The incidence of celiac disease (CD) has increased over the last decades in part due to better disease awareness. Small bowel ultrasound (sb US) enables dynamic assessment of the bowel; although this topic has been addressed, the use of sb US in the diagnosis and in the follow-up of CD patients is limited to a few specialized tertiary referral centers. Herein, we aimed at summarizing the available literature on this topic to better define the potential clinical implications of sb US in CD, also through a comparison with other available diagnostic techniques. RECENT FINDINGS According to available data, sb US can be of help in confirming or excluding CD in patients with clinical suspicion; specifically, the finding of increased gall bladder volume, free abdominal fluid and enlargement of mesenteric lymph nodes reliably and accurately predicts the diagnosis of CD, whereas the absence of bowel dilatation and increased peristalsis may exclude the diagnosis. However, the place of intestinal US in the diagnostic algorithm of CD is likely to vary depending on the probability of the disease in a given population. There are only a few studies on the role of sb US in complicated CD, even if recent reports suggest a possible clinical role. There is a lack of data on follow-up of CD patients, particularly with the aim of detecting a poor diet adherence. According to current data sb US parameters have been shown to be of value in confirming and excluding the diagnosis of CD. Prospective studies with large sample size are warranted to determine whether to include sb US in the available guidelines for CD diagnosis and monitoring.
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Affiliation(s)
- Roberta Elisa Rossi
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Anita Busacca
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Luca Brandaleone
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Benedetta Masoni
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Sara Massironi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Ospedale San Gerardo, and Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandro Repici
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
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5
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Costantino A, Piagnani A, Caccia R, Sorge A, Maggioni M, Perbellini R, Donato F, D'Ambrosio R, Sed NPO, Valenti L, Prati D, Vecchi M, Lampertico P, Fraquelli M. Reproducibility and accuracy of a pocket-size ultrasound device in assessing liver steatosis. Dig Liver Dis 2023:S1590-8658(23)01032-0. [PMID: 38016894 DOI: 10.1016/j.dld.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/07/2023] [Accepted: 11/09/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND This diagnostic prospective study compared the feasibility and diagnostic accuracy of Pocket-size Ultrasound Devices (PUDs) against standard ultrasound (US) in detecting liver steatosis using the controlled attenuation parameter (CAP) and liver biopsy as reference standards. MATERIALS AND METHODS Consecutive patients with chronic liver diseases were assessed for the presence of steatosis using PUD and US. A CAP cut-off value >275 dB/m was applied to establish ≥S1. A 26-patient subgroup underwent liver biopsy. PUD reproducibility was evaluated using Cohen's k statistic. Diagnostic accuracy of PUD and US was given as Sensibility (Sn), Specificity (Sp), Positive and Negative Predictive Values (PPV, NPV), positive and negative Likelihood Ratio (LR+, LR-). RESULTS 81 consecutive patients (69% males) with multiple etiologies were enroled. PUD inter-observer agreement was good (k 0.77, 95%CI 0.62-0.93). PUD and US identified ≥S1 according to CAP values respectively with Sn 0.87, Sp 0.61, PPV 0.49, NPV 0.91, LR+ 2.04, LR- 0.07, AUROC 0.74 and Sn 0.96, Sp 0.54, PPV 0.47, NPV 0.97, LR+ 2.10, LR- 0.07, AUROC 0.75. CONCLUSIONS PUD shows good reproducibility and diagnostic accuracy in ruling liver steatosis out, representing a useful point-of-care tool to avail of hepatologists interested in excluding NAFLD, but with basic US skills.
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Affiliation(s)
- Andrea Costantino
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Gastroenterology and Endoscopy Unit, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alessandra Piagnani
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Riccardo Caccia
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Andrea Sorge
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Marco Maggioni
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Pathology Unit, Milan, Italy
| | - Riccardo Perbellini
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Gastroenterology and Hepatology Unit, Milan, Italy
| | - Francesca Donato
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Gastroenterology and Hepatology Unit, Milan, Italy
| | - Roberta D'Ambrosio
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Gastroenterology and Hepatology Unit, Milan, Italy
| | - Nicole Piazza O Sed
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Gastroenterology and Endoscopy Unit, Milan, Italy
| | - Luca Valenti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy Translational Medicine, Department of Transfusion Medicine and Hematology, Milan, Italy
| | - Daniele Prati
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy Translational Medicine, Department of Transfusion Medicine and Hematology, Milan, Italy
| | - Maurizio Vecchi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Gastroenterology and Endoscopy Unit, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Pietro Lampertico
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Gastroenterology and Hepatology Unit, Milan, Italy; CRC "A. M. and A. Migliavacca" Center for Liver Disease, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Mirella Fraquelli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Gastroenterology and Endoscopy Unit, Milan, Italy.
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6
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Dajti E, Ravaioli F, Zykus R, Rautou PE, Elkrief L, Grgurevic I, Stefanescu H, Hirooka M, Fraquelli M, Rosselli M, Chang PEJ, Piscaglia F, Reiberger T, Llop E, Mueller S, Marasco G, Berzigotti A, Colli A, Festi D, Colecchia A. Accuracy of spleen stiffness measurement for the diagnosis of clinically significant portal hypertension in patients with compensated advanced chronic liver disease: a systematic review and individual patient data meta-analysis. Lancet Gastroenterol Hepatol 2023; 8:816-828. [PMID: 37478880 DOI: 10.1016/s2468-1253(23)00150-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/06/2023] [Accepted: 05/10/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND The diagnosis of clinically significant portal hypertension is crucial for prognosis and treatment guidance in patients with compensated advanced chronic liver disease (ACLD). Spleen stiffness measurement (SSM) might improve the non-invasive diagnosis of clinically significant portal hypertension, but previous studies have reported heterogeneous SSM cutoffs. We aimed to evaluate the accuracy of SSM and SSM-based algorithms in this setting. METHODS In this systematic review and individual patient data meta-analysis, we searched PubMed, Embase, Scopus, Web of Science, and the Cochrane Library from database inception to Dec 31, 2022, for articles, abstracts, and letters, with no restrictions on language. Cross-sectional studies reporting hepatic venous pressure gradient and SSM by different techniques (transient elastography; two-dimensional shear-wave elastography [2D-SWE]; point shear-wave elastography [p-SWE]) in adults (≥18 years) with compensated ACLD were eligible for inclusion. The main outcome was the diagnostic performance of two SSM-based algorithms, with the Baveno VII model as a reference, evaluating sensitivity and specificity, as well as summary negative predictive values (NPVs) and positive predictive values (PPVs). In the Baveno VII model, clinically significant portal hypertension was ruled out if patients had a liver stiffness measurement (LSM) of 15 kPa or less and a platelet count of 150 × 109 platelets per L or higher and ruled in if they had an LSM of greater than 25 kPa. The two SSM-based models combined these same cutoffs with additional criteria. In the Baveno VII-SSM single cutoff model, clinically significant portal hypertension was ruled out if at least two of the following were present: LSM of 15 kPa or less, platelet count of 150 × 109 platelets per L or higher, and SSM of 40 kPa or less; and ruled in if at least two were present: LSM of greater than 25 kPa, platelet count of less than 150 × 109 platelets per L, and SSM of greater than 40 kPa. The Baveno VII-SSM dual cutoff model used the same criteria, but with a cutoff of SSM of less than 21 kPa to rule out, and greater than 50 kPa to rule in, clinically significant portal hypertension. This study is registered with PROSPERO, CRD42019127164. FINDINGS Of the 44 records assessed for eligibility, 17 studies (with 1245 patients) were included in the meta-analysis. In the transient elastography cohort (n=600), the Baveno VII algorithm was validated for both ruling out (NPV 100%, 95% CI 64-100; sensitivity 100%, 95% CI 70-100) and ruling in (PPV 95%, 85-98; specificity 94%, 95% CI 87-97) clinically significant portal hypertension, but the proportion of patients with indeterminate results (grey zone) was 48% (95% CI 44-52); 57% (95% CI 52-62) of patients with clinically significant portal hypertension were included in the rule-in zone. The Baveno VII-SSM dual cutoff model had adequate NPV (98%, 95% CI 58-100; sensitivity 100%, 95% CI 91-100) and PPV (93%, 95% CI 84-97; specificity 89%, 95% CI 84-93), with 32% (95% CI 28-36) of patients in the grey zone; 76% (95% CI 72-80) of the patients with clinically significant portal hypertension were in the rule-in zone. The Baveno VII-SSM single cutoff model had a sensitivity of 93% (95% CI 85-97) and a NPV of 85% (95% CI 60-96) for ruling out, and a specificity of 86% (95% CI 80-91) and a PPV of 92% (95% CI 83-95) for ruling in, clinically significant portal hypertension. 88% (95% CI 84-91) of patients with clinically significant portal hypertension were included in the rule-in zone and 9% (95% CI 7-12) of patients were in the grey zone. In the 2D-SWE cohort (n=225), all three algorithms could safely rule in clinically significant portal hypertension with adequate PPV (≥90%), but NPV was inadequate for ruling out clinically significant portal hypertension. Insufficient data were available to evaluate the performance of SSM assessed by p-SWE. Heterogeneity was low (I2<25%) for most estimates. INTERPRETATION Algorithms combining Baveno VII criteria with SSM showed good performance and reduced the diagnostic grey zone for clinically significant portal hypertension compared with Baveno VII criteria alone. Future studies should evaluate whether SSM-based diagnosis allows for the identification of patients who would benefit from non-selective β-blocker treatment. FUNDING None.
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Affiliation(s)
- Elton Dajti
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, European Reference Network on Hepatological Diseases, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Federico Ravaioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Department of Medical Specialities, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Romanas Zykus
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Pierre-Emmanuel Rautou
- Centre de Recherche sur l'Inflammation, Inserm, Université Paris-Cité, Paris, France; Service d'Hépatologie, Hôpital Beaujon, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, European Reference Network on Hepatological Diseases, Clichy, France
| | - Laure Elkrief
- Hepatogastroenterology Unit, Hôpital Trousseau, CHRU de Tours, Tours, France
| | - Ivica Grgurevic
- Department of Gastroenterology, Hepatology and Clinical Nutrition, University Hospital Dubrava, University of Zagreb School of Medicine and Faculty of Pharmacy and Biochemistry, Zagreb, Croatia
| | - Horia Stefanescu
- Hepatology Department, Octavian Fodor Regional Institute of Gastroenterology and Hepatology, luliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Masashi Hirooka
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Matteo Rosselli
- Department of Internal Medicine, Ospedale San Giuseppe, Empoli, Italy; Division of Medicine, Institute for Liver and Digestive Health, University College London, Royal Free Hospital, London, UK
| | - Pik Eu Jason Chang
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Fabio Piscaglia
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, European Reference Network on Hepatological Diseases, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Thomas Reiberger
- Department of Internal Medicine III, Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Elba Llop
- Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Universidad Autònoma de Madrid, Madrid, Spain
| | - Sebastian Mueller
- Department of Internal Medicine, Center for Alcohol Research, University of Heidelberg, Heidelberg, Germany
| | - Giovanni Marasco
- Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, European Reference Network on Hepatological Diseases, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Agostino Colli
- Department of Transfusion Medicine and Haematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Antonio Colecchia
- Department of Medical Specialities, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy.
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Fraquelli M, Fichera A. Ultrasound-based elastography combined with Baveno VI criteria: A new era begins in the prediction of high-risk varices in cirrhotic patients. Dig Liver Dis 2023; 55:1060-1061. [PMID: 37164893 DOI: 10.1016/j.dld.2023.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 04/25/2023] [Accepted: 04/28/2023] [Indexed: 05/12/2023]
Affiliation(s)
- Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy.
| | - Anna Fichera
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan 20122, Italy
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Colli A, Fraquelli M, Prati D, Casazza G. Granulocyte colony-stimulating factor with or without stem or progenitor cell or growth factors infusion for people with compensated or decompensated advanced chronic liver disease. Cochrane Database Syst Rev 2023; 6:CD013532. [PMID: 37278488 PMCID: PMC10243114 DOI: 10.1002/14651858.cd013532.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Advanced chronic liver disease is characterised by a long compensated phase followed by a rapidly progressive 'decompensated' phase, which is marked by the development of complications of portal hypertension and liver dysfunction. Advanced chronic liver disease is considered responsible for more than one million deaths annually worldwide. No treatment is available to specifically target fibrosis and cirrhosis; liver transplantation remains the only curative option. Researchers are investigating strategies to restore liver functionality to avoid or slow progression towards end-stage liver disease. Cytokine mobilisation of stem cells from the bone marrow to the liver could improve liver function. Granulocyte colony-stimulating factor (G-CSF) is a 175-amino-acid protein currently available for mobilisation of haematopoietic stem cells from the bone marrow. Multiple courses of G-CSF, with or without stem or progenitor cell or growth factors (erythropoietin or growth hormone) infusion, might be associated with accelerated hepatic regeneration, improved liver function, and survival. OBJECTIVES To evaluate the benefits and harms of G-CSF with or without stem or progenitor cell or growth factors (erythropoietin or growth hormone) infusion, compared with no intervention or placebo in people with compensated or decompensated advanced chronic liver disease. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, three other databases, and two trial registers (October 2022) together with reference-checking and web-searching to identify additional studies. We applied no restrictions on language and document type. SELECTION CRITERIA We only included randomised clinical trials comparing G-CSF, independent of the schedule of administration, as a single treatment or combined with stem or progenitor cell infusion, or with other medical co-interventions, with no intervention or placebo, in adults with chronic compensated or decompensated advanced chronic liver disease or acute-on-chronic liver failure. We included trials irrespective of publication type, publication status, outcomes reported, or language. DATA COLLECTION AND ANALYSIS We followed standard Cochrane procedures. All-cause mortality, serious adverse events, and health-related quality of life were our primary outcomes, and liver disease-related morbidity, non-serious adverse events, and no improvement of liver function scores were our secondary outcomes. We undertook meta-analyses, based on intention-to-treat, and presented results using risk ratios (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CI) and I2 statistic values as a marker of heterogeneity. We assessed all outcomes at maximum follow-up. We determined the certainty of evidence using GRADE, evaluated the risk of small-study effects in regression analyses, and conducted subgroup and sensitivity analyses. MAIN RESULTS We included 20 trials (1419 participants; sample size ranged from 28 to 259), which lasted between 11 and 57 months. Nineteen trials included only participants with decompensated cirrhosis; in one trial, 30% had compensated cirrhosis. The included trials were conducted in Asia (15), Europe (four), and the USA (one). Not all trials provided data for our outcomes. All trials reported data allowing intention-to-treat analyses. The experimental intervention consisted of G-CSF alone or G-CSF plus any of the following: growth hormone, erythropoietin, N-acetyl cysteine, infusion of CD133-positive haemopoietic stem cells, or infusion of autologous bone marrow mononuclear cells. The control group consisted of no intervention in 15 trials and placebo (normal saline) in five trials. Standard medical therapy (antivirals, alcohol abstinence, nutrition, diuretics, β-blockers, selective intestinal decontamination, pentoxifylline, prednisolone, and other supportive measures depending on the clinical status and requirement) was administered equally to the trial groups. Very low-certainty evidence suggested a decrease in mortality with G-CSF, administered alone or in combination with any of the above, versus placebo (RR 0.53, 95% CI 0.38 to 0.72; I2 = 75%; 1419 participants; 20 trials). Very low-certainty evidence suggested no difference in serious adverse events (G-CSF alone or in combination versus placebo: RR 1.03, 95% CI 0.66 to 1.61; I2 = 66%; 315 participants; three trials). Eight trials, with 518 participants, reported no serious adverse events. Two trials, with 165 participants, used two components of the quality of life score for assessment, with ranges from 0 to 100, where higher scores indicate better quality of life, with a mean increase from baseline of the physical component summary of 20.7 (95% CI 17.4 to 24.0; very low-certainty evidence) and a mean increase from baseline of the mental component summary of 27.8 (95% CI 12.3 to 43.3; very low-certainty evidence). G-CSF, alone or in combination, suggested a beneficial effect on the proportion of participants who developed one or more liver disease-related complications (RR 0.40, 95% CI 0.17 to 0.92; I2 = 62%; 195 participants; four trials; very low-certainty evidence). When we analysed the occurrences of single complications, there was no suggestion of a difference between G-CSF, alone or in combination, versus control, in participants in need of liver transplantation (RR 0.85, 95% CI 0.39 to 1.85; 692 participants; five trials), in the development of hepatorenal syndrome (RR 0.65, 95% CI 0.33 to 1.30; 520 participants; six trials), in the occurrence of variceal bleeding (RR 0.68, 95% CI 0.37 to 1.23; 614 participants; eight trials), and in the development of encephalopathy (RR 0.56, 95% CI 0.31 to 1.01; 605 participants; seven trials) (very low-certainty evidence). The same comparison suggested that G-CSF reduces the development of infections (including sepsis) (RR 0.50, 95% CI 0.29 to 0.84; 583 participants; eight trials) and does not improve liver function scores (RR 0.67, 95% CI 0.53 to 0.86; 319 participants; two trials) (very low-certainty evidence). AUTHORS' CONCLUSIONS G-CSF, alone or in combination, seems to decrease mortality in people with decompensated advanced chronic liver disease of whatever aetiology and with or without acute-on-chronic liver failure, but the certainty of evidence is very low because of high risk of bias, inconsistency, and imprecision. The results of trials conducted in Asia and Europe were discrepant; this could not be explained by differences in participant selection, intervention, and outcome measurement. Data on serious adverse events and health-related quality of life were few and inconsistently reported. The evidence is also very uncertain regarding the occurrence of one or more liver disease-related complications. We lack high-quality, global randomised clinical trials assessing the effect of G-CSF on clinically relevant outcomes.
