Showing papers by "Ioan Sporea published in 2019"

The EFSUMB Guidelines and Recommendations for the Clinical Practice of Elastography in Non-Hepatic Applications: Update 2018

Abstract: This manuscript describes the use of ultrasound elastography, with the exception of liver applications, and represents an update of the 2013 EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) Guidelines and Recommendations on the clinical use of elastography.

EFSUMB Position Paper: Recommendations for Gastrointestinal Ultrasound (GIUS) in Acute Appendicitis and Diverticulitis.

Abstract: An interdisciplinary task force of European experts summarizes the value of gastrointestinal ultrasound (GIUS) in the management of acute appendicitis and diverticulitis. Based on an extensive literature review, clinical recommendations for these highly common diseases in visceral medicine are presented. In patients with acute appendicitis, preoperative sonography has been established as a routine procedure in most European countries for medical and legal reasons. Routine sonography in these patients may reduce the rate of unnecessary surgery by half. The sensitivity, specificity, and accuracy of ultrasound reach values above 90 % and are equivalent to CT and MRI. However, the high operator dependence may be a problem, for example in point-of-care ultrasound in emergency departments. Structured training programs, quality controls and standardized ultrasound reporting should be increasingly implemented. In the case of suspected acute diverticulitis, “ultrasound first” should also be a basic element in the approach to all patients. Sonography can confirm the diagnosis and allows early risk stratification. As treatment strategies have become less aggressive and more tailored to the stage of diverticulitis, accurate staging has become increasingly important. GIUS and CT have proven to have similar sensitivity and specificity. Especially in cases of uncomplicated diverticulitis, GIUS will be the one and only imaging procedure. CT may work as a backup and has particular advantages for diverticulitis located in the distal sigmoid, inflammation deep in the small pelvis and insufficient ultrasound scanning conditions. This step-up approach (ultrasound first and CT only in case of a negative or inconclusive ultrasound result) has proven to yield the best accuracy.

EFSUMB Gastrointestinal Ultrasound (GIUS) Task Force Group: Celiac sprue and other rare gastrointestinal diseases ultrasound features

Abstract: Transabdominal gastrointestinal ultrasound (GIUS) is unique in its capacity to examine the bowel non-invasively and in its physiological condition, including extra-intestinal features such as the splanchnic vessels, mesentery, omentum and lymph nodes- even at the bedside. Despite this, and its extensive documentation for its usefulness, it has only been fully implemented in a few European countries and expert centres. Therefore, the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) established a GIUS Task Force Group in 2014 consisting of international experts from 9 European countries with the objectives to standardize and promote the use of GIUS in a clinical setting. This is achieved by publishing clinical guidelines and recommendations on indications and use of GIUS and so far,4 guidelines have been published: first on "examination techniques and normal findings", second on "inflammatory bowel disease", third on "acute appendicitis and diverticulitis" and fourth on "transrectal and perineal ultrasound".This paper describes the ultrasound features of miscellaneous disorders such as celiac disease, cystic fibrosis, omental infarction, Meckel's diverticle, endometriosis, intestinal neoplasia, mucocele, amyloidosis, GVHD, foreign bodies, vasculitis, and pneumatosis cystoides intestinalis. Bowel ultrasound can be indicated in most of these conditions to investigate intestinal symptoms but in other cases the alterations of the bowel can be also an incidental finding that suggest other examinations which finally help to discover an unknown pathological condition.

General advice in ultrasound based elastography of pediatric patients

Abstract: Ultrasound elastography including transient elastography (TE), point shear wave elastography, (pSWE) and two (three)- dimensional shear wave elastography (2D-SWE) have been introduced mainly for the evaluation of the liver. All the techniques are also feasible for the examination of spleen, whereas pSWE and 2D-SWE can be used for the assessment of the pancreas, kidney, gastrointestinal tract and other organs. Strain elastography also plays a role for non-liver applications. The aim of the current report is to highlight unique features and techniques for the elastographic examinations in children and to report initial results in non-liver applications.

Contrast-Enhanced Ultrasound for the Characterization of Malignant versus Benign Focal Liver Lesions in a Prospective Multicenter Experience - The SRUMB Study.

