Diagnostic value of Transient Elastography (Fibroscan) in the evaluation of liver fibrosis in chronic viral hepatitis C: Comparison to liver biopsy

Purpose

To assess the Transient Elastography diagnostic and staging role in liver fibrosis in chronic hepatitis C in comparison to hepatic biopsy.

Accuracy of ultrasound in the detection of liver fibrosis in chronic viral hepatitis

PURPOSE: To assess the accuracy of ultrasonography (US) in the identification and grading of hepatic fibrosis in patients afflicted with chronic viral liver disease, compared to histological examination as a gold standard. MATERIALS AND METHODS: We prospectively studied 105 patients (32 F, 73 M) affected by chronic viral liver disease in 36 months. Patients were studied with B-mode US and then underwent US-guided liver biopsy. All the patients were studied with conventional US with a Sequoia 512, 6.0 (Acuson, Mountain View CA, USA). We evaluated the following US parameters: liver margins, parenchymal echotexture, portal vein caliber and spleen diameter. The four B-mode US parameters were used for the US grading (from 0 to 4). Scheuer's grading (from 0 to 4) was used for the histological score. Grades 3 and 4 were considered as positive for fibrosis. Sensitivity, specificity, positive and negative predictive values and accuracy were calculated in the case of absence, positivity of one or all the US parameters. The correlation between US and histological scores was evaluated with Spearman's test. RESULTS: At histology seventy-seven patients (73%) had absent grade 0 (1 patient; 1%), low-moderate grade 1 (35 patients; 33%) or grade 2 (41 patients; 39%) liver fibrosis. Twenty-eight patients (27%) had severe grade 3 (16 patients; 15%) or grade 4 (12 patients; 11%) fibrosis. In the case of absence of US parameters sensitivity was 32%, specificity 32%, positive predictive value 15%, negative predictive value 57% and accuracy 32%. In the case of positivity of at least one of the US parameters the values were 68%, 68%, 43%, 84% and 69%. In the case of presence of all the US signs the results were 25%, 100%, 100%, 79% and 80%. None of the 77 patients with a healthy liver or with low-grade fibrosis was positive for all the US parameters. All the patients positive for all of the ultrasonographic parameters had high-grade fibrosis or cirrhosis at liver biopsy. Correlation between B-mode and histological scores was not statistically significant (Rs=0.45; p=0.0001). CONCLUSIONS: US identification of liver fibrosis in chronic liver disease is possible with 25% sensitivity, 100% specificity, 100% positive predictive value and 79% negative predictive value, with an 80% diagnostic accuracy.     

超声引导下经皮肝穿刺活检220例临床分析

目的讨论肝穿活检病理组织学特点,分析肝穿病检结果中疾病分布情况,研究肝穿活检对临床诊断的参考意义。方法对本院近2年各科室送检的220例超声引导下肝脏穿刺活检病理切片标本进行回顾性分析,总结其l临床诊断和病理诊断的疾病分布情况。结果所有病例均成功穿刺,无并发症发生。因肝脏占位送检病例中,有63．9％为恶性肿瘤,且以肝细胞癌为主;因HBV-DNA〉10^4拷贝／ml、转氨酶轻度升高而送检的慢性乙肝患者中,有41．5％炎症活动度大于2级,需接受抗病毒治疗;23例不明原因肝损害者经肝穿刺活检均明确病因。结论超声引导下肝脏穿刺活检安全性高,是肝脏疾病诊断的重要辅助手段。     

超声引导下经皮肾穿刺活检术在慢性肾脏疾病中诊断价值

目的探讨超声引导下经皮肾脏穿刺活检术在诊断慢性肾脏病变中的应用价值。方法对我院94例慢性肾病患者采用超声引导下经皮肾穿刺活检术,取得组织送病理检查;术后观察患者是否有腰痛、腰酸、血尿、肾包膜下血肿等症状,并于第1、2、3天对穿刺患者行彩色多普勒超声检查,观察是否有肾包膜下血肿;查看病理结果,分析超声引导下经皮穿刺肾活检术的成功率。结果 94例行超声引导下经皮肾穿刺活检术的患者均取材成功,取材长度从13~18 mm,根据取材长度穿刺1~3次。穿刺后对患者进行观察,94例患者中有45例患者自述有腰痛、腰酸症状,其中有12例患者有肾包膜下血肿;8例患者出现肉眼血尿,62例患者出现镜下血尿,余患者无明显不适症状。结论超声引导下肾脏穿刺活检术是一种安全有效的辅助检查方法,能提高穿刺的成功率,降低术后并发症,具有较重要的临床应用价值。     