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Affiliation(s)
- Agostino Colli
- Department of Transfusion Medicine and Haematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Prati
- Department of Transfusion Medicine and Haematology, Ospedale Alessandro Manzoni, Lecco, Italy
| | - Giovanni Casazza
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Colli A, Fraquelli M, Casazza G. Are there any reliable predictors of unreported alcohol consumption in individuals with MAFLD? J Hepatol 2023; 78:e65-e66. [PMID: 35760222 DOI: 10.1016/j.jhep.2022.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/09/2022] [Indexed: 01/24/2023]
Affiliation(s)
- Agostino Colli
- The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Center for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Transfusion Medicine and Haematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mirella Fraquelli
- The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Center for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Giovanni Casazza
- Dipartimento di Scienze Cliniche e di Comunità, Universita' Degli Studi di Milano, Milan, Italy
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Fraquelli M, Vranić L, Nadarevic T, Štimac D, Manzotti C, Fichera A, Casazza G, Colli A. Liver and spleen stiffness for the diagnosis of oesophageal varices in adults with chronic liver disease. Cochrane Database Syst Rev 2023; 2023:CD015547. [PMCID: PMC9890918 DOI: 10.1002/14651858.cd015547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This is a protocol for a Cochrane Review (diagnostic). The objectives are as follows: To assess the diagnostic accuracy of liver stiffness and spleen stiffness, separately or in combination, as measured by vibration‐controlled transient elastography (VCTE) in detection of any oesophageal varices in adults with chronic liver disease. We will regard a combination of tests as positive when at least one is positive. To compare the diagnostic accuracy of individual tests (liver stiffness and spleen stiffness measured by VCTE) directly and versus the combination of both tests (considering positive when at least one is positive) in detecting any oesophageal varices. To assess the diagnostic accuracy of liver stiffness and spleen stiffness, separately or in combination, as measured by other elastography techniques (2D‐shear wave elastography (2D‐SWE), point shear wave elastography (pSWE), magnetic resonance elastography (MRE)) in detection of any oesophageal varices in adults with chronic liver disease. We will regard a combination of tests as positive when at least one is positive. To compare the diagnostic accuracy of liver stiffness and spleen stiffness measured by VCTE with other techniques (pSWE, 2D‐SWE, MRE) in detection of any oesophageal varices in adults with chronic liver disease.
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Affiliation(s)
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy UnitFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, MilanoMilanItaly
| | - Luka Vranić
- Department of GastroenterologyClinical Hospital Centre RijekaRijekaCroatia
| | - Tin Nadarevic
- Department of RadiologyClinical Hospital Centre RijekaRijekaCroatia
| | - Davor Štimac
- Department of GastroenterologyClinical Hospital Centre RijekaRijekaCroatia
| | - Cristina Manzotti
- Department of Pathophysiology and TransplantationUniversità degli Studi di MilanoMilanItaly
| | - Anna Fichera
- UOC di Gastroenterologia ed EpatologiaPoliclinico Paolo GiacconePalermoItaly
| | - Giovanni Casazza
- Department of Clinical Sciences and Community Health – Laboratory of Medical Statistics, Biometry and Epidemiology "G.A. Maccacaro"Università degli Studi di MilanoMilanItaly
| | - Agostino Colli
- Department of Transfusion Medicine and HaematologyFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
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Degasperi E, Anolli MP, Uceda Renteria SC, Sambarino D, Borghi M, Perbellini R, Scholtes C, Facchetti F, Loglio A, Monico S, Fraquelli M, Costantino A, Ceriotti F, Zoulim F, Lampertico P. Bulevirtide monotherapy for 48 weeks in patients with HDV-related compensated cirrhosis and clinically significant portal hypertension. J Hepatol 2022; 77:1525-1531. [PMID: 35973578 DOI: 10.1016/j.jhep.2022.07.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/19/2022] [Accepted: 07/24/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Bulevirtide (BLV) has recently been conditionally approved for the treatment of chronic hepatitis delta (CHD) in Europe, but its effectiveness and safety in patients with compensated cirrhosis and clinically significant portal hypertension (CSPH) are unknown. METHODS Consecutive patients with HDV-related compensated cirrhosis and CSPH who started BLV 2 mg/day were enrolled in this single-center study. Clinical/virological characteristics were collected at baseline, weeks 4, 8 and every 8 weeks thereafter. HDV RNA was quantified by Robogene 2.0 (lower limit of detection 6 IU/ml). RESULTS Eighteen Caucasian patients with compensated cirrhosis and CSPH under nucleos(t)ide analogue treatment were enrolled: median (IQR) age was 48 (29-77) years, and 67% were male. Median (IQR) platelet count was 70 (37-227) x103/μl, liver stiffness measurement (LSM) 16.4 (7.8-57.8) kPa, alanine aminotransferase (ALT) 106 (32-222) U/L, HBsAg 3.7 (2.5-4.3) log IU/ml, HDV RNA 4.9 (3.3-6.6) log IU/ml. During 48 weeks of BLV monotherapy, HDV RNA declined by 3.1 (0.2-4.3) log IU/ml (p <0.001 vs. baseline), becoming undetectable in 5 patients (23%). A virological response was observed in 14 (78%) patients while a non-response was observed in 2 (11%). ALT decreased to 35 (15-86) U/L (p <0.001 vs. baseline), normalizing in 83% of patients. A combined response was observed in 67% of patients. Aspartate aminotransferase and gamma-glutamyltransferase levels significantly improved. Concerning liver function parameters, albumin values significantly increased and bilirubin remained stable. LSM significantly improved in patients with virological response, while platelet count was unchanged. None of the patients developed decompensating events or hepatocellular carcinoma. BLV was well tolerated, no patient discontinued treatment and the increase in bile acids was fully asymptomatic. CONCLUSIONS A 48-week course of BLV 2 mg/day monotherapy is safe and effective even for difficult-to treat patients with HDV-related compensated cirrhosis and CSPH. LAY SUMMARY Hepatitis delta virus (HDV) is associated with the most severe form of viral hepatitis. A new treatment for HDV called bulevirtide has recently received conditional approval for patients with chronic HDV infection. However, its safety and effectiveness in patients with more advanced liver disease is not known. Herein, we show that it is safe and effective in patients with HDV-related cirrhosis and clinically significant portal hypertension.
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Affiliation(s)
- Elisabetta Degasperi
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, Milan, Italy
| | - Maria Paola Anolli
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, Milan, Italy
| | | | - Dana Sambarino
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, Milan, Italy
| | - Marta Borghi
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, Milan, Italy
| | - Riccardo Perbellini
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, Milan, Italy
| | - Caroline Scholtes
- Hepatology Department, Hospices Civils de Lyon (HCL) and Université Claude Bernard Lyon 1 (UCBL1), Lyon, France; INSERM U1052, Centre de Recherche sur le Cancer de Lyon (CRCL), France
| | - Floriana Facchetti
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, Milan, Italy
| | - Alessandro Loglio
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, Milan, Italy
| | - Sara Monico
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, Milan, Italy
| | - Mirella Fraquelli
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Endoscopy, Milan, Italy
| | - Andrea Costantino
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Endoscopy, Milan, Italy
| | - Ferruccio Ceriotti
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Virology Unit, Milan, Italy
| | - Fabien Zoulim
- Hepatology Department, Hospices Civils de Lyon (HCL) and Université Claude Bernard Lyon 1 (UCBL1), Lyon, France; INSERM U1052, Centre de Recherche sur le Cancer de Lyon (CRCL), France
| | - Pietro Lampertico
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, Milan, Italy; CRC "A. M. and A. Migliavacca" Center for Liver Disease, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
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12
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Pessarelli T, Basilisco G, Spina L, Fraquelli M. Intestinal pseudo-obstruction caused by Giardia lambliainfection. BMJ Case Rep 2022; 15:15/11/e252319. [DOI: 10.1136/bcr-2022-252319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A woman in her 40s presented with malaise, nausea, reduced appetite, abdominal distention, loose stools and weight loss. Symptoms had started 6 months earlier and worsened in the last 2 weeks. CT enterography showed hypotonic dilated small bowel loops in absence of any mechanical obstruction. Endoscopic examinations including capsule endoscopy did not reveal any obstructing lesion, but a delayed small bowel transit time of the capsule. Duodenal histology revealed Marsh 3a villous atrophy. Secondary causes of intestinal pseudo-obstruction and villous atrophy were investigated.Giardia lambliatrophozoites were found in the stools and in the duodenal biopsies. The patient’s symptoms quickly resolved after metronidazole treatment with complete normalisation of duodenal histology.
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Rigamonti C, Cittone MG, Manfredi GF, Sorge A, Moia R, Patriarca A, Donato MF, Gaidano G, Pirisi M, Fraquelli M. High reproducibility of spleen stiffness measurement by vibration-controlled transient elastography with a spleen-dedicated module. Hepatol Commun 2022; 6:3006-3014. [PMID: 36082990 PMCID: PMC9592765 DOI: 10.1002/hep4.2070] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/29/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023] Open
Abstract
Spleen stiffness measurement (SSM) by vibration-controlled transient elastography (VCTE) is a noninvasive technique for estimating portal hypertension in patients with chronic liver disease (CLD), with its reproducibility yet to be established and its feasibility still unknown beyond CLD. We have studied 420 participants from two tertiary referral centers for liver diseases (Novara, Milan): 297 patients with CLD (32% with cirrhosis) of different etiology (Group A), 63 Philadelphia-negative myeloproliferative neoplasms (Group B), and 60 heathy volunteers (Group C). All underwent SSM by VCTE with a spleen-dedicated module (SSM@100 Hz) and liver stiffness measurement (LSM), blindly performed by 2 different operators. In total, 1680 VCTE examinations for SSM were performed (1000 in Novara, 680 in Milan), with an overall 3.2% failure rate. Median SSM was 26.5 kPa (interquartile range [IQR] 20.0-42.3) in Group A, 26.3 kPa (IQR 22.3-33.6) in Group B, and 16.1 kPa (IQR 14.6-18.7) in Group C. In Group A, the median LSM was 6.8 kPa (IQR 4.9-11.3) in Novara and 8.3 kPa (IQR 7.1-10.8) in Milan, the proportion of patients with cirrhosis being 34% in Novara and 31% in Milan. The Group A interobserver agreement ICC was 0.90 (0.88-0.92), significantly lower in the absence of splenomegaly (ICC 0.87 vs. 0.91) and in absence of cirrhosis (ICC 0.84 vs. 0.90); overweight slightly, but not significantly reduced the interobserveragreement. The intra-observer agreement ICC ranged from 0.91 to 0.96 for the four operators. The Group B interobserver agreement ICC was 0.90 (0.83-0.94). In conclusion, SSM measured by the new spleen-dedicated VCTE module is a feasible, reliable, and highly reproducible tool in patients with CLD and hematological disorders, and in healthy volunteers.