Abstract: Aim This study evaluated the accuracy of contrast-enhanced ultrasound (CEUS) for the differential diagnosis of benign vs. malignant focal liver lesions (FLL) in a real-life, multicenter experience. Methods This prospective study, including 14 Romanian centers, was performed over a 6 year period (February 2011- April 2017) and included 2062 FLLs assessed by CEUS. Inclusion criteria were: newly diagnosed FLL on B-mode ultrasound, less than three lesions/patient, all FLLs evaluated by CEUS and by a second-line imaging technique (contrast enhanced CT or contrast enhanced MRI) or histology, considered as reference. The trial was registered in clinicaltrials.gov (Identifier NCT01329458). Results From the 2062 FLLs included in the study, 57.2% (1179) were malignant and 42.8% (883) were benign. CEUS had 83.9% sensitivity (Se), 97.8% specificity (Sp), 98.1% positive predictive value (PPV), 82.2% negative predictive value (NPV) and a diagnostic accuracy (Ac) of 89.9% for the positive diagnosis of malignant lesions. For the benign lesions, CEUS had 97.8% Se, 83.9% Sp, 82.2% PPV, 98.1% NPV 89.9% Ac. The diagnostic performance of CEUS for hepatocellular carcinoma was 76.6% Se, 98.4% Sp, and 91.2% Ac; for hemangioma: 89.2% Se, 99% Sp, and 96.9% Ac and for metastases: 90.9% Se, 98.4% Sp, and 96.9% Ac. Conclusions CEUS proved a high accuracy in differentiating the malignant vs. benign character of a FLL. It can be confidently used as a first line imaging method in daily practice.

Shear Wave Elastography in Diagnosing Secondary Hyperparathyroidism

Abstract: This study evaluates the diagnostic value of two-dimensional shear wave elastography (2 D-SWE) technique in the evaluation of hyperplastic parathyroid glands in cases with secondary and tertiary hyperparathyroidism. A total of 59 patients (end-stage renal disease, under supplemental dialysis program) with visible parathyroid hyperplastic glands on ultrasound, confirmed by biochemical assay and scintigraphy, were enrolled; they were examined on grayscale ultrasound and 2 D shear wave elastography. We determined the elasticity index (EI) in the parathyroid gland, thyroid parenchyma and surrounding muscles, and the elasticity ratio of hyperplastic parathyroid glands compared to muscle, specifically sternocleidomastoid muscle. Patients presented fibrocystic bone disease with secondary hyperparathyroidism induced by end-stage chronic kidney disease; being on prolonged chronic dialysis therapy, they had positive sestamibi scintigraphy and high values of serum parathormone (1141.04 pg/mL). Nodules placed posterior to the thyroid capsule that were cystic, had a hypoechoic aspect, and were homogenous with an independent afferent artery were found. Mean EI in the parathyroid gland was 7.83 kPa, the median value in thyroid parenchyma was 13.76 kPa, and mean muscle EI value was 15.78 kPa. The observed mean parathyroid/muscle SWE ratio was 0.5356 and the value for parathyroid/normal thyroid parenchyma was 0.5995. Using receiver operating characteristic (ROC) analysis, we found that EI below 9.74 kPa correctly identifies parathyroid tissue, with a sensitivity of 94.8%, specificity of 90.7%, and accuracy of 92.26% when compared to normal thyroid tissue. Compared with the muscle tissue, we identified that EI below 9.98 kPa has a sensitivity, specificity, and accuracy of 93.8%, 90.7%, and 91.75%, respectively. Ultrasound elastography is a helpful tool in identifying parathyroid hyperplasia in patients with chronic kidney disease. A cutoff value of 9.98 kPa can be used in 2 D-SWE for accurate diagnosis of parathyroid disease.

2D Shear Wave Elastography for Liver Fibrosis Evaluation

Abstract: 2D shear wave elastography is a technique embedded in ultrasound machines which allows the interrogation of the tissue by acoustic radiation force impulses induced into the tissues by focused ultrasonic beams and captures the propagation of resulting shear waves in real time. Elasticity is displayed using a color-coded image superimposed on a B-mode image, and at the same time, a quantitative estimation of liver stiffness (LS) can be performed in a certain region of interest (ROI). The published data showed a real value of this method for liver stiffness estimation in patients with chronic hepatitis. It has the following advantages: it is integrated into standard ultrasound systems; it is a real-time elastographic method; and it is also feasible in patients with ascites and with large and adjustable size of the ROI that will be evaluated.

