实时组织弹性成像联合超声造影技术在慢性乙型肝炎患者肝纤维化诊断中的应用

目的探讨实时组织弹性成像（RTE）联合超声造影技术评估乙型肝炎肝纤维化的临床应用价值,为评价慢性乙型肝炎肝纤维化提供新的无创诊断方法。 方法选取2016年10月至2017年5月在哈尔滨医科大学附属第一医院就诊的慢性乙型肝炎患者61例,并行肝活检,根据Scheuer标准分为5期（S0~S4）,所有患者均行RTE及超声造影检查,计算肝纤维化指数（LFI）与肝肾达峰时间差（Lt-Kt）。采用方差分析比较肝纤维化各组的LFI值与Lt-Kt值,并与病理结果做相关分析。进一步两两比较采用LSD-t检验,以肝活检为"金标准"得到各组诊断受试者工作特征（ROC）曲线。 结果LFI值S1期与S2期间比较,差异无统计学意义（P>0.05）,Lt-Kt值S0期与S1期间比较,差异无统计学意义（P>0.05）,LFI值S0与S1、S2、S3、S4期多重比较（t=-2.32、-3.92、-6.35、-11.58）,LFI值S1与S0、S2、S3、S4期多重比较（t=2.32、-1.59、-4.15、-9.44）,LFI值S2与S0、S1、S3、S4期多重比较（t=3.92、1.59、-3.31、-9.86）,LFI值S3与S0、S1、S2、S4期多重比较（t=6.35、4.15、3.31、6.28）,LFI值S4与S0、S1、S2、S3期多重比较（t=11.58、9.44、9.86、6.28）。Lt-Kt值S0与S1、S2、S3、S4期多重比较（t=-1.81、-4.51、-5.98、-9.58）,Lt-Kt值S1与S0、S2、S3、S4期多重比较（t=1.81、-2.37、-3.94、-7.60）,Lt-Kt值S2与S0、S1、S3、S4期多重比较（t=4.51、2.37、-2.12、-6.69）,Lt-Kt值S3与S0、S1、S2、S4期多重比较（t=5.98、3.94、2.12、-4.37）,Lt-Kt值S4与S0、S1、S3、S4期多重比较（t=9.58、7.60、6.69、4.37）,差异均有统计学意义（P均<0.05）。LFI对应ROC曲线下面积分别为0.953、0.924、0.916、0.983;Lt-Kt对应ROC曲线下面积分别为0.979、0.967、0.902、0.949。二者联合后对应ROC曲线下面积分别为0.988、0.974、0.918、0.966。 结论RTE及超声造影在乙型肝炎肝纤维化诊断中均有重要价值,超声造影在纤维化早期（S1~S2）较RTE更有优势,而RTE在纤维化中晚期（S3~S4）较超声造影更有优势,二者联合可在（S1~S3期）提高纤维化诊断的准确性。

Value of real-time tissue elastography and contrast-enhanced ultrasonography in liver fibrosis assessment in patients with chronic hepatitis B

ObjectiveTo investigate the clinical value of real-time elastography (RTE) and contrast-enhanced ultrasound (CEUS) in the evaluation of liver fibrosis in patients with chronic hepatitis B, in order to provide a new noninvasive method for assessment of liver fibrosis in chronic hepatitis B. MethodsSixty-one patients with chronic hepatitis B were divided into five groups according to the pathological stage of hepatic fibrosis: S0-S4. All the patients underwent RTE and CEUS examinations. The liver fibrosis index (LFI) and liver-kidney peak time difference (Lt-Kt) were calculated and analyzed by one-way ANOVA, followed by pairwise comparisons using the LSD-t test and the SNK test. The receiver operating characteristic curves (ROCs) were plotted based on the stage of liver fibrosis and used to evaluate the diagnostic value of real-time elastography and CEUS, alone or in combination. ResultsThere was no significant difference in LFI values between stages S1 and S2 and between stages S0 and S1 (P>0.05); however, a significant difference was observed in LFI values between S0 and S1, S2, S3, or S4 (t=2.32, 3.92, 6.35, 11.58), between S1 and S0, S2, S3, or S4 (t=2.32, 1.59, 4.15, 9.44), between S2 and S0, S1, S3, or S4 (t=3.92, 1.59, -3.31, -9.86), between S3 and S0, S1, S2, or S4 (t=6.35, 4.15, 3.31, 6.28), and between S4 and S0, S1, S2, or S4 (t=11.58, 9.44, 9.86, 6.28) (P<0.05 for all). A significant difference was also observed in Lt-Kt values between S0 and S1, S2, S3, or S4 (t=-1.81, -4.51, -5.98, -9.58), between S1 and S0, S2, S3, or S4 (t=1.81, -2.37, -3.94, -7.60), between S2 and S0, S1, S3, or S4 (t=4.51, 2.37, -2.12, -6.69), between S3 and S0, S1, S2, or S4 (t=5.98, 3.94, 2.12, -4.37), and between S4 and S0, S1, S3, or S4 (t=9.58, 7.60, 6.69, 4.37) (P<0.05 for all). The areas under the ROCs (AUROCs) of LFI for S1-S4 were 0.953, 0.924, 0.916, and 0.983, respectively, and the AUROCs of Lt-Kt for S1-S4 were 0.979, 0.967, 0.902, and 0.949, respectively. The AUROCs of LFI combined with Lt-Kt for S1-S4 were 0.988, 0.974, 0.918, and 0.966, respectively. ConclusionRTE and CEUS have important value in the diagnosis of hepatic fibrosis in chronic hepatitis B. CEUS is superior to RTE in the diagnosis of early fibrosis (S1-S2), while RTE has advantages over CEUS in the detection of middle and late fibrosis (S3-S4). The combination of the two modality can improve the accuracy of diagnosis of liver fibrosis (S1-S3).