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Affiliation(s)
- Cristina Rigamonti
- Department of Translational MedicineUniversità del Piemonte Orientale and Division of Internal Medicine, Azienda Ospedaliero‐Universitaria Maggiore della CaritàNovaraItaly
| | - Micol Giulia Cittone
- Department of Translational MedicineUniversità del Piemonte Orientale and Division of Internal Medicine, Azienda Ospedaliero‐Universitaria Maggiore della CaritàNovaraItaly
| | - Giulia Francesca Manfredi
- Department of Translational MedicineUniversità del Piemonte Orientale and Division of Internal Medicine, Azienda Ospedaliero‐Universitaria Maggiore della CaritàNovaraItaly
| | - Andrea Sorge
- Gastroenterology and Endoscopy UnitFondazione IRCCS Ca' Granda–Ospedale Maggiore PoliclinicoMilanItaly
| | - Riccardo Moia
- Division of Hematology, Department of Translational MedicineUniversità del Piemonte Orientale and Azienda Ospedaliero–Universitaria Maggiore della CaritàNovaraItaly
| | - Andrea Patriarca
- Division of Hematology, Department of Translational MedicineUniversità del Piemonte Orientale and Azienda Ospedaliero–Universitaria Maggiore della CaritàNovaraItaly
| | - Maria Francesca Donato
- Gastroenterology and Hepatology UnitFondazione IRCCS Ca' Granda–Ospedale Maggiore PoliclinicoMilanItaly
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational MedicineUniversità del Piemonte Orientale and Azienda Ospedaliero–Universitaria Maggiore della CaritàNovaraItaly
| | - Mario Pirisi
- Department of Translational MedicineUniversità del Piemonte Orientale and Division of Internal Medicine, Azienda Ospedaliero‐Universitaria Maggiore della CaritàNovaraItaly
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy UnitFondazione IRCCS Ca' Granda–Ospedale Maggiore PoliclinicoMilanItaly
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Fraquelli M, Nadarevic T, Colli A, Manzotti C, Giljaca V, Miletic D, Štimac D, Casazza G. Contrast-enhanced ultrasound for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease. Cochrane Database Syst Rev 2022; 9:CD013483. [PMID: 36053210 PMCID: PMC9438628 DOI: 10.1002/14651858.cd013483.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Hepatocellular carcinoma occurs mostly in people with chronic liver disease. Worldwide, it ranks sixth in terms of incidence of cancer, and fourth in terms of cancer-related deaths. Contrast-enhanced ultrasound (CEUS) is used as an add-on test to confirm the presence of focal liver lesions suspected as hepatocellular carcinoma after prior diagnostic tests such as abdominal ultrasound or measurement of alpha-foetoprotein, or both. According to guidelines, a single contrast-enhanced imaging investigation, with either computed tomography (CT) or magnetic resonance imaging (MRI), may show the typical hepatocellular carcinoma hallmarks in people with cirrhosis, which will be sufficient to diagnose hepatocellular carcinoma. However, a significant number of hepatocellular carcinomas show atypical imaging features, and therefore, are missed at imaging. Dynamic CEUS images are obtained similarly to CT and MRI images. CEUS differentiates between arterial and portal venous phases, in which sonographic hepatocellular carcinoma hallmarks, such as arterial hyperenhancement and subsequent washout appearance, are investigated. The advantages of CEUS over CT and MRI include real-time imaging, use of contrast agents that do not contain iodine and are not nephrotoxic, and quick image acquisition. Despite the advantages, the use of CEUS in the diagnostic algorithm for HCC remains controversial, with disagreement on relevant guidelines. There is no clear evidence of the benefit of surveillance programmes in terms of overall survival as the conflicting results can be a consequence of an inaccurate detection, ineffective treatment, or both. Therefore, assessing the diagnostic accuracy of CEUS may clarify whether the absence of benefit could be related to underdiagnosis. Furthermore, an assessment of the accuracy of CEUS for the diagnosis of hepatocellular carcinoma is needed for either diagnosing hepatocellular carcinoma or ruling it out in people with chronic liver disease who are not included in surveillance programmes. OBJECTIVES 1. To assess the diagnostic accuracy of contrast-enhanced ultrasound (CEUS) for the diagnosis of hepatocellular carcinoma of any size and at any stage in adults with chronic liver disease, in a surveillance programme or in a clinical setting. 2. To assess the diagnostic accuracy of CEUS for the diagnosis of resectable hepatocellular carcinoma in people with chronic liver disease and identify potential sources of heterogeneity in the results. SEARCH METHODS We used standard, extensive Cochrane search methods. The last date of search was 5 November 2021. SELECTION CRITERIA We included studies assessing the diagnostic accuracy of CEUS for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease, with cross-sectional designs, using one of the acceptable reference standards, such as pathology of the explanted liver, and histology of resected or biopsied focal liver lesion with at least a six-month follow-up. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods to screen studies, extract data, and assess the risk of bias and applicability concerns, using the QUADAS-2 checklist. We used the bivariate model and provided estimates of summary sensitivity and specificity. We assessed the certainty of the evidence using GRADE. We presented uncertainty-of-the-accuracy estimates using 95% confidence intervals (CIs). MAIN RESULTS We included 23 studies with 6546 participants. Studies were published between 2001 and 2021. We judged all 23 studies at high-risk of bias in at least one domain, and 13/23 studies at high concern for applicability. Most studies used different reference standards to exclude the presence of the target condition. The time interval between the index test and the reference standard was rarely defined. We also had major concerns on their applicability due to the characteristics of the participants. - CEUS for hepatocellular carcinoma of any size and stage: sensitivity 77.8% (95% CI 69.4% to 84.4%) and specificity 93.8% (95% CI 89.1% to 96.6%) (23 studies, 6546 participants; very low-certainty evidence). - CEUS for resectable hepatocellular carcinoma: sensitivity 77.5% (95% CI 62.9% to 87.6%) and specificity 92.7% (95% CI 86.8% to 96.1%) (13 studies, 1257 participants; low-certainty evidence). The observed heterogeneity in the results remains unexplained. The sensitivity analyses, including only studies with clearly prespecified positivity criteria and only studies in which the reference standard results were interpreted with no knowledge of the results about the index test, showed no differences in the results. AUTHORS' CONCLUSIONS We found that by using CEUS, as an add-on test following abdominal ultrasound, to diagnose hepatocellular carcinoma of any size and stage, 22% of people with hepatocellular carcinoma would be missed, and 6% of people without hepatocellular carcinoma would unnecessarily undergo further testing or inappropriate treatment. As to resectable hepatocellular carcinoma, we found that 23% of people with resectable hepatocellular carcinoma would incorrectly be unresected, while 8% of people without hepatocellular carcinoma would undergo further inappropriate testing or treatment. The uncertainty resulting from the high risk of bias of the included studies, heterogeneity, and imprecision of the results and concerns on their applicability limit our ability to draw confident conclusions.
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Affiliation(s)
- Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca´ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Tin Nadarevic
- Department of Radiology, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Agostino Colli
- Department of Transfusion Medicine and Haematology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milano, Italy
| | - Cristina Manzotti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca´ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Vanja Giljaca
- Department of Gastroenterology, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Damir Miletic
- Department of Radiology, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Davor Štimac
- Department of Gastroenterology, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Giovanni Casazza
- Department of Clinical Sciences and Community Health - Laboratory of Medical Statistics, Biometry and Epidemiology "G.A. Maccacaro", Università degli Studi di Milano, Milan, Italy
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15
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Valenti L, Tripodi A, La Mura V, Pelusi S, Bianco C, Scalambrino E, Margarita S, Malvestiti F, Ronzoni L, Clerici M, D’Ambrosio R, Fraquelli M, Carpani R, Prati D, Peyvandi F. Interplay between coagulation and determinants of liver disease in patients with metabolic dysfunction. JHEP Rep 2022; 4:100598. [PMID: 36313186 PMCID: PMC9597122 DOI: 10.1016/j.jhepr.2022.100598] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background & Aims The aim of this study was to examine the determinants of the interplay between liver damage and the coagulation balance in individuals at risk of non-alcoholic fatty liver disease (NAFLD). Methods We considered 581 healthy participants with ≥3 metabolic alterations undergoing clinical and genomic evaluation, measurement of liver stiffness (LSM) and controlled attenuation parameter (CAP) by Fibroscan, Pro-C3, coagulation balance (von Willebrand factor [vWF], factor VIII/protein C ratio [F8/PC] as the main outcome, D-dimer as marker of coagulation/fibrinolysis activation). Results Liver fibrosis indices (both Fibrosis-4 [FIB-4] and liver stiffness measurement [LSM]), but not liver fat (CAP), were independently associated with higher F8/PC ratio (p <0.01), triggering D-dimer formation (p = 2E-21). In keeping with a causal role of liver damage in determining a procoagulant status, the main fatty liver inherited risk variant PNPLA3 p.I148M was independently associated with the F8/PC ratio (p = 0.048). Vice versa, the main determinant of the coagulation balance was ABO locus variation (p = 1E-16), through the impact on vWF (p = 8E-26). Both rs687289 ABO and factor V Leiden were independently associated with higher Pro-C3 (p <0.025), with the effect of ABO being mediated by the impact on vWF (p = 5E-10 for association with Pro-C3). Mendelian randomisation analysis was consistent with a causal association of procoagulant imbalance with heightened fibrogenesis (p = 0.001 at robust MR-Egger for Pro-C3), but not with fibrosis (for LSM; p = not significant). Conclusions In individuals with metabolic dysfunction, liver damage severity and possibly the PNPLA3 p.I148M variant were associated with procoagulant status. Vice versa, evaluation of inherited variants in ABO and other genes influencing coagulation was consistent with a causal role of procoagulant imbalance in activation of early stages of fibrogenesis. Lay summary In individuals with metabolic alterations at risk of metabolic fatty liver disease, there is a tendency toward heightened blood coagulation (clotting), but the cause and the impact on the progression of liver disease remain unclear. Here we show that liver damage severity and metabolic alterations, but not hepatic fat, are mainly responsible for heightened coagulation in patients with metabolic fatty liver disease. By using genetic approaches, we showed that hepatic inflammation due to lipotoxicity may favour heightened coagulation, which in turn can trigger liver fibrosis, igniting a vicious cycle that leads to progressive liver disease. There is a complex interplay between liver damage and the coagulation balance in individuals at risk of non-alcoholic fatty liver disease. Non-invasive indices and genetic determinants of liver damage, but not fat, were associated with a procoagulant imbalance. Vice versa, genetic predisposition to hypercoagulability was associated with fibrogenesis. In individuals with metabolic dysfunction, liver damage appears to promote coagulation, which in turn can activate fibrogenesis.
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16
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Vranić L, Nadarevic T, Štimac D, Fraquelli M, Manzotti C, Casazza G, Colli A. Liver and spleen stiffness as assessed by vibration controlled transient elastography for diagnosing clinically significant portal hypertension in comparison with other elastography-based techniques in adults with chronic liver disease. Hippokratia 2022. [DOI: 10.1002/14651858.cd015415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Luka Vranić
- Department of Gastroenterology; Clinical Hospital Centre Rijeka; Rijeka Croatia
| | - Tin Nadarevic
- Department of Radiology; Clinical Hospital Centre Rijeka; Rijeka Croatia
| | - Davor Štimac
- Department of Gastroenterology; Clinical Hospital Centre Rijeka; Rijeka Croatia
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit; Fondazione IRCCS Ca´ Granda - Ospedale Maggiore Policlinico, Milano; Milan Italy
| | - Cristina Manzotti
- Department of Pathophysiology and Transplantation; Università degli Studi di Milano; Milan Italy
| | - Giovanni Casazza
- Department of Clinical Sciences and Community Health - Laboratory of Medical Statistics, Biometry and Epidemiology "G.A. Maccacaro"; Università degli Studi di Milano; Milan Italy
| | - Agostino Colli
- Department of Transfusion Medicine and Haematology; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan Italy
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17
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Elli L, Centorrino E, Costantino A, Vecchi M, Orlando S, Fraquelli M. Capsule enteroscopy versus small-bowel ultrasonography for the detection and differential diagnosis of intestinal diseases. Clin Endosc 2022; 55:532-539. [PMID: 35898151 PMCID: PMC9329643 DOI: 10.5946/ce.2021.224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 02/25/2022] [Indexed: 11/14/2022] Open
Abstract
Background/Aims Capsule enteroscopy (CE) and intestinal ultrasonography (IUS) are techniques that are currently used for investigating small-bowel (SB) diseases. The aim of this study was to compare the main imaging findings and the lesion detection rate (LDR) of CE and IUS in different clinical scenarios involving the SB.
Methods We retrospectively enrolled patients who underwent CE and IUS for obscure gastrointestinal bleeding (OGIB), complicated celiac disease (CeD), and suspected or known inflammatory bowel disease (IBD). We evaluated the LDR of both techniques. The accuracy of IUS was determined using CE as the reference standard.
Results A total of 159 patients (113 female; mean age, 49±19 years) were enrolled. The LDR was 55% and 33% for CE and IUS (p<0.05), respectively. Subgroup analysis showed that the LDR of CE was significantly higher than that of IUS in patients with OGIB (62% vs. 14%, p<0.05) and CeD (55% vs. 35%, p<0.05). IUS showed a similar LDR to CE in patients with suspected or known IBD (51% vs. 46%, p=0.83).
Conclusions CE should be preferred in cases of OGIB and CeD, whereas IUS should be considered an early step in the diagnosis and follow-up of IBD even in patients with a proximal SB localization of the disease.
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Affiliation(s)
- Luca Elli
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Erica Centorrino
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Andrea Costantino
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Stefania Orlando
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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18
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Nadarevic T, Colli A, Giljaca V, Fraquelli M, Casazza G, Manzotti C, Štimac D, Miletic D. Magnetic resonance imaging for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease. Cochrane Database Syst Rev 2022; 5:CD014798. [PMID: 35521901 PMCID: PMC9074390 DOI: 10.1002/14651858.cd014798.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatocellular carcinoma occurs mostly in people with chronic liver disease and ranks sixth in terms of global incidence of cancer, and third in terms of cancer deaths. In clinical practice, magnetic resonance imaging (MRI) is used as a second-line diagnostic imaging modality to confirm the presence of focal liver lesions suspected as hepatocellular carcinoma on prior diagnostic test such as abdominal ultrasound or alpha-fetoprotein, or both, either in surveillance programmes or in clinical settings. According to current guidelines, a single contrast-enhanced imaging study (computed tomography (CT) or MRI) showing typical hallmarks of hepatocellular carcinoma in people with cirrhosis is considered valid to diagnose hepatocellular carcinoma. The detection of hepatocellular carcinoma amenable to surgical resection could improve the prognosis. However, a significant number of hepatocellular carcinomas do not show typical hallmarks on imaging modalities, and hepatocellular carcinoma may, therefore, be missed. There is no clear evidence of the benefit of surveillance programmes in terms of overall survival: the conflicting results can be a consequence of inaccurate detection, ineffective treatment, or both. Assessing the diagnostic accuracy of MRI may clarify whether the absence of benefit could be related to underdiagnosis. Furthermore, an assessment of the accuracy of MRI in people with chronic liver disease who are not included in surveillance programmes is needed for either ruling out or diagnosing hepatocellular carcinoma. OBJECTIVES Primary: to assess the diagnostic accuracy of MRI for the diagnosis of hepatocellular carcinoma of any size and at any stage in adults with chronic liver disease. Secondary: to assess the diagnostic accuracy of MRI for the diagnosis of resectable hepatocellular carcinoma in adults with chronic liver disease, and to identify potential sources of heterogeneity in the results. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Hepato-Biliary Group Diagnostic Test of Accuracy Studies Register, the Cochrane Library, MEDLINE, Embase, and three other databases to 9 November 2021. We manually searched articles retrieved, contacted experts, handsearched abstract books from meetings held during the last 10 years, and searched for literature in OpenGrey (9 November 2021). Further information was requested by e-mails, but no additional information was provided. No data was obtained through correspondence with investigators. We applied no language or document-type restrictions. SELECTION CRITERIA Studies assessing the diagnostic accuracy of MRI for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease, with cross-sectional designs, using one of the acceptable reference standards, such as pathology of the explanted liver and histology of resected or biopsied focal liver lesion with at least a six-month follow-up. DATA COLLECTION AND ANALYSIS At least two review authors independently screened studies, extracted data, and assessed the risk of bias and applicability concerns, using the QUADAS-2 checklist. We presented the results of sensitivity and specificity, using paired forest plots, and we tabulated the results. We used a hierarchical meta-analysis model where appropriate. We presented uncertainty of the accuracy estimates using 95% confidence intervals (CIs). We double-checked all data extractions and analyses. MAIN RESULTS We included 34 studies, with 4841 participants. We judged all studies to be at high risk of bias in at least one domain because most studies used different reference standards, often inappropriate to exclude the presence of the target condition, and the time interval between the index test and the reference standard was rarely defined. Regarding applicability, we judged 15% (5/34) of studies to be at low concern and 85% (29/34) of studies to be at high concern mostly owing to characteristics of the participants, most of whom were on waiting lists for orthotopic liver transplantation, and due to pathology of the explanted liver being the only reference standard. MRI for hepatocellular carcinoma of any size and stage: sensitivity 84.4% (95% CI 80.1% to 87.9%) and specificity 93.8% (95% CI 90.1% to 96.1%) (34 studies, 4841 participants; low-certainty evidence). MRI for resectable hepatocellular carcinoma: sensitivity 84.3% (95% CI 77.6% to 89.3%) and specificity 92.9% (95% CI 88.3% to 95.9%) (16 studies, 2150 participants; low-certainty evidence). The observed heterogeneity in the results remains mostly unexplained. The sensitivity analyses, which included only studies with clearly prespecified positivity criteria and only studies in which the reference standard results were interpreted without knowledge of the results of the index test, showed no variation in the results. AUTHORS' CONCLUSIONS We found that using MRI as a second-line imaging modality to diagnose hepatocellular carcinoma of any size and stage, 16% of people with hepatocellular carcinoma would be missed, and 6% of people without hepatocellular carcinoma would be unnecessarily treated. For resectable hepatocellular carcinoma, we found that 16% of people with resectable hepatocellular carcinoma would improperly not be resected, while 7% of people without hepatocellular carcinoma would undergo inappropriate surgery. The uncertainty resulting from the high risk of bias in the included studies and concerns regarding their applicability limit our ability to confidently draw conclusions based on our results.