MR扩散加权成像评价慢性病毒性肝炎肝纤维化的临床研究

目的 探讨MR DWI对肝纤维化程度定量分析的能力.方法 应用1.5 T MR对12名志愿者、47例慢性乙型或丙型肝炎患者进行常规扫描及DWI检查,b值选择0、250、500、750及1000 s/mm~2,联合b值b_(250～1000)及b_(500～1000)分别取b=250、500、750和1000 s/mm~2及b=500、750和1000 s/mm~2的ADC平均值.采用Scheuer法进行纤维化(S)分期和炎症(G)分级,探讨病理分期与ADC值的相关性,采用Mann-Whitney U检验及Logistic回归分析评价ADC预测不同纤维化分期的能力.结果 当b=750 s/mm~2时,S0、S1、S2、S3、S4期纤维化下ADC平均值分别为(1.41±0.11)×10~(-3)、(1.37±0.09)×10~(-3)、(1.27±0.05)×10~(-3)、(1.26±0.04)×10~(-3)、(1.22±0.06)×10~(-3)mm~2/s,ADC值在不同S分期间差异最大(F=18.31,P<0.01).随着S分期的增加,各b值下的ADC平均值逐渐下降,两者存在负相关性,b_(250～1000)相关性最强(r=-0.727,P<0.01).选择b_(750)及b_(250～1000)、b_(500～1000)时,ADC值在S2期以上(与S0和S1相比)及S3期以上(与S0和S1相比)纤维化时均明显降低(P<0.01);在预测S2期以上纤维化时,选择b(750)时曲线下面积(AUC)最大(0.909),敏感性85.7%,特异性100.0%(ADC标准≤1.35×10~(-3)mm~2/s);在预测S3期以上纤维化时,选择b_(250～1000)时AUC最大(0.864),敏感性69.6%,特异性95.8%(ADC标准≤1.53×10~(-3)mm~2/s).结论 DWI对于预测S2期以上及S3期以上肝纤维化程度具有良好的效果,b值b_(750)、b_(250～1000)或b_(500～1000)均适合慢性病毒性肝炎患者的纤维化评价.     

背向散射积分对慢性肝炎肝纤维化检测的研究

目的：讨论背向散射积分（integrated backscatter,IBS）超声组织定位对慢性病毒性肝炎肝纤维化程度定量分析的临床应用价值。方法：应用HP5500彩色超声仪,分别检测30例慢性病毒性肝炎患者和64例正常人的肝脏近场、中场、远场的IBS值。结果：慢性病毒性肝炎肝组织的IBS值分别为：近场31.2±3.4 dB,中场36.9±3.5 dB,远场32.3±2.6 dB,正常对照组肝组织的IBS值分别为近场24.1±4.3 dB,中场20.9±5.0 dB,远场14.8±3.5 dB,二者间有显著差异（P〈0.01）;与病理诊断对比,IBS值随肝纤维化程度的加重而增大,轻、中、重度肝纤维化之间对比均存在差异（P〈0.05）。结论：背向散射积分值能反映慢性病毒性肝炎肝纤维化的程度,对慢性肝病的诊断有一定的临床意义。     

Influence of operator experience on performance of ultrasound-guided percutaneous liver biopsy

The purpose was to evaluate the influence of radiologists experience on the diagnostic yield and complications of a percutaneous liver biopsy (PLB) method. Six hundred patients underwent an ultrasound-guided PLB by an inexperienced operator in 25.2% of cases (experience of less than 15 percutaneous liver biopsies performed alone—group I) or by an experienced operator (experience of more than 150 percutaneous liver biopsies—group II). The two groups were well-matched with respect to sex, age, percentage with viral hepatitis without histological cirrhosis, number of needle passes, history of liver biopsy and pain before the biopsy. A histological diagnosis was available in 97.3% of cases without any significant difference between the two groups (P=0.25). However, group II samples were significantly longer and contained more portal tracts (P=0.01). Pain was mild immediately and 6 h after the biopsy, without significant difference between both groups. Eight vasovagal reactions (five in group II) and one arteriobiliary fistula (in group II) occurred. With the method of PLB used for this study, operators experience did not influence either the final histological diagnosis or the degree of pain suffered.     