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Affiliation(s)
- Tin Nadarevic
- Department of Radiology, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Agostino Colli
- Department of Transfusion Medicine and Haematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Vanja Giljaca
- Department of Gastroenterology, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca´ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Cristina Manzotti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca´ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Davor Štimac
- Department of Gastroenterology, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Damir Miletic
- Department of Radiology , Clinical Hospital Centre Rijeka, Rijeka, Croatia
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19
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Mazza S, Conforti FS, Forzenigo LV, Piazza N, Bertè R, Costantino A, Fraquelli M, Coletta M, Rimola J, Vecchi M, Caprioli F. Agreement between real-time elastography and delayed enhancement magnetic resonance enterography on quantifying bowel wall fibrosis in Crohn's disease. Dig Liver Dis 2022; 54:69-75. [PMID: 34116973 DOI: 10.1016/j.dld.2021.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/14/2021] [Accepted: 05/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND the assessment of fibrosis in Crohn's disease (CD) bowel lesions helps to guide therapeutic decisions. Real-time elastography (RTE) and delayed-enhancement magnetic resonance enterography (DE-MRE) have demonstrated good accuracy in quantifying CD-related ileal fibrosis as compared with histological examination. To date no study has compared DE-MRE and RTE. AIMS we aimed to evaluate the agreement between RTE and DE-MRE on quantifying CD-related ileal fibrosis. METHODS consecutive patients with ileal or ileocolonic CD underwent RTE and DE-MRE. Ileal fibrosis was quantified by calculating the strain ratio (SR) at RTE and the 70s-7 min percentage of enhancement gain (%EG) of both mucosa and submucosa at DE-MRE. A SR ≥2 was applied to define severe fibrosis. Clinically relevant outcomes occurring at follow-up were recorded. RESULTS 40 CD patients were enrolled. A significant linear correlation was observed between SR and submucosal %EG (r = 0.594, p < 0.001). Patients with severe fibrosis (SR ≥2) had significantly higher submucosal %EG values than patients with low/moderate fibrosis (median values 26.4% vs. 9.5%, p < 0.001). During a median 43.8-month follow-up relevant disease outcomes occurred more frequently in the severe-fibrosis group (75% vs. 36%, HR 5.4, 95% CI 1.2-24.6, p = 0.029). CONCLUSIONS the study demonstrates an excellent agreement between RTE and DE-MRE in assessing ileal fibrosis in CD.
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Affiliation(s)
- Stefano Mazza
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Francesco Simone Conforti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | | | - Nicole Piazza
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Roberto Bertè
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Andrea Costantino
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Marina Coletta
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via F. Sforza 35, Milan 20122, Italy
| | - Jordi Rimola
- IBD unit, Department of Radiology, Hospital Clínic de Barcelona, Barcelona 08036, Spain
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20122, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via F. Sforza 35, Milan 20122, Italy
| | - Flavio Caprioli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20122, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via F. Sforza 35, Milan 20122, Italy.
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20
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Valenti L, Pelusi S, Bianco C, Ceriotti F, Berzuini A, Iogna Prat L, Trotti R, Malvestiti F, D'Ambrosio R, Lampertico P, Colli A, Colombo M, Tsochatzis EA, Fraquelli M, Prati D. Definition of Healthy Ranges for Alanine Aminotransferase Levels: A 2021 Update. Hepatol Commun 2021; 5:1824-1832. [PMID: 34520121 PMCID: PMC8557310 DOI: 10.1002/hep4.1794] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/22/2021] [Accepted: 07/02/2021] [Indexed: 12/12/2022] Open
Abstract
The changing epidemiology of liver disease, and modifications in the recommended analytical methodology call for a re-evaluation of the upper reference limits (URLs) of alanine aminotransferase (ALT) levels. Using the same approach consolidated 20 years ago to define the healthy population, we defined the URL for the newly recommended International Federation of Clinical Chemistry (IFCC) standardized test. In a cross-sectional study, we examined 21,296 apparently healthy blood donors (age 18-65 years) and calculated the sex-specific URL by the 95th percentile in individuals without risk factors for liver disease. These were tested for the ability to predict liver damage in a subset of 745 participants with dysmetabolism, in an independent cohort of 977 unselected donors, and in 899 patients with chronic liver disease. ALT levels were measured by the IFCC test. Male sex, body mass index, glucose, lipids, ferritin, hypertension, and younger age were independent ALT predictors (P < 0.001). Updated URLs were identified at 42/30 U/L in males/females, approximately 30% lower than those currently recommended by the IFCC. Due to improved sensitivity, they conferred the ability to detect steatosis and significant fibrosis in individuals with dysmetabolism (odds ratio [OR] = 2.31, range 1.40-3.80, P = 0.001; and OR = 3.35, range 1.19-9.42, P = 0.021; respectively), although with a limited accuracy, and significant fibrosis in unselected donors (OR = 2.32, 1.02-5.31, P = 0.045). Updated URLs had a moderate to high accuracy to discriminate liver conditions (area under the receiver operating characteristic curve = 0.81, range 0.78-0.91). Conclusion: Updated URLs by the IFCC method were lower than those calculated in initial studies, but higher than those in use with the recommended old, nonstandardized method, and were able to better predict liver disease. The limited awareness that different techniques are still in use should be regarded as a possible source of medical errors.
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Affiliation(s)
- Luca Valenti
- Department of Pathophysiology and TransplantationUniversità degli Studi di MilanoMilanItaly.,Department of Transfusion Medicine and HaematologyFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Serena Pelusi
- Department of Pathophysiology and TransplantationUniversità degli Studi di MilanoMilanItaly.,Department of Transfusion Medicine and HaematologyFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Cristiana Bianco
- Department of Transfusion Medicine and HaematologyFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly.,Department of MedicineUdine HospitalUdineItaly
| | - Ferruccio Ceriotti
- Clinical LaboratoryFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico MilanMilanItaly
| | - Alessandra Berzuini
- Department of Transfusion Medicine and HaematologyFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Laura Iogna Prat
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUnited Kingdom
| | - Roberta Trotti
- Department of Transfusion Medicine and HaematologyFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Francesco Malvestiti
- Department of Pathophysiology and TransplantationUniversità degli Studi di MilanoMilanItaly.,Department of Transfusion Medicine and HaematologyFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Roberta D'Ambrosio
- Division of Gastroenterology and HepatologyFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico MilanMilanItaly
| | - Pietro Lampertico
- Division of Gastroenterology and HepatologyFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico MilanMilanItaly.,CRC "A. M. and A. Migliavacca" Center for Liver DiseaseDepartment of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | - Agostino Colli
- Department of Transfusion Medicine and HaematologyFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | | | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUnited Kingdom
| | - Mirella Fraquelli
- Department of Gastroenterology and EndoscopyFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico MilanMilanItaly
| | - Daniele Prati
- Department of Transfusion Medicine and HaematologyFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
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Nadarevic T, Giljaca V, Colli A, Fraquelli M, Casazza G, Miletic D, Štimac D. Computed tomography for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease. Cochrane Database Syst Rev 2021; 10:CD013362. [PMID: 34611889 PMCID: PMC8493329 DOI: 10.1002/14651858.cd013362.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hepatocellular carcinoma occurs mostly in people with chronic liver disease and ranks sixth in terms of global incidence of cancer, and fourth in terms of cancer deaths. In clinical practice, computed tomography (CT) is used as a second-line diagnostic imaging modality to confirm the presence of focal liver lesions suspected as hepatocellular carcinoma on prior diagnostic test such as abdominal ultrasound or alpha-foetoprotein, or both, either in surveillance programmes or in clinical settings. According to current guidelines, a single contrast-enhanced imaging study CT or magnetic resonance imaging (MRI) showing typical hallmarks of hepatocellular carcinoma in people with cirrhosis is valid to diagnose hepatocellular carcinoma. However, a significant number of hepatocellular carcinomas do not show typical hallmarks on imaging modalities, and hepatocellular carcinoma is, therefore, missed. There is no clear evidence of the benefit of surveillance programmes in terms of overall survival: the conflicting results can be a consequence of inaccurate detection, ineffective treatment, or both. Assessing the diagnostic accuracy of CT may clarify whether the absence of benefit could be related to underdiagnosis. Furthermore, an assessment of the accuracy of CT in people with chronic liver disease, who are not included in surveillance programmes is needed for either ruling out or diagnosing hepatocellular carcinoma. OBJECTIVES Primary: to assess the diagnostic accuracy of multidetector, multiphasic contrast-enhanced CT for the diagnosis of hepatocellular carcinoma of any size and at any stage in adults with chronic liver disease, either in a surveillance programme or in a clinical setting. Secondary: to assess the diagnostic accuracy of CT for the diagnosis of resectable hepatocellular carcinoma in adults with chronic liver disease. SEARCH METHODS We searched the Cochrane Hepato-Biliary Trials Register, Cochrane Hepato-Biliary Diagnostic-Test-Accuracy Studies Register, the Cochrane Library, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index - Science until 4 May 2021. We applied no language or document-type restrictions. SELECTION CRITERIA Studies assessing the diagnostic accuracy of CT for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease, with cross-sectional designs, using one of the acceptable reference standards, such as pathology of the explanted liver and histology of resected or biopsied focal liver lesion with at least a six-month follow-up. DATA COLLECTION AND ANALYSIS At least two review authors independently screened studies, extracted data, and assessed the risk of bias and applicability concerns, using the QUADAS-2 checklist. We presented the results of sensitivity and specificity, using paired forest plots, and tabulated the results. We used a hierarchical meta-analysis model where appropriate. We presented uncertainty of the accuracy estimates using 95% confidence intervals (CIs). We double-checked all data extractions and analyses. MAIN RESULTS We included 21 studies, with a total of 3101 participants. We judged all studies to be at high risk of bias in at least one domain because most studies used different reference standards, often inappropriate to exclude the presence of the target condition, and the time-interval between the index test and the reference standard was rarely defined. Regarding applicability in the patient selection domain, we judged 14% (3/21) of studies to be at low concern and 86% (18/21) of studies to be at high concern owing to characteristics of the participants who were on waiting lists for orthotopic liver transplantation. CT for hepatocellular carcinoma of any size and stage: sensitivity 77.5% (95% CI 70.9% to 82.9%) and specificity 91.3% (95% CI 86.5% to 94.5%) (21 studies, 3101 participants; low-certainty evidence). CT for resectable hepatocellular carcinoma: sensitivity 71.4% (95% CI 60.3% to 80.4%) and specificity 92.0% (95% CI 86.3% to 95.5%) (10 studies, 1854 participants; low-certainty evidence). In the three studies at low concern for applicability (861 participants), we found sensitivity 76.9% (95% CI 50.8% to 91.5%) and specificity 89.2% (95% CI 57.0% to 98.1%). The observed heterogeneity in the results remains mostly unexplained. The sensitivity analyses, which included only studies with clearly prespecified positivity criteria and only studies in which the reference standard results were interpreted without knowledge of the results of the index test, showed no variation in the results. AUTHORS' CONCLUSIONS In the clinical pathway for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease, CT has roles as a confirmatory test for hepatocellular carcinoma lesions, and for staging assessment. We found that using CT in detecting hepatocellular carcinoma of any size and stage, 22.5% of people with hepatocellular carcinoma would be missed, and 8.7% of people without hepatocellular carcinoma would be unnecessarily treated. For resectable hepatocellular carcinoma, we found that 28.6% of people with resectable hepatocellular carcinoma would improperly not be resected, while 8% of people without hepatocellular carcinoma would undergo inappropriate surgery. The uncertainty resulting from the high risk of bias in the included studies and concerns regarding their applicability limit our ability to confidently draw conclusions based on our results.
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Affiliation(s)
- Tin Nadarevic
- Department of Radiology, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Vanja Giljaca
- Department of Gastroenterology, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Agostino Colli
- Department of Transfusion Medicine and Haematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 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, Milan, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Damir Miletic
- Department of Radiology , Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Davor Štimac
- Department of Gastroenterology, Clinical Hospital Centre Rijeka, Rijeka, Croatia
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22
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Nadarevic T, Colli A, Giljaca V, Fraquelli M, Casazza G, Manzotti C, Štimac D, Miletic D. Magnetic resonance imaging for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease. Hippokratia 2021. [DOI: 10.1002/14651858.cd014798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Tin Nadarevic
- Department of Radiology; Clinical Hospital Centre Rijeka; Rijeka Croatia
| | - Agostino Colli
- Department of Transfusion Medicine and Haematology; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milano Italy
| | - Vanja Giljaca
- Department of Gastroenterology; Heart of England NHS Foundation Trust; Birmingham UK
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit; Fondazione IRCCS Ca´ Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano; Milan Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche "L. Sacco"; Università degli Studi di Milano; Milan Italy
| | - Cristina Manzotti
- Obstetrics and Gynecology Department; Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano; Milan Italy
| | - Davor Štimac
- Department of Gastroenterology; Clinical Hospital Centre Rijeka; Rijeka Croatia
| | - Damir Miletic
- Department of Radiology ; Clinical Hospital Centre Rijeka; Rijeka Croatia
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23
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Abstract
The prognosis of chronic liver diseases, which represent a major public health problem, is mainly linked to the extent and progression of liver fibrosis and the subsequent risk of developing cirrhosis and related complications, mainly hepatocellular carcinoma. During the past decade many noninvasive methods and in particular electrographic techniques, have been developed to reduce the need for liver biopsy in staging fibrosis and to overcome whenever possible its limitations, mainly: invasiveness, costs, low reproducibility and poor acceptance by patients. The aim of this review was to provide a comprehensive review of the role of elastography techniques in viral chronic liver diseases and autoimmune hepatitis, with the focus on the possible advantages and limitations of these techniques and on their diagnostic accuracy in predicting the stage of liver fibrosis.
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Affiliation(s)
- Nicoletta Nandi
- Unit of Gastroenterology and Endoscopy, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Mirella Fraquelli
- Unit of Gastroenterology and Endoscopy, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy -
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24
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Colli A, Nadarevic T, Miletic D, Giljaca V, Fraquelli M, Štimac D, Casazza G. Abdominal ultrasound and alpha-foetoprotein for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease. Cochrane Database Syst Rev 2021; 4:CD013346. [PMID: 33855699 PMCID: PMC8078581 DOI: 10.1002/14651858.cd013346.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) occurs mostly in people with chronic liver disease and ranks sixth in terms of global instances of cancer, and fourth in terms of cancer deaths for men. Despite that abdominal ultrasound (US) is used as an initial test to exclude the presence of focal liver lesions and serum alpha-foetoprotein (AFP) measurement may raise suspicion of HCC occurrence, further testing to confirm diagnosis as well as staging of HCC is required. Current guidelines recommend surveillance programme using US, with or without AFP, to detect HCC in high-risk populations despite the lack of clear benefits on overall survival. Assessing the diagnostic accuracy of US and AFP may clarify whether the absence of benefit in surveillance programmes could be related to under-diagnosis. Therefore, assessment of the accuracy of these two tests for diagnosing HCC in people with chronic liver disease, not included in surveillance programmes, is needed. OBJECTIVES Primary: the diagnostic accuracy of US and AFP, alone or in combination, for the diagnosis of HCC of any size and at any stage in adults with chronic liver disease, either in a surveillance programme or in a clinical setting. Secondary: to assess the diagnostic accuracy of abdominal US and AFP, alone or in combination, for the diagnosis of resectable HCC; to compare the diagnostic accuracy of the individual tests versus the combination of both tests; to investigate sources of heterogeneity in the results. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Hepato-Biliary Group Diagnostic-Test-Accuracy Studies Register, Cochrane Library, MEDLINE, Embase, LILACS, Science Citation Index Expanded, until 5 June 2020. We applied no language or document-type restrictions. SELECTION CRITERIA Studies assessing the diagnostic accuracy of US and AFP, independently or in combination, for the diagnosis of HCC in adults with chronic liver disease, with cross-sectional and case-control designs, using one of the acceptable reference standards, such as pathology of the explanted liver, histology of resected or biopsied focal liver lesion, or typical characteristics on computed tomography, or magnetic resonance imaging, all with a six-months follow-up. DATA COLLECTION AND ANALYSIS We independently screened studies, extracted data, and assessed the risk of bias and applicability concerns, using the QUADAS-2 checklist. We presented the results of sensitivity and specificity, using paired forest-plots, and tabulated the results. We used a hierarchical meta-analysis model where appropriate. We presented uncertainty of the accuracy estimates using 95% confidence intervals (CIs). We double-checked all data extractions and analyses. MAIN RESULTS We included 373 studies. The index-test was AFP (326 studies, 144,570 participants); US (39 studies, 18,792 participants); and a combination of AFP and US (eight studies, 5454 participants). We judged at high-risk of bias all but one study. Most studies used different reference standards, often inappropriate to exclude the presence of the target condition, and the time-interval between the index test and the reference standard was rarely defined. Most studies with AFP had a case-control design. We also had major concerns for the applicability due to the characteristics of the participants. As the primary studies with AFP used different cut-offs, we performed a meta-analysis using the hierarchical-summary-receiver-operating-characteristic model, then we carried out two meta-analyses including only studies reporting the most used cut-offs: around 20 ng/mL or 200 ng/mL. AFP cut-off 20 ng/mL: for HCC (147 studies) sensitivity 60% (95% CI 58% to 62%), specificity 84% (95% CI 82% to 86%); for resectable HCC (six studies) sensitivity 65% (95% CI 62% to 68%), specificity 80% (95% CI 59% to 91%). AFP cut-off 200 ng/mL: for HCC (56 studies) sensitivity 36% (95% CI 31% to 41%), specificity 99% (95% CI 98% to 99%); for resectable HCC (two studies) one with sensitivity 4% (95% CI 0% to 19%), specificity 100% (95% CI 96% to 100%), and one with sensitivity 8% (95% CI 3% to 18%), specificity 100% (95% CI 97% to 100%). US: for HCC (39 studies) sensitivity 72% (95% CI 63% to 79%), specificity 94% (95% CI 91% to 96%); for resectable HCC (seven studies) sensitivity 53% (95% CI 38% to 67%), specificity 96% (95% CI 94% to 97%). Combination of AFP (cut-off of 20 ng/mL) and US: for HCC (six studies) sensitivity 96% (95% CI 88% to 98%), specificity 85% (95% CI 73% to 93%); for resectable HCC (two studies) one with sensitivity 89% (95% CI 73% to 97%), specificity of 83% (95% CI 76% to 88%), and one with sensitivity 79% (95% CI 54% to 94%), specificity 87% (95% CI 79% to 94%). The observed heterogeneity in the results remains mostly unexplained, and only in part referable to different cut-offs or settings (surveillance programme compared to clinical series). The sensitivity analyses, excluding studies published as abstracts, or with case-control design, showed no variation in the results. We compared the accuracy obtained from studies with AFP (cut-off around 20 ng/mL) and US: a direct comparison in 11 studies (6674 participants) showed a higher sensitivity of US (81%, 95% CI 66% to 90%) versus AFP (64%, 95% CI 56% to 71%) with similar specificity: US 92% (95% CI 83% to 97%) versus AFP 89% (95% CI 79% to 94%). A direct comparison of six studies (5044 participants) showed a higher sensitivity (96%, 95% CI 88% to 98%) of the combination of AFP and US versus US (76%, 95% CI 56% to 89%) with similar specificity: AFP and US 85% (95% CI 73% to 92%) versus US 93% (95% CI 80% to 98%). AUTHORS' CONCLUSIONS In the clinical pathway for the diagnosis of HCC in adults, AFP and US, singularly or in combination, have the role of triage-tests. We found that using AFP, with 20 ng/mL as a cut-off, about 40% of HCC occurrences would be missed, and with US alone, more than a quarter. The combination of the two tests showed the highest sensitivity and less than 5% of HCC occurrences would be missed with about 15% of false-positive results. The uncertainty resulting from the poor study quality and the heterogeneity of included studies limit our ability to confidently draw conclusions based on our results.
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Affiliation(s)
- Agostino Colli
- Department of Transfusion Medicine and Haematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Tin Nadarevic
- Department of Radiology, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Damir Miletic
- Department of Radiology , Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Vanja Giljaca
- Department of Gastroenterology, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca´ Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Davor Štimac
- Department of Gastroenterology, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche "L. Sacco", Università degli Studi di Milano, Milan, Italy
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25
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Allocca M, Filippi E, Costantino A, Bonovas S, Fiorino G, Furfaro F, Peyrin-Biroulet L, Fraquelli M, Caprioli F, Danese S. Milan ultrasound criteria are accurate in assessing disease activity in ulcerative colitis: external validation. United European Gastroenterol J 2021; 9:438-442. [PMID: 33349199 PMCID: PMC8259285 DOI: 10.1177/2050640620980203] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/15/2020] [Indexed: 12/12/2022] Open
Abstract
Introduction The aim of this study was to provide an external validation of bowel ultrasound (US) predictors of activity in ulcerative colitis (UC) and quantitative Milan Ultrasound Criteria (MUC). Methods Forty‐three consecutive patients with UC (16 in endoscopic remission and 27 with endoscopic activity) underwent bowel US and colonoscopy in a tertiary referral inflammatory bowel disease unit. Results An MUC score >6.2 discriminated patients with active versus non‐active UC with a sensitivity of 0.85 (95% confidence interval (CI) 0.66–0.96), specificity of 0.94 (95% CI 0.70–0.99) and an area under the curve of 0.902 (95% CI 0.772–0.971) in complete agreement with the derivation study. Conclusion The external validation of MUC confirms that it is an accurate tool for assessing disease activity in patients with UC.
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Affiliation(s)
- Mariangela Allocca
- Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Elisabetta Filippi
- Gastroenterology and Endoscopy Unit, La Fondazione IRCCS Ca' Granda Ospedale Maggiore di Milano Policlinico, Milan, Italy
| | - Andrea Costantino
- Gastroenterology and Endoscopy Unit, La Fondazione IRCCS Ca' Granda Ospedale Maggiore di Milano Policlinico, Milan, Italy
| | - Stefanos Bonovas
- Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Gionata Fiorino
- Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Federica Furfaro
- Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm U954, University Hospital of Nancy, Lorraine University, Nancy, France
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, La Fondazione IRCCS Ca' Granda Ospedale Maggiore di Milano Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Flavio Caprioli
- Gastroenterology and Endoscopy Unit, La Fondazione IRCCS Ca' Granda Ospedale Maggiore di Milano Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
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26
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Giunta M, La Mura V, Conti CB, Casazza G, Tosetti G, Gridavilla D, Segato S, Nicolini A, Primignani M, Lampertico P, Fraquelli M. The Role of Spleen and Liver Elastography and Color-Doppler Ultrasound in the Assessment of Transjugular Intrahepatic Portosystemic Shunt Function. Ultrasound Med Biol 2020; 46:1641-1650. [PMID: 32402671 DOI: 10.1016/j.ultrasmedbio.2020.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/11/2020] [Accepted: 04/09/2020] [Indexed: 06/11/2023]
Abstract
The reference standard for assessing transjugular intrahepatic portosystemic shunt (TIPS) function is venography with portosystemic pressure gradient (PPG) measurement. This procedure is invasive and expensive; thus, we assessed the feasibility, reproducibility and diagnostic accuracy of color-Doppler ultrasound (CDUS) and spleen and liver stiffness (LS) measurements for identifying TIPS dysfunction. Twenty-four patients (15 undergoing TIPS placement and nine undergoing TIPS revision) consecutively underwent CDUS examination and LS and spleen stiffness (SS) determination by transient elastography (TE) and point shear-wave elastography (pSWE). All parameters were taken before TIPS placement/revision (1-15 d before) and 24 h after, just before revision by venography. pSWE inter-observer agreement was assessed by intra-class correlation coefficient (ICC). CDUS and elastographic data were correlated (Pearson coefficient) with pressure gradients (hepatic venous pressure gradient [HVPG], PPG). Main determinants of TIPS dysfunction were investigated by linear regression. Forty-nine paired examinations were performed in total: 49 (100%) SS reliable measurements by pSWE and 38 (88%) by TE. The ICC for pSWE values was 0.90 (95% confidence interval [CI] 0.81‒0.94). SS values significantly correlated with HVPG and PPG (R = 0.51, p = 0.01). The area under the Receiver-Operating Characteristic (AUROC) curve of SS for diagnosing TIPS dysfunction was 0.86 (95% CI 0.70‒0.96) using a 25 kPa cutoff. At multivariate analysis, the flow direction of the intrahepatic portal vein branches and SS values were independently associated to TIPS dysfunction. The intrahepatic portal vein branches flow direction and SS value are two simple, highly sensitive parameters accurately excluding TIPS dysfunction. SS measurement by pSWE is feasible, reproducible and both positively and significantly correlates with HVPG and PPG values.
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Affiliation(s)
- Mariangela Giunta
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Gastroenterologia ed Endoscopia, Milan, Italy
| | - Vincenzo La Mura
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Medicina Generale, Emostasi e Trombosi, Milan, Italy; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy; Centro di Ricerca Coordinata "A.M. e A. Migliavacca" per lo Studio e la Cura delle Malattie del Fegato, Milan, Italy; Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Gastroenterologia ed Epatologia, Milan, Italy
| | - Clara Benedetta Conti
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Gastroenterologia ed Endoscopia, Milan, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche "L. Sacco", Universita' degli Studi di Milano, Milan, Italy
| | - Giulia Tosetti
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Medicina Generale, Emostasi e Trombosi, Milan, Italy; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy; Centro di Ricerca Coordinata "A.M. e A. Migliavacca" per lo Studio e la Cura delle Malattie del Fegato, Milan, Italy
| | - Daniele Gridavilla
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Gastroenterologia ed Endoscopia, Milan, Italy
| | - Simone Segato
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Gastroenterologia ed Endoscopia, Milan, Italy
| | - Antonio Nicolini
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Radiologia, Milan, Italy
| | - Massimo Primignani
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Medicina Generale, Emostasi e Trombosi, Milan, Italy; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy; Centro di Ricerca Coordinata "A.M. e A. Migliavacca" per lo Studio e la Cura delle Malattie del Fegato, Milan, Italy
| | - Pietro Lampertico
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Medicina Generale, Emostasi e Trombosi, Milan, Italy; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy; Centro di Ricerca Coordinata "A.M. e A. Migliavacca" per lo Studio e la Cura delle Malattie del Fegato, Milan, Italy
| | - Mirella Fraquelli
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Gastroenterologia ed Endoscopia, Milan, Italy.
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27
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Bortolotti M, D'Ambrosio R, Fraquelli M, Pedrotti P, Consonni D, Migone De Amicis M, Scaramellini N, Di Pierro E, Graziadei G. Liver damage and sickle cell disease: genotype relationship. Ann Hematol 2020; 99:2065-2072. [PMID: 32572524 DOI: 10.1007/s00277-020-04113-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 06/01/2020] [Indexed: 11/30/2022]
Abstract
Sickle hepatopathy is a severe and not rare complication of sickle cell disease (SCD), showing mainly a cholestatic pattern. So far, no effective approaches to prevent or treat this condition have been recognized. We conducted a single-center observational study in 68 adult sickle cell patients, encompassing 17 with sickle cell anemia (SCA), 38 with sickle cell thalassemia (HbS/β-Thal), and 13 with HbSC disease. The aim of our study was to assess liver damage in the three main forms of SCD, through the evaluation of clinical, laboratory, and imaging findings. In our population, the role of hepatotropic viruses, high BMI, and alcohol consumption in liver damage was ruled out. SCA and HbS/β-Thal patients with lower Hb (p < 0.001), higher HbS (p < 0.001), and frequent vaso-occlusive crises showed functional (GGT values: SCA and HbS/β-Thal vs HbSC p = 0.047 and p = 0.009, respectively) and structural liver abnormalities, defined by abdominal ultrasound and vibration-controlled transient elastography (liver stiffness values: SCA and HbS/β-Thal vs HbSC p 0.022 and p 0.19, respectively), more severe than HbSC patients. Through univariate and multivariate analyses, male sex, SCA genotype, lower HbF, frequent transfusions, increased GGT values, and abnormal liver ultrasound and stiffness were identified as potentially early markers of sickle hepatopathy.
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Affiliation(s)
- Marta Bortolotti
- Dip. di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Roberta D'Ambrosio
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy
| | - Mirella Fraquelli
- Dip. di Gastroenterologia ed Endoscopia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Patrizia Pedrotti
- Dip. di Cardiologia, Unità di Risonanza Magnetica, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Dario Consonni
- Dip. di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
- Unità di Epidemiologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Margherita Migone De Amicis
- Unità di Medicina Generale, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Natalia Scaramellini
- Dip. di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Elena Di Pierro
- Unità di Medicina Generale, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Giovanna Graziadei
- Unità di Medicina Generale, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy.
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28
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Ferretti F, Fraquelli M, Cantù P, Penagini R, Casazza G, Vecchi M, Orlando S, Invernizzi F, Branchi F, Donato FM, Elli L. Efficacy and safety of device-assisted enteroscopy ERCP in liver transplantation: A systematic review and meta-analysis. Clin Transplant 2020; 34:e13864. [PMID: 32236978 DOI: 10.1111/ctr.13864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 03/14/2020] [Accepted: 03/22/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Enterobiliary anastomoses are the main source of complications after liver transplantation. An endoscopic approach combining device-assisted enteroscopy and ERCP (DAE-ERCP) is technically feasible in postsurgical anatomy. AIMS This study aimed at assessing the efficacy, feasibility, and safety of DAE-ERCP in liver-transplanted patients (LT) and other subsets (non-LT). METHODS A systematic review and meta-analysis of studies involving DAE procedures in LT patients (between January 2000 and May 2017) was conducted. The main endpoints were as follows: endoscopic, diagnostic, therapeutic, and overall success rates, complications, and the need for surgery. RESULTS A total of 155 studies were retrieved, and 6 relevant trials were analyzed. Overall, 132 subjects (72 LT and 60 non-LT) undergoing 257 DAE-ERCP (135 and 122) were included. Complications were rare (4/257), and no deaths occurred. These are the pooled success rates among LT and non-LT patients: 80%-100% and 82%-95% (enteroscopic), 75%-100% and 89%-100% (diagnostic), 67%-100% and 92%-100% (therapeutic), and 60%-100% and 79%-83% (overall results). The requirement for surgery was similar in the two subgroups. CONCLUSION In managing biliary complications, the high diagnostic and therapeutic success rates of DAE-ERCP combined with its safety and feasibility encourage its application as a first-line approach to transplanted patients.