彩超引导定位移植肝活组织穿刺检查的安全性评价

目的:评价彩超引导定位移植肝脏活组织穿刺检查的安全性。方法:分析2002年4月~2005年12月间,我中心肝脏移植受者中186例次彩超实时引导下肝脏穿刺活检的安全性及与穿刺方法、凝血功能和穿刺次数之间的关系。结果:141例肝穿活检中除1例出现肝内出血合并胆瘘外,未出现任何穿刺相关并发症。结论:凝血功能轻度异常患者进行肝穿刺活检是安全的,而穿刺方法、穿刺次数在本组研究中与肝穿刺活检的安全性无明显相关;彩超引导定位移植肝组织穿刺活检是一种具有较高安全性的诊断方法。     

Virtual reality, ultrasound-guided liver biopsy simulator: development and performance discrimination

Objectives

The aim of this article was to identify and prospectively investigate simulated ultrasound-guided targeted liver biopsy performance metrics as differentiators between levels of expertise in interventional radiology.

Methods

Task analysis produced detailed procedural step documentation allowing identification of critical procedure steps and performance metrics for use in a virtual reality ultrasound-guided targeted liver biopsy procedure. Consultant (n=14; male=11, female=3) and trainee (n=26; male=19, female=7) scores on the performance metrics were compared. Ethical approval was granted by the Liverpool Research Ethics Committee (UK). Independent t-tests and analysis of variance (ANOVA) investigated differences between groups.

Results

Independent t-tests revealed significant differences between trainees and consultants on three performance metrics: targeting, p=0.018, t=−2.487 (−2.040 to −0.207); probe usage time, p = 0.040, t=2.132 (11.064 to 427.983); mean needle length in beam, p=0.029, t=−2.272 (−0.028 to −0.002). ANOVA reported significant differences across years of experience (0–1, 1–2, 3+ years) on seven performance metrics: no-go area touched, p=0.012; targeting, p=0.025; length of session, p=0.024; probe usage time, p=0.025; total needle distance moved, p=0.038; number of skin contacts, p<0.001; total time in no-go area, p=0.008. More experienced participants consistently received better performance scores on all 19 performance metrics.

Conclusion

It is possible to measure and monitor performance using simulation, with performance metrics providing feedback on skill level and differentiating levels of expertise. However, a transfer of training study is required.Training in interventional radiology (IR) uses the traditional apprenticeship model despite recognised drawbacks, e.g. difficulty articulating expertise, pressure to train more rapidly [1], reduced number of training opportunities. Moreover, it has been described as inefficient, unpredictable and expensive [2,3] and its suitability for training has been questioned owing to there being no mechanism for measuring post-training skill [4]. There is an increasing need to develop alternative training methods [5]. Using simulators to train offers numerous benefits, including gaining experience free from risk to patients, learning from mistakes and rehearsal of complex cases [6]. IR is particularly appropriate for simulator training as skills, such as interpreting two-dimensional radiographs or ultrasound images, can be reproduced in a simulator in the same way as in real-life procedures.There is increased use of medical virtual reality simulators, with some validated to show improved clinical skills, e.g. laparascopic surgery [7], colonoscopy [8] and anaesthetics [9]. However, within IR no simulator has met this standard [5,6,10], with validation studies typically failing to discriminate accurately between experts and novices [11], although differences have been observed [12]. Length of time to complete procedures on simulators is a frequently reported expertise discriminator [6] but there is a worrying lack of emphasis on the number of errors made or other clinically relevant parameters. A recent review [6] reported “fundamental inconsistencies” and “wide variability in results” in validation studies, concluding that the analysis of errors and quality of the end product should be the focus of assessment. The authors proposed that, to fully develop and validate simulators, there is a need for task analysis (TA) to deconstruct individual procedural tasks followed by metric definition and critical performance indicator identification. This echoes previous calls for expert involvement in simulator design [13].To the best of our knowledge, no IR simulators have been developed through the use of TA of real-world tasks despite the critical role of such techniques in training development and system design for the past 100 years [14]. TA identifies knowledge and thought processes supporting task performance, and the structure and order of individual steps, with particular relevance in deconstructing tasks conducted by experts [15,16]. TA techniques are increasingly being used as a medical educational resource, e.g. the development of surgical training [17] and the teaching of technical skills within surgical skills laboratories [18].Using task analysis, this research identified and prospectively investigated simulated ultrasound-guided targeted liver biopsy performance metrics as differentiators between levels of expertise in IR.     

Two cases of lethal complications following ultrasound-guided percutaneous fine-needle biopsy of the liver

Two cases with lethal complications are reported among 1750 ultrasound (US)-guided percutaneous fine-needle liver biopsies performed in our department. The first patient had angiosarcoma of the liver which was not suspected after computed tomography (CT) and US studies had been performed. The other patient had hepatocellular carcinoma in advanced hepatic cirrhosis. Death was due to bleeding in both cases. Preprocedure laboratory tests did not reveal the existence of major bleeding disorders in either case. Normal liver tissue was interposed in the needle track between the liver capsule and the lesions which were targeted.     