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Affiliation(s)
- Francesca Ferretti
- Gastroenterology and Endoscopy Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Cantù
- Gastroenterology and Endoscopy Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche Luigi Sacco, Università degli Studi di Milano, Milan, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Stefania Orlando
- Gastroenterology and Endoscopy Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Invernizzi
- Transplant Hepatology Unit, Division of Gastroenterology and Hepatology, A.M. & A. Migliavacca Center for Liver Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Federica Branchi
- Gastroenterology and Endoscopy Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Francesca Maria Donato
- Transplant Hepatology Unit, Division of Gastroenterology and Hepatology, A.M. & A. Migliavacca Center for Liver Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Luca Elli
- Gastroenterology and Endoscopy Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.,Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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29
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Colli A, Prati D, Fraquelli M, Casazza G. Granulocyte colony-stimulating factor with or without stem or progenitor cell infusion for people with compensated or decompensated advanced chronic liver disease. Hippokratia 2020. [DOI: 10.1002/14651858.cd013532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Agostino Colli
- A Manzoni Hospital ASST Lecco; Department of Internal Medicine; Via dell'Eremo, 9/11 Lecco Italy 23900
| | - Daniele Prati
- Ospedale Alessandro Manzoni; Department of Transfusion Medicine and Haematology; Lecco Italy
| | - Mirella Fraquelli
- Fondazione IRCCS Ca´ Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano; Gastroenterology and Endoscopy Unit; Via F. Sforza, 35 Milan Italy 20122
| | - Giovanni Casazza
- Università degli Studi di Milano; Dipartimento di Scienze Biomediche e Cliniche "L. Sacco"; via GB Grassi 74 Milan Italy 20157
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30
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Fraquelli M, Castiglione F, Calabrese E, Maconi G. Impact of intestinal ultrasound on the management of patients with inflammatory bowel disease: how to apply scientific evidence to clinical practice. Dig Liver Dis 2020; 52:9-18. [PMID: 31732443 DOI: 10.1016/j.dld.2019.10.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/27/2019] [Accepted: 10/08/2019] [Indexed: 12/11/2022]
Abstract
Technological improvements and growing sonographers' expertise boost the role of intestinal ultrasound (IUS) in assessing patients with inflammatory bowel diseases (IBD). Non-invasiveness, low cost and good reproducibility make IUS attractive. Leveraging on the Authors' long-term field experience, this review focuses on the IUS role in IBD patients' clinical management. For detecting IBD, particularly Crohn's disease, the IUS parameters - above all the evidence of a thickened bowel wall (BWT) - show very good diagnostic accuracy similar to that of MRI or CT scan. The standard IUS parameters are not accurate enough to detect inflammatory activity, but intravenous contrast-enhanced US (CEUS) is highly accurate in ruling active inflammation out. However, its routinely use remains limited in clinical practice and its parameters need standardization. IUS is accurate in detecting IBD main complications: in particular, fistulae and abscesses. As to stenosis the recent introduction of IUS-based elastographic techniques allows to differentiate prevalently inflammatory from highly fibrotic strictures. IUS proves valid also for monitoring IBD patients. In particular, the evidence of transmural healing, defined as BWT normalization, has got an important prognostic meaning, as associated with better long-term clinical outcomes. Post-surgery CD recurrence can be suggested by early IUS assessment.
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Affiliation(s)
- Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.
| | - Fabiana Castiglione
- Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine, "Federico II" University of Naples, Naples, Italy
| | - Emma Calabrese
- Gastroenterology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, "Luigi Sacco" Hospital, University of Milan, Italy
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Costantino A, Giunta M, Casazza G, Arona S, Colli A, Conte D, Vecchi M, Fraquelli M. Is pocket-size ultrasound a reliable tool for bowel investigation? A study on its feasibility, reproducibility and diagnostic accuracy. Dig Liver Dis 2020; 52:38-43. [PMID: 31409578 DOI: 10.1016/j.dld.2019.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 06/26/2019] [Accepted: 07/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Intestinal ultrasound (IUS) examination is a first-line non-invasive imaging procedure for patients with suspicion of bowel diseases. AIM To assess the feasibility, reproducibility and diagnostic accuracy of a pocket-size ultrasound device (PUD) in identifying the presence of intestinal alterations in patients consecutively recruited to undergo IUS examination. METHODS 200 consecutive patients (57% female, 48.8 years) underwent both PUD (two independent investigators) and IUS examination on the same day. Nine ultrasonographic signs were systematically searched for. PUD inter-observer reproducibility was assessed by kappa statistic and ICC. The diagnostic accuracy of PUD as compared to IUS results was assessed by calculating sensitivity, specificity and corresponding positive and negative likelihood ratios. RESULTS PUD and IUS examinations were successful in 100% of the patients. PUD reproducibility was good/excellent at evidencing the presence (ICC 0.84) and length (ICC 0.85) of an intestinal tract with thickened wall and abdominal free fluid (ICC 0.87). The diagnostic accuracy of PUD, compared to traditional IUS, was good with regard to the presence of bowel wall thickening (sensitivity 92%, specificity 95%), the length of the thickened bowel (sensitivity 94%, specificity 95%) and the presence of free fluid (sensitivity 81%, specificity 99%). CONCLUSIONS PUD is a feasible, reproducible and accurate first-line screening tool for the assessment of the gastro-intestinal tract.
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Affiliation(s)
- Andrea Costantino
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università di Milano, Milan, Italy
| | | | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche, Ospedale "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Silvia Arona
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università di Milano, Milan, Italy
| | - Agostino Colli
- Dipartimento di Medicina Interna, Ospedale "A. Manzoni", Lecco, Italy
| | - Dario Conte
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università di Milano, Milan, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università di Milano, Milan, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università di Milano, Milan, Italy.
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Stefanescu H, Marasco G, Calès P, Fraquelli M, Rosselli M, Ganne-Carriè N, de Ledinghen V, Ravaioli F, Colecchia A, Rusu C, Andreone P, Mazzella G, Festi D. A novel spleen-dedicated stiffness measurement by FibroScan® improves the screening of high-risk oesophageal varices. Liver Int 2020; 40:175-185. [PMID: 31444849 DOI: 10.1111/liv.14228] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/23/2019] [Accepted: 08/20/2019] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Several non-invasive tests (NITs) have been developed to diagnose oesophageal varices (EV), including the recent Baveno VI criteria to rule out high-risk varices (HRV). Spleen stiffness measurement (SSM) with the standard FibroScan® (SSM@50Hz) has been evaluated. However, the EV grading could be underestimated because of a ceiling threshold (75 kPa) of the SSM@50Hz. The aims were to evaluate SSM by a novel spleen-dedicated FibroScan® (SSM@100Hz) for EV diagnosis compared with SSM@50Hz, other validated NITs and Baveno VI criteria. METHODS This prospective multicentre study consecutively enrolled patients with chronic liver disease; blood data, endoscopy, liver stiffness measurement (LSM), SSM@50Hz and SSM@100Hz were collected. RESULTS Two hundred and sixty patients met inclusion criteria. SSM@100Hz success rate was significantly higher than that of SSM@50Hz (92.5% vs 76.0%, P < .001). SSM@100Hz accuracy for the presence of EV (AUC = 0.728) and HRV (AUC = 0.756) was higher than in other NITs. SSM@100Hz AUC for large EV (0.782) was higher than SSM@50Hz (0.720, P = .027). AUC for HRV with SSM@100Hz (0.780) was higher than with LSM (0.615, P < .001). The spared endoscopy rate of Baveno VI criteria (8.1%) was significantly increased by the combination to SSM@50Hz (26.5%) or SSM@100Hz (38.9%, P < .001 vs others). The missed HRV rate was, respectively, 0% and 4.7% for combinations. CONCLUSIONS SSM@100Hz is a new performant non-invasive marker for EV and HRV providing a higher accuracy than SSM@50Hz and other NITs. The combination of Baveno VI criteria and SSM@100Hz significantly increased the spared endoscopy rate compared to Baveno VI criteria alone or combined with SSM@50Hz. Clinical trial number: NCT02180113.
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Affiliation(s)
- Horia Stefanescu
- Liver Unit, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Paul Calès
- Hepato-Gastroenterology Department, University hospital, Angers, France
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Matteo Rosselli
- Institute for Liver and Digestive Health, Royal Free Hospital, University College of London, London, UK
| | - Nathalie Ganne-Carriè
- INSERM UMR 1162, Hepato-Gastroenterology Department, APHP Jean Verdier Hospital, University Paris 13, Paris, France
| | | | - Federico Ravaioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Antonio Colecchia
- Gastroenterology Unit, University Hospital Borgo Trento, Verona, Italy
| | - Corina Rusu
- Liver Unit, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Pietro Andreone
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Giuseppe Mazzella
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Fraquelli M, Nadarevic T, Giljaca V, Colli A, Miletic D, Štimac D, Casazza G. Contrast-enhanced ultrasound for the diagnosis of hepatocellular carcinoma in advanced chronic liver disease. Cochrane Database of Systematic Reviews 2019. [DOI: 10.1002/14651858.cd013483] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Mirella Fraquelli
- Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano; Gastroenterology and Endoscopy Unit; Via F. Sforza, 35 Milan Italy 20122
| | - Tin Nadarevic
- Clinical Hospital Centre Rijeka; Department of Radiology; Kresimirova 42 Rijeka Croatia 51000
| | - Vanja Giljaca
- Heart of England NHS Foundation Trust, Birmingham Heartlands Hospital; Directorate of Surgery, Department of Gastroenterology; Bordesley Green East Birmingham UK B9 5SS
| | - Agostino Colli
- A Manzoni Hospital ASST Lecco; Department of Internal Medicine; Via dell'Eremo, 9/11 Lecco Italy 23900
| | - Damir Miletic
- Clinical Hospital Centre Rijeka; Department of Radiology; Kresimirova 42 Rijeka Croatia 51000
| | - Davor Štimac
- Clinical Hospital Centre Rijeka; Department of Gastroenterology; Kresimirova 42 Rijeka Croatia 51000
| | - Giovanni Casazza
- Università degli Studi di Milano; Dipartimento di Scienze Biomediche e Cliniche "L. Sacco"; via GB Grassi 74 Milan Italy 20157
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Tosetti G, Primignani M, La Mura V, D'Ambrosio R, Degasperi E, Mezzina N, Viganò M, Rumi M, Fracanzani AL, Lombardi R, Fargion S, Fraquelli M, Aghemo A, Lampertico P. Evaluation of three "beyond Baveno VI" criteria to safely spare endoscopies in compensated advanced chronic liver disease. Dig Liver Dis 2019; 51:1135-1140. [PMID: 30691777 DOI: 10.1016/j.dld.2018.12.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/14/2018] [Accepted: 12/25/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Liver stiffness measurement (LSM) <20 kPa and platelet count >150,000/mm3 exclude varices needing treatment (VNT) in viral compensated advanced chronic liver disease (cACLD), saving-up to 20-25% endoscopies (Baveno VI criteria). Refinements of such criteria to further reduce endoscopies and an approach without LSM (Platelet 150/MELD 6) were later proposed. AIMS To assess LSM 25/platelet 125, LSM 25/platelet 110 (Expanded-Baveno VI) and Platelet 150/MELD 6 accuracy versus Baveno VI criteria, and the impact of platelet count variability on criteria accuracy in all-etiologies cACLD. METHODS cACLD patients undergoing screening endoscopy with laboratory data within 6 months and LSM within one year. RESULTS Of 442 patients, 31% had varices (7% with VNT). Baveno VI criteria had 100% sensitivity (Se) and negative predictive value (NPV) and spared 19.5% endoscopies. "LSM 25/platelet 125" and "Expanded-Baveno VI" criteria maintained such accuracy, sparing 15% and 24% more endoscopies, respectively (p < 0.001). Platelet 150/MELD 6 was less accurate, misclassifying 10% VNT. Platelet count variability exceeded 8% and one VNT patient was misclassified with both "Expanded-Baveno VI" and "LSM 25/platelet 125" criteria considering the previous platelet count. CONCLUSIONS Both "Expanded-Baveno VI" and "LSM 25/platelet 125" criteria are accurate in cACLD, but the former are more advantageous. Platelet 150/MELD 6 proved inadequate.
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Affiliation(s)
- Giulia Tosetti
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Massimo Primignani
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy.
| | - Vincenzo La Mura
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy; Department of Biomedical Sciences For Health, University of Milan, Milan, Italy
| | - Roberta D'Ambrosio
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Elisabetta Degasperi
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Nicolò Mezzina
- Hepatology Unit, Ospedale San Giuseppe, University of Milan, Milan, Italy
| | - Mauro Viganò
- Hepatology Unit, Ospedale San Giuseppe, University of Milan, Milan, Italy
| | - Mariagrazia Rumi
- Hepatology Unit, Ospedale San Giuseppe, University of Milan, Milan, Italy
| | - Anna Ludovica Fracanzani
- Internal Medicine, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Rosa Lombardi
- Internal Medicine, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Silvia Fargion
- Internal Medicine, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Alessio Aghemo
- Humanitas University Department of Biomedical Sciences, Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Pietro Lampertico
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Nadarevic T, Giljaca V, Colli A, Fraquelli M, Casazza G, Miletic D, Štimac D. Computed tomography for the diagnosis of hepatocellular carcinoma in chronic advanced liver disease. Cochrane Database of Systematic Reviews 2019. [DOI: 10.1002/14651858.cd013362] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Tin Nadarevic
- Clinical Hospital Centre Rijeka; Department of Radiology; Kresimirova 42 Rijeka Croatia 51000
| | - Vanja Giljaca
- Heart of England NHS Foundation Trust, Birmingham Heartlands Hospital; Directorate of Surgery, Department of Gastroenterology; Bordesley Green East Birmingham UK B9 5SS
| | - Agostino Colli
- A Manzoni Hospital ASST Lecco; Department of Internal Medicine; Via dell'Eremo, 9/11 Lecco Italy 23900
| | - Mirella Fraquelli
- Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano; Gastroenterology and Endoscopy Unit; Via F. Sforza, 35 Milan Italy 20122
| | - Giovanni Casazza
- Università degli Studi di Milano; Dipartimento di Scienze Biomediche e Cliniche "L. Sacco"; via GB Grassi 74 Milan Italy 20157
| | - Damir Miletic
- Clinical Hospital Centre Rijeka; Department of Radiology; Kresimirova 42 Rijeka Croatia 51000
| | - Davor Štimac
- Clinical Hospital Centre Rijeka; Department of Gastroenterology; Kresimirova 42 Rijeka Croatia 51000
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Colli A, Nadarević T, Miletić D, Giljaca V, Fraquelli M, Štimac D, Casazza G. Abdominal ultrasound and alpha‐fetoprotein for the diagnosis of hepatocellular carcinoma. Cochrane Database Syst Rev 2019; 2019:CD013346. [PMCID: PMC6547443 DOI: 10.1002/14651858.cd013346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
This is a protocol for a Cochrane Review (Diagnostic test accuracy). The objectives are as follows: To assess the diagnostic accuracy of abdominal ultrasound and alpha‐fetoprotein (AFP), alone or in combination, for the diagnosis of hepatocellular carcinoma (HCC) of any size and at any stage in people with chronic advanced liver disease, either in a surveillance programme or in a clinical setting.
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Affiliation(s)
- Agostino Colli
- A Manzoni Hospital ASST LeccoDepartment of Internal MedicineVia dell'Eremo, 9/11LeccoItaly23900
| | - Tin Nadarević
- Clinical Hospital Centre RijekaDepartment of RadiologyKresimirova 42RijekaCroatia51000
| | - Damir Miletić
- Clinical Hospital Centre RijekaDepartment of RadiologyKresimirova 42RijekaCroatia51000
| | - Vanja Giljaca
- Heart of England NHS Foundation Trust, Birmingham Heartlands HospitalDirectorate of Surgery, Department of GastroenterologyBordesley Green EastBirminghamUKB9 5SS
| | - Mirella Fraquelli
- Fondazione IRCCS Cà Granda ‐ Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di MilanoGastroenterology and Endoscopy UnitVia F. Sforza, 35MilanItaly20122
| | - Davor Štimac
- Clinical Hospital Centre RijekaDepartment of GastroenterologyKresimirova 42RijekaCroatia51000
| | - Giovanni Casazza
- Università degli Studi di MilanoDipartimento di Scienze Biomediche e Cliniche "L. Sacco"via GB Grassi 74MilanItaly20157
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D'Ambrosio R, Aghemo A, Rumi MG, Degasperi E, Sangiovanni A, Maggioni M, Fraquelli M, Perbellini R, Rosenberg W, Bedossa P, Colombo M, Lampertico P. Persistence of hepatocellular carcinoma risk in hepatitis C patients with a response to IFN and cirrhosis regression. Liver Int 2018; 38:1459-1467. [PMID: 29377616 DOI: 10.1111/liv.13707] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/12/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM In patients with HCV-related cirrhosis, a sustained virological response may lead to cirrhosis regression. Whether histological changes translate into prevention of long-term complications, particularly hepatocellular carcinoma is still unknown. This was investigated in a cohort of histological cirrhotics who had been prospectively followed-up for 10 years after the achievement of a sustained virological response to IFN. METHODS In all, 38 sustained virological response cirrhotics who underwent a liver biopsy 5 years post-SVR were prospectively followed to assess the impact of cirrhosis regression on clinical endpoints. RESULTS During a follow-up of 86 (30-96) months from liver biopsy, no patients developed clinical decompensation, whilst 5 (13%) developed hepatocellular carcinoma after 79 (7-88) months. The 8-year cumulative probability of hepatocellular carcinoma was 17%, without differences between patients with or without cirrhosis regression (19% [95% CI 6%-50%] vs 14% [95% CI 4%-44%], P = .88). Patients who developed or did not an hepatocellular carcinoma had similar rates of residual cirrhosis (P = 1.0), collagen content (P = .48), METAVIR activity (P = .34), portal inflammation (P = .06) and steatosis (P = .17). At baseline, patients who developed an hepatocellular carcinoma had higher γGT (HR 1.03, 95% CI 1.00-1.06; P = .014) and glucose (HR 1.02, 95% CI 1.00-1.02; P = .012) values; moreover, they had increased Forns Score (HR 12.8, 95% CI 1.14-143.9; P = .039), Lok Index (HR 6.24, 95% CI 1.03-37.6; P = .046) and PLF (HR 19.3, 95% CI 1.72-217.6; P = .016) values. One regressor died of lung cancer. The 8-year cumulative survival probability was 97%, independently on cirrhosis regression (96% vs 100%, P = 1.0) or hepatocellular carcinoma (100% vs 97%, P = 1.0). CONCLUSIONS Post-SVR cirrhosis regression does not prevent hepatocellular carcinoma occurrence.
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Affiliation(s)
- Roberta D'Ambrosio
- A. M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Alessio Aghemo
- Department of Biomedical Sciences, Humanitas University, Rozzano-Milan, Italy.,Humanitas Clinical and Research Center, Rozzano-Milan, Italy
| | - Maria Grazia Rumi
- Division of Hepatology, Ospedale San Giuseppe, Università degli Studi di Milano, Milan, Italy
| | - Elisabetta Degasperi
- A. M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Angelo Sangiovanni
- A. M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Marco Maggioni
- Division of Pathology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Mirella Fraquelli
- Division of Gastroenterology and Endoscopy, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Riccardo Perbellini
- A. M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - William Rosenberg
- Center for Hepatology, Division of Medicine, University College of London, London, UK
| | - Pierre Bedossa
- Department of Pathology and INSERM U773, Hopital Beaujon, Universitée Paris-Diderot, Clichy, France
| | - Massimo Colombo
- Humanitas Clinical and Research Center, Rozzano-Milan, Italy
| | - Pietro Lampertico
- A. M. and A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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Conti CB, Fraquelli M, Conte D. Abdominal infection reveals a rare disease. Intern Emerg Med 2018; 13:535-538. [PMID: 28815401 DOI: 10.1007/s11739-017-1737-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/09/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Clara Benedetta Conti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milan, Italy.
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Dario Conte
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Fabrizi F, Aghemo A, Lampertico P, Fraquelli M, Cresseri D, Moroni G, Passerini P, Donato FM, Messa P. Immunosuppressive and antiviral treatment of hepatitis C virus-associated glomerular disease: A long-term follow-up. Int J Artif Organs 2018; 41:306-318. [PMID: 29595085 DOI: 10.1177/0391398818762358] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The evidence in the medical literature on the treatment of hepatitis C virus-associated glomerular disease is extremely limited. The advent of nonconventional immunosuppressive agents and direct-acting antivirals promises high efficacy and safety. AIMS We conducted an open-label, single-arm clinical study to examine the efficacy and safety of a combined approach for hepatitis C virus-associated glomerular disease. METHODS In the first phase of the study, patients with hepatitis C virus-associated glomerular disease received interferon-based antiviral therapy and immunosuppressive agents; since 2013, interferon-free antiviral therapy was adopted and novel immunosuppressants (including B-cell depleting agents and mycophenolate mofetil) or immunomodulators (ribavirin) were choiced. Virological and clinical responses were evaluated over a long observation period (median follow-up of 60 weeks and 46.5 months after the end of treatment with interferon and direct-acting antiviral agents, respectively). RESULTS We enrolled 25 consecutive patients with hepatitis C virus-associated glomerular disease, 8 being liver transplant recipients for hepatitis C. A total of 13 patients received therapy with direct-acting antivirals and experienced sustained viral response (serum hepatitis C virus RNA <12 IU/mL, 12 weeks after treatment ended, sustained viral response12). The mean (±standard deviation) proteinuria decreased from 2.61 ± 1.01 at baseline to 1.71 ± 1.43 (g/day) at sustained viral response 48, p = 0.031; microscopic hematuria and serum cryoglobulins disappeared in six (50%) and seven (64%) patients, respectively, after sustained viral response by direct-acting antivirals. Adverse events occurred in 69% (9/13) of patients and were mild, with four cases of ribavirin-related anemia requiring blood transfusions (no drop-outs). After sustained viral response by direct-acting antivirals, immunosuppressive and immunomodulatory agents were initiated in clinical relapsers ( n = 2) and nonresponders ( n = 3) with some benefit. Among patients on interferon-based regimens ( n = 12), viral response (sustained viral response 24) and dropout rates were 58% (7/12) and 33% (4/12), respectively. After sustained viral response by interferon-based therapy, clinical relapsers ( n = 3) were successfully managed with immunosuppressive agents in two patients. CONCLUSION Treatment with direct-acting antivirals provides excellent rates of viral response and safety in patients with hepatitis C virus-related glomerular disease; viral response was frequently accompanied by clinical improvement. The absence of hepatitis C virus RNA from serum allowed immunosuppressive and immunomodulatory therapies with benefits for glomerular abnormalities and no concern on hepatitis C virus replication.
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Affiliation(s)
- Fabrizio Fabrizi
- 1 Division of Nephrology, Maggiore Hospital and IRCCS Foundation, Milano, Italy
| | - Alessio Aghemo
- 2 Division of Gastroenterology and Hepatology, Maggiore Hospital and IRCCS Foundation, Milano, Italy
| | - Pietro Lampertico
- 2 Division of Gastroenterology and Hepatology, Maggiore Hospital and IRCCS Foundation, Milano, Italy.,3 School of Medicine, University of Milan, Italy
| | - Mirella Fraquelli
- 2 Division of Gastroenterology and Hepatology, Maggiore Hospital and IRCCS Foundation, Milano, Italy
| | - Donata Cresseri
- 1 Division of Nephrology, Maggiore Hospital and IRCCS Foundation, Milano, Italy
| | - Gabriella Moroni
- 1 Division of Nephrology, Maggiore Hospital and IRCCS Foundation, Milano, Italy
| | - Patrizia Passerini
- 1 Division of Nephrology, Maggiore Hospital and IRCCS Foundation, Milano, Italy
| | - Francesca M Donato
- 2 Division of Gastroenterology and Hepatology, Maggiore Hospital and IRCCS Foundation, Milano, Italy
| | - Piergiorgio Messa
- 1 Division of Nephrology, Maggiore Hospital and IRCCS Foundation, Milano, Italy.,3 School of Medicine, University of Milan, Italy
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Terzi E, Iavarone M, Pompili M, Veronese L, Cabibbo G, Fraquelli M, Riccardi L, De Bonis L, Sangiovanni A, Leoni S, Zocco MA, Rossi S, Alessi N, Wilson SR, Piscaglia F. Contrast ultrasound LI-RADS LR-5 identifies hepatocellular carcinoma in cirrhosis in a multicenter restropective study of 1,006 nodules. J Hepatol 2018; 68:485-492. [PMID: 29133247 DOI: 10.1016/j.jhep.2017.11.007] [Citation(s) in RCA: 174] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 10/28/2017] [Accepted: 11/01/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The use of contrast enhanced ultrasound (CEUS) for the diagnosis of hepatocellular carcinoma (HCC) in cirrhosis was questioned because of the risk of a false positive diagnosis in cases of cholangiocarcinoma. The American College of Radiology has recently released a scheme (CEUS Liver Imaging Reporting and Data System [LI-RADS®]) to classify lesions at risk of HCC investigated by CEUS. The aim of the present study was to validate this LI-RADS scheme for the diagnosis of HCC. METHODS A total of 1,006 nodules from 848 patients with chronic liver disease at risk of HCC were collected in five Italian centers and retrospectively analyzed. Nodules were classified as LR-5, (HCC) if ≥1 cm with arterial phase hyperenhancement, and late washout (onset ≥60 s after contrast injection) of mild degree. Rim enhancement and/or early and/or marked washout qualified lesions as LR-M (malignant, but not specific for HCC). Other combinations qualified lesions at intermediate risk for HCC (LR-3) or probable HCC (LR-4). Diagnostic reference standard was CT/MRI diagnosis of HCC (n = 506) or histology (n = 500). RESULTS The median nodule size was 2 cm. Of 1,006 nodules, 820 (81%) were HCC, 40 (4%) were cholangiocarcinoma, 116 (11%) regenerative nodules (±dysplastic). The LR-5 category (52% of all nodules) was 98.5% predictive of HCC, with no risk of misdiagnosis for pure cholangiocarcinoma. Sensitivity for HCC was 62%. All LR-M nodules were malignant and the majority of non-hepatocellular origin. Over 75% of cholangiocarcinomas were LR-M. The LR-3 category included 203 lesions (HCC 96 [47%]) and the LR-4 202 (HCC 173 [87%]). CONCLUSIONS The CEUS LI-RADS class LR-5 is highly specific for HCC, enabling its use for a confident non-invasive diagnosis. LAY SUMMARY This is a retrospective study of approximately 1,000 focal lesions at risk for hepatocellular carcinoma (HCC). Herein, we demonstrate that the refined definition of the typical contrast enhanced ultrasound pattern of HCC introduced by the Liver Imaging Reporting and Data System (LI-RADS®) practically abolishes the risk of misdiagnosis of other malignant entities (e.g. cholangiocarcinoma) for HCC with negligible reduction in sensitivity. These data support the use of contrast enhanced ultrasound to diagnose HCC in cirrhosis.
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Affiliation(s)
- Eleonora Terzi
- Department of Medical and Surgical Sciences, Division of Internal Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Massimo Iavarone
- A.M. & A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Maggiore Hospital, University of Milan, Milan, Italy
| | - Maurizio Pompili
- Internal Medicine, Gastroenterology and Hepatology, Gemelli Hospital, University of Rome, Rome, Italy
| | - Letizia Veronese
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Giuseppe Cabibbo
- Section of Gastroenterology, Biomedical Department of Internal and Specialized Medicine (Di.Bi.M.I.S.), University of Palermo, Palermo, Italy
| | - Mirella Fraquelli
- Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca' Granda Maggiore Hospital, University of Milan, Milan, Italy
| | - Laura Riccardi
- Internal Medicine, Gastroenterology and Hepatology, Gemelli Hospital, University of Rome, Rome, Italy
| | - Ludovico De Bonis
- Department of Medical and Surgical Sciences, Division of Internal Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Angelo Sangiovanni
- A.M. & A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Maggiore Hospital, University of Milan, Milan, Italy
| | - Simona Leoni
- Department of Medical and Surgical Sciences, Division of Internal Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Maria Assunta Zocco
- Internal Medicine, Gastroenterology and Hepatology, Gemelli Hospital, University of Rome, Rome, Italy
| | - Sandro Rossi
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Nicola Alessi
- Section of Gastroenterology, Biomedical Department of Internal and Specialized Medicine (Di.Bi.M.I.S.), University of Palermo, Palermo, Italy
| | - Stephanie R Wilson
- Radiology and Medicine, Division of Gastroenterology, University of Calgary, Canada
| | - Fabio Piscaglia
- Department of Medical and Surgical Sciences, Division of Internal Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
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Orlando S, Fraquelli M, Coletta M, Branchi F, Magarotto A, Conti CB, Mazza S, Conte D, Basilisco G, Caprioli F. Ultrasound Elasticity Imaging Predicts Therapeutic Outcomes of Patients With Crohn's Disease Treated With Anti-Tumour Necrosis Factor Antibodies. J Crohns Colitis 2018; 12:63-70. [PMID: 28961950 DOI: 10.1093/ecco-jcc/jjx116] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 08/22/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIMS Ultrasound elasticity imaging is a non-invasive technique developed to evaluate fibrosis. Measuring tissue strain by ultrasound elasticity imaging can reliably detect severe ileal fibrosis in patients with Crohn's disease [CD]. We have hypothesised that a more severe range of fibrosis might influence the therapeutic response to anti-tumour necrosis factor [TNF] treatment. The aim of this study was to assess the ability of ultrasound elasticity imaging to predict the therapeutic outcome for CD patients. METHODS Consecutive patients with ileal/ileocolonic CD, starting anti-TNF treatment, were enrolled for the study. These patients underwent bowel ultrasound and ultrasound elasticity imaging at baseline and at 14 and 52 weeks after anti-TNF treatment. Bowel wall stiffness was quantified by calculating the strain ratio between the mesenteric tissue and the bowel wall. Strain ratio ≥ 2 was used to identify severe ileal fibrosis. Transmural healing at 14 and 52 weeks was defined as bowel wall thickness ≤ 3 mm. RESULTS Thirty patients with CD were enrolled. Five patients underwent surgery for bowel obstruction. The frequency of surgeries was significantly greater in patients with a strain ratio ≥ 2 at baseline [p = 0.003]. A significant reduction of the bowel thickness was observed after 14 and 52 weeks of anti-TNF treatment [p < 0.005]. A significant inverse correlation was observed between the strain ratio values at baseline and the thickness variations following anti-TNF therapy [p = 0.007]; 27% of patients achieved transmural healing at 14 weeks. The baseline strain ratio was significantly lower in patients with transmural healing [p < 0.05]. CONCLUSIONS This study shows that ultrasound elasticity imaging predicts therapeutic outcomes for CD patients treated with anti-TNF.