拉米夫定联合复方鳖甲软肝片治疗慢性乙型肝炎早期肝硬化临床观察

慢性乙型肝炎发展到后期将导致肝硬化甚至肝癌,乙型肝炎肝硬化目前尚无特效治疗方法。我们采用拉米夫定联合复方鱉甲软肝片治疗慢性乙型肝炎早期肝硬化,初步探讨其临床疗效。     

超声引导下胸膜活检的操作技巧

目的评价各种操作技巧在超声引导下胸膜活检中的应用价值。方法对150例临床需要胸膜活检的患者应用各种不同的操作技巧进行穿刺活检。对于胸腔积液量少或病程短的患者,活检针应该尽量与肺组织、胸膜呈平行状态;根据胸水量的多少,选择侧卧位或者坐位;标本的处理方面,可将红色的肌肉组织剔除,减少病理取材上的失误。结果根据患者不同情况,采用各种不同的操作技巧进行穿刺活检,肉眼取材成功率100%,病理阳性率76.7%。病理确诊结核95例(63.3%),腺癌20例(13.3%),纤维组织慢性炎27例(18%),纤维骨骼肌8例(5.3%)。病理阳性率76.7%。结论超声引导下胸膜活检应用各种操作技巧非常有必要,能提高取材成功率和病理阳性率。     

肾脏病彩超导向快速活检26例

1临床资料1.1一般资料本组26例经皮快速肾穿刺病例为住院患者。临床诊断为肾病且符合肾穿标准,无明显出血、重度高血压、孤立肾、肾动脉瘤、肾脏感染性疾病等肾穿禁忌证患者。男15例,女11例,年龄15~71岁,平均26.7岁,临床表现为不明原因血尿、蛋白尿、水肿。临床拟诊为肾小球肾炎10例,肾病综合征7例,IgA肾病4例,狼疮性肾炎2例,糖尿病肾病3例。其中肾功能正常者17例,肾功能不全代偿者6例,失代偿者2例。急性肾功能衰竭1例。1.2仪器PHILIPS超凡彩超诊断仪,BARD穿刺活检枪。1.3方法术前常规查血小板数量,凝血酶原时间、活化部分凝血活酶时…     

The use of DWI to assess spleen and liver quantitative ADC changes in the detection of liver fibrosis stages in chronic viral hepatitis

This study aimed to evaluate the changes in spleen and liver diffusion-weighted magnetic resonance imaging (DWI) in chronic viral hepatitis patients.     

Randomized controlled trial of aspiration needle versus automated biopsy device for transjugular liver biopsy

PURPOSE: The efficacy and safety of transjugular liver biopsy used to obtain liver specimens in patients with coagulation disorders have been widely proven. However, histopathologic examination is not always possible because of fragmented samples provided by the aspiration technique. Recently, an automated device with a Tru-Cut-type needle was designed. In this randomized controlled trial, the use of this new device is compared with the traditional method in terms of efficacy and safety. METHOD: Fifty-six patients were included in the study; 28 were randomized to undergo the aspiration technique and 28 were randomized to undergo the automated biopsy technique. RESULTS: Correct positioning of the device was achieved in 93% of patients undergoing the aspiration technique and 96% of patients undergoing the automated biopsy technique (P = NS). Mean duration of the procedure and total number of passes were significantly higher in the aspiration needle group than in the automated device group (22.6 min +/- 12.6 vs 15.5 min +/- 9.4; P = .03, and 3.3 min +/- 1.9 vs 1.5 min +/- 0.63; P < .001, respectively). The number of portal tracts was significantly higher in the automated device group (4.7 +/- 2.5 vs. 2.7 +/- 3.4; P < .05). Adequate specimens for histopathologic evaluation were obtained in 26 patients in the automated device group and 24 patients in the aspiration needle group (92.8% vs 85.7%; P = NS), but a definite histopathologic diagnosis was more frequently obtained with the automated biopsy device (68% vs 43%; P = .05). No significant differences were observed in complication rates (7.14% vs. 10.7%; P = NS). CONCLUSION: The automated biopsy device for transjugular liver biopsy is more effective than an aspiration needle in obtaining good samples for a definite histologic diagnosis.     

Quantitative assessment of liver fibrosis in chronic viral hepatitis C patients using shear wave elastography with elastography point quantification feature

Introduction

Hepatic fibrosis is the underlying pathological condition in chronic hepatitis C virus (HCV) infection. Shear wave elastography (SWE) with elastography point quantification (ElastPQ) feature is a recently developed method for measuring tissue elasticity.