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Affiliation(s)
- Stefania Orlando
- Postgraduate School of Gastroenterology, University of Milan, Milan, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Marina Coletta
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Federica Branchi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Andrea Magarotto
- Postgraduate School of Gastroenterology, University of Milan, Milan, Italy
| | | | - Stefano Mazza
- Postgraduate School of Gastroenterology, University of Milan, Milan, Italy
| | - Dario Conte
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Guido Basilisco
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Flavio Caprioli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Maira D, Cassinerio E, Marcon A, Mancarella M, Fraquelli M, Pedrotti P, Cappellini MD. Progression of liver fibrosis can be controlled by adequate chelation in transfusion-dependent thalassemia (TDT). Ann Hematol 2017; 96:1931-1936. [DOI: 10.1007/s00277-017-3120-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/21/2017] [Indexed: 01/19/2023]
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Elli L, Casazza G, Locatelli M, Branchi F, Ferretti F, Conte D, Fraquelli M. Use of enteroscopy for the detection of malignant and premalignant lesions of the small bowel in complicated celiac disease: a meta-analysis. Gastrointest Endosc 2017; 86:264-273.e1. [PMID: 28433612 DOI: 10.1016/j.gie.2017.04.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/06/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Enteroscopy (wireless or wired) is the reference standard for small-bowel (SB) diseases, and it has been applied to detect SB malignancies in complicated celiac disease (CD) with heterogeneous results. The aim of this meta-analysis was to obtain a diagnostic yield (DY) by pooling the data of studies that investigated the use of enteroscopy to detect SB adverse events in CD. METHODS We performed an online search for studies estimating the DY of wireless and wired enteroscopy in predicting the presence of SB premalignant and/or malignant lesions. The DerSimonian and Laird random-effects method was used to pool the arcsine-transformed proportions of patients with the events. Three meta-analyses were performed considering the following events: the presence of a malignancy, premalignant damage (ulcerative jejunoileitis [UJ]), or the presence of a malignancy or UJ. A subgroup analysis was performed after extracting (if possible) patients with refractory CD (RCD). RESULTS Of the 529 titles initially resulting from the search, 10 studies on capsule enteroscopy (CE) and 3 on double-balloon or push enteroscopy met the inclusion criteria. Overall, 439 and 76 patients were enrolled in these studies using CE and enteroscopy, respectively. Twelve tumors and 47 UJs were found by CE versus 8 tumors and 13 UJs detected by wired enteroscopy. For malignancies the CE yield was 1.9% (95% CI, .5%-3.8%) and wired enteroscopy yield 8.7% (95% CI, 0%-21.2%); similarly, for UJ the DYs were 8.4% (95% CI, 2.1%-17.7%) and 16.7% (95% CI, 8.7%-26.3%); for either UJ or neoplasia the DYs were 13.0% (95% CI, 5.6%-22.5%) and 27.7% (95% CI, 14.8%-42.6%). For RCD the DYs of all enteroscopic techniques were 1.8% (95% CI, 0%-7.7%) for neoplasia, 22.3% (95% CI, 8.2%-39.7%) for UJ, and 27.5% (95% CI, 13.1%-44.2%) for either. CONCLUSIONS Enteroscopy is a powerful and efficient diagnostic tool for the detection of SB malignancies in complicated CD.
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Affiliation(s)
- Luca Elli
- Center for the Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Martina Locatelli
- Center for the Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Federica Branchi
- Center for the Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Francesca Ferretti
- Center for the Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Dario Conte
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Vigone B, Caronni M, Severino A, Bellocchi C, Baldassarri AR, Fraquelli M, Montanelli G, Santaniello A, Beretta L. Preliminary safety and efficacy profile of prucalopride in the treatment of systemic sclerosis (SSc)-related intestinal involvement: results from the open label cross-over PROGASS study. Arthritis Res Ther 2017. [PMID: 28633671 PMCID: PMC5477745 DOI: 10.1186/s13075-017-1340-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Prokinetics are used to treat enteric dismotility symptoms in systemic sclerosis (SSc) patients, but they often lack adequate efficacy. The most effective prokinetics belonging to the serotonin (5-HT4) receptor agonists class were withdrawn due to cardiac toxicity in relation to modest 5-HT4 receptor affinity. Prucalopride is a high-affinity 5-HT4 receptor agonist with no major cardiac issues, for which the efficacy in SSc has not yet been assessed. Methods Forty patients with self-reported mild to moderately severe enteric symptoms were enrolled in a cross-over 2 × 2 study. Subjects were randomized 1:1 to prucalopride 2 mg/day or no treatment for one month and vice versa after a 2-week washout period. Before and after each sequence the patients compiled the University of California Los Angeles gastrointestinal tract (UCLA GIT) 2.0 questionnaire and the numbers of complete intestinal movements were recorded. Oro-cecal transit time (OCTT) was evaluated by lactulose breath test in a subgroup of patients. Data were evaluated by mixed linear models corrected for the number of laxatives used during the study periods. Results There were 29 subjects who completed the study; 7 subjects withdrew due to side-effects and 4 subjects were not compliant with the study procedures. As compared to dummy treatment, prucalopride was associated with more intestinal evacuations (p < 0.001), improvement of UCLA GIT constipation (-0.672 ± 0.112 vs 0.086 ± 0.115; p < 0.001), reflux (-0.409 ± 0.094 vs 0.01 ± 0.096; p < 0.005) and bloating (-0.418 ± 0.088 vs -0.084 ± 0.09; p = 0.01) scores. Treatment was ranked moderately to more than moderately effective by 22 patients (72.4%). OCTT was significantly reduced during prucalopruide consumption (prucalopride: -20.1 ± 20.1 vs no treatment: 45.8 ± 21.3 minutes; treatment effect = -65.9 minutes; p = 0.035). Conclusions The safety profile of prucalopride in SSc is similar to what is known from the literature. In patients with mild to severe gastrointestinal problems, prucalopride may be effective in treating dismotility symptoms, increasing the number of complete bowel movements and improving bowel transit, reducing reflux disease and bloating. Trial registration EU Clinical Trial Registry, EudraCT2012-005348-92. Registered on 19 February 2013.
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Affiliation(s)
- Barbara Vigone
- Scleroderma Unit, Referral Center for Systemic Autoimmune Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Pace 9, 20122, Milano, Italy
| | - Monica Caronni
- Scleroderma Unit, Referral Center for Systemic Autoimmune Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Pace 9, 20122, Milano, Italy
| | - Adriana Severino
- Scleroderma Unit, Referral Center for Systemic Autoimmune Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Pace 9, 20122, Milano, Italy
| | - Chiara Bellocchi
- Scleroderma Unit, Referral Center for Systemic Autoimmune Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Pace 9, 20122, Milano, Italy
| | - Anna Rita Baldassarri
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza 35, Milano, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza 35, Milano, Italy
| | - Gaia Montanelli
- Scleroderma Unit, Referral Center for Systemic Autoimmune Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Pace 9, 20122, Milano, Italy
| | - Alessandro Santaniello
- Scleroderma Unit, Referral Center for Systemic Autoimmune Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Pace 9, 20122, Milano, Italy
| | - Lorenzo Beretta
- Scleroderma Unit, Referral Center for Systemic Autoimmune Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Pace 9, 20122, Milano, Italy.
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Branchi F, Caprioli F, Orlando S, Conte D, Fraquelli M. Non-invasive evaluation of intestinal disorders: The role of elastographic techniques. World J Gastroenterol 2017; 23:2832-2840. [PMID: 28522902 PMCID: PMC5413779 DOI: 10.3748/wjg.v23.i16.2832] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 01/27/2017] [Accepted: 03/31/2017] [Indexed: 02/06/2023] Open
Abstract
Over the recent years the non-invasive techniques for the evaluation of the small bowel have been playing a major role in the management of chronic intestinal diseases, such as inflammatory bowel diseases (IBD). The diagnostic performances of magnetic resonance imaging, computed tomography and ultrasound in the field of small bowel disorders, have been assessed and established for more than two decades. Newer sonographic techniques, such as strain elastography and shear wave elastography, have been put forward for the assessment of disease activity and characterization of IBD-related damage in the setting of Crohn’s disease and other gastrointestinal disorders. The data from the preliminary research and clinical studies have shown promising results as regards the ability of elastographic techniques to differentiate inflammatory from fibrotic tissue. The distinction between IBD activity (inflammation) and IBD-related damage (fibrosis) is currently considered crucial for the assessment and management of patients. Moreover, all the elastographic techniques are currently being considered in the setting of other intestinal disorders (e.g., rectal tumors, appendicitis). The aim of this paper is to offer both a comprehensive narrative review of the non-invasive techniques available for the assessment of small-bowel disorders, with particular emphasis on inflammatory bowel diseases, and a summary of the current evidence on the use of elastographic techniques in this setting.
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Conti CB, Giunta M, Gridavilla D, Conte D, Fraquelli M. Role of Bowel Ultrasound in the Diagnosis and Follow-up of Patients with Crohn's Disease. Ultrasound Med Biol 2017; 43:725-734. [PMID: 28185694 DOI: 10.1016/j.ultrasmedbio.2016.12.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 11/18/2016] [Accepted: 12/20/2016] [Indexed: 06/06/2023]
Abstract
Crohn's disease (CD) is an inflammatory chronic bowel disorder; it can involve the whole gastrointestinal tract, but its localization in the ileum or colon is most common. The reference standard for the diagnosis of CD is ileocolonoscopy with histologic assessment. The reference standard for the detection of any complications is surgery. However, imaging techniques have an important role both in the detection/localization of CD and in the follow-up of CD patients. In the last few years, the technical development of ultrasound equipment, the advent of new technologies such as elastography and mostly the increased expertise of sonographers have boosted the role of bowel ultrasound in assessment of the gastrointestinal tract. In fact, bowel ultrasound is particularly attractive thanks to its widespread availability, non-invasiveness, low cost and good reproducibility, as it can be easily repeated during follow-up. The aim of this article is to provide an extensive overview of the actual role of bowel ultrasound in the detection and follow-up of patients with CD.
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Affiliation(s)
- Clara Benedetta Conti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; and Department of Pathophysiology and Organ Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Mariangela Giunta
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; and Department of Pathophysiology and Organ Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Daniele Gridavilla
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; and Department of Pathophysiology and Organ Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Dario Conte
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; and Department of Pathophysiology and Organ Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; and Department of Pathophysiology and Organ Transplantation, Università degli Studi di Milano, Milan, Italy.
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Colli A, Fraquelli M, Prati D, Riva A, Berzuini A, Conte D, Aghemo A, Colombo M, Casazza G. Deciding on Interferon-Free Treatment for Chronic Hepatitis C: Updating Liver Stiffness Cut-Off Values to Maximize Benefit. PLoS One 2016; 11:e0164452. [PMID: 27723770 PMCID: PMC5056756 DOI: 10.1371/journal.pone.0164452] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/26/2016] [Indexed: 01/06/2023] Open
Abstract
Introduction In a perspective of economic constraints the prioritizing of patients to IFN-free regimens is mainly based on the determination of liver stiffness by transient elastography (TE). Being a continuous variable the interpretation of TE results requires the identification of cut-off values, to date set to maximize diagnostic accuracy even if such values should be better based on more helpful outcome prediction endpoints. Aim To define the TE cut-off values in different clinical scenarios, including new IFN-free regimens, and to balance the clinical benefits versus harms in treated and untreated patients. Methods We assessed the accuracy of TE in staging 728 consecutive HCV patients and the distribution of TE values in 1,001 blood donors. Ten experts quantified the expected harm/benefit ratio for 6 scenarios resulting from 2 stages of liver disease (F≥2 or F≥3) and 3 treatment regimens: PEGIFN+ribavirin, PEGIFN+RBV+first-generation protease inhibitor, and IFN-free regimens. The optimal TE cut-off values were identified using the Metz equation. Results The estimated mean expected harm/benefit ratio for IFN-free regimens was 1/8.3 in patients with F≥2 and 1/10 in those with F≥3. The resulting optimal cut-off values were respectively 4.5 kPa with sensitivity at 99% and specificity at 12%, and 6.8 kPa with sensitivity at 94% and specificity at 41%. These cut-off values are lower than those maximizing accuracy and allow to reduce the number of false negative results. Conclusions The optimal TE cut-off values to prioritize patients for IFN-free regimens, are sensibly lower than those used to maximize diagnostic accuracy.
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Affiliation(s)
- Agostino Colli
- Department of Internal Medicine, Ospedale A. Manzoni, Lecco, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- * E-mail:
| | - Daniele Prati
- Department of Transfusion Medicine and Hematology, Ospedale A Manzoni, Lecco, Italy
| | - Alessia Riva
- Department of Internal Medicine, Ospedale A. Manzoni, Lecco, Italy
| | - Alessandra Berzuini
- Department of Transfusion Medicine and Hematology, Ospedale A Manzoni, Lecco, Italy
| | - Dario Conte
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessio Aghemo
- Gastroenterology and Hepatology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Colombo
- Gastroenterology and Hepatology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Casazza
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, Milan, Italy
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Giunta M, Conte D, Fraquelli M. Role of spleen elastography in patients with chronic liver diseases. World J Gastroenterol 2016; 22:7857-7867. [PMID: 27672283 PMCID: PMC5028802 DOI: 10.3748/wjg.v22.i35.7857] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 08/16/2016] [Accepted: 08/30/2016] [Indexed: 02/06/2023] Open
Abstract
The development of liver cirrhosis and portal hypertension (PH), one of its major complications, are structural and functional alterations of the liver, occurring in many patients with chronic liver diseases (CLD). Actually the progressive deposition of hepatic fibrosis has a key role in the prognosis of CLD patients. The subsequent development of PH leads to its major complications, such as ascites, hepatic encephalopathy, variceal bleeding and decompensation. Liver biopsy is still considered the reference standard for the assessment of hepatic fibrosis, whereas the measurement of hepatic vein pressure gradient is the standard to ascertain the presence of PH and upper endoscopy is the method of choice to detect the presence of oesophageal varices. However, several non-invasive tests, including elastographic techniques, are currently used to evaluate the severity of liver disease and predict its prognosis. More recently, the measurement of the spleen stiffness has become particularly attractive to assess, considering the relevant role accomplished by the spleen in splanchnic circulation in the course of liver cirrhosis and in the PH. Moreover, spleen stiffness as compared with liver stiffness better represents the dynamic changes occurring in the advanced stages of cirrhosis and shows higher diagnostic performance in detecting esophageal varices. The aim of this review is to provide an exhaustive overview of the actual role of spleen stiffness measurement as assessed by several elastographic techniques in evaluating both liver disease severity and the development of cirrhosis complications, such as PH and to highlight its potential and possible limitations.
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