Value of viscosity, viscoelasticity and attenuation measurement using shear wave ultrasound elastography

Abstract: Nonalcoholic Liver Disease (NAFLD) is increasing in frequency in daily practice. Evaluation of such patients needs to assess steatosis, fibrosis and inflammation.A new Ultrasound(US) system from Canon noninvasively evaluates these parameters by measuring shear waves speed (2D-SWE) - related to viscoelasticity and fibrosis; dispersion (DI) - related to viscosity and inflammation, and attenuation parameter (ATI) - related to steatosis. Aim: To evaluate the usefulness of 2D-SWE, DI and ATI measurements obtained using Aplio i800 from Canon, for the noninvasive assessment of liver fibrosis, inflammation, and steatosis using Transient Elastography (TE) with Controlled Attenuation Parameter (CAP) as the reference method. Material and Method: 113 consecutive subjects were included in the study group, mostly NAFLD patients, in whom liver stiffness (LS) and steatosis were evaluated in the same session by means of 2 elastography techniques: TE with CAP (FibroScan, EchoSens) and 2D-SWE with ATI(Aplio I800, Canon). Reliable LS measurements were defined for TE as the median value of 10 measurements with an interquartile range/median ratio (IQR/M) To discriminate between TE fibrosis stages we used the following cut-offs [1]: F ≥ 2: 8.4 kPa and F4: 13.2 kPa and to discriminate between steatosis stages we used the following cut-offs recommended by the manufacturer: S1(mild) – 230db/m, S2(moderate) - 275db/m, S3(severe) - 300db/m. Results: Reliable LS measurements were obtained in 99.1% subjects by both 2D-SWE and TE.A very strong positive correlation was found between the LS values obtained by the 2 Methods: r = 0.88, p The best cut-off value for fibrosis, for F0/1 was ≤ 6.2 kPa (AUROC 0.82; Se = 75%; Sp = 85.5%), for F ≥ 2 it was 7.9 kPa (AUROC 0.96; Se = 90.4%; Sp = 95.6%), for F4 it was 11.7 kPa (AUROC 0.99; Se = 100%; Sp = 96%). Regarding steatosis, the best cut-off values were: for S1 = 0.64 dB/cm/mHz (AUROC 0.89; Se = 73.6%; Sp = 88.8%), for S2 = 0.79 dB/cm/mHz (AUROC 0.88; Se = 63.4%; Sp = 96.4%), for S3 = 0.86dB/cm/mHz (AUROC 0.95; Se = 45%; Sp = 100%). When we divided the cohort into healthy vs patients with chronic hepatopathies, we found out that the mean DI values in the pathology group were higher than in the healthy group(12.4 ± 2.7 vs 11.5 ± 1.9, p = 0.03) Conclusion: 2D-SWE and ATI measurements with the new system strongly correlate with TE and CAP results 110.1111/apt.14529

Liver Fibrosis Assessment by Point Shear-Wave Elastography Techniques

Abstract: Point shear-wave elastographic (pSWE) techniques use acoustic radiation force impulse (ARFI) to stimulate the liver tissue and to generate shear waves that propagate into the liver. The shear-wave velocity (SWV) increases with the severity of fibrosis. The first type of pSWE was Virtual Touch Quantification (VTQ ) developed by Siemens, followed by ElastPQ by Philips, and nowadays pSWE is available on other systems (Hitachi, Esaote, Samsung). To evaluate liver fibrosis by pSWE, ten valid measurements are performed in the right liver lobe; a median value is calculated, with the results expressed in meters/second or in kilopascals (kPa) (if the operator chooses). VTQ is a reproducible method, the intraclass correlation coefficient (ICC) for interand intraobserver measurements ranging from 0.81 to 0.87. Confounding factors for VTQ are non-fasting conditions, elevated aminotransferases, congestive heart failure, and extrahepatic cholestasis. In patients with chronic hepatopathies, the AUROCs for predicting significant fibrosis range between 0.75 and 0.85 and for predicting cirrhosis between 0.85 and 0.95. There were promising results regarding the value of VTQ to predict liver cirrhosis complications, especially portal hypertension. ElastPQ is a newly developed point shearwave elastographic method (from Philips). Only few data were published but with promising results.

Comparison between the performance of Two-Dimensional and Point Shear Wave elastography for the noninvasive assessment of liver cirrhosis

Abstract: Background and aim The goals of this study were to compare the noninvasive diagnostic performance of two elastography techniques for the diagnosis of liver cirrhosis in a cohort of patients with known hepatitis C virus using Transient Elastography FibroScan as the method of reference since it is a validated tool for the non-invasive assessment of liver fibrosis. Material and Methods The study included 122 patients aged 38-80 (62 ± 7.9), 35% male (43/122), 65% female (79/122) with known hepatitis C virus in whom liver stiffness was evaluated during the same session by means of three elastography Methods: Point Shear Wave Elastography (pSWE) using virtual touch quantification(VTQ) technology Siemens Acuson S2000TM, Two-Dimensional Shear Wave Elastography (2D-SWE) embedded in General Electrics LOGIQ E9 ultrasound machine and Transient Elastography(TE;FibroScan, EchoSens). Reliable LS measurements were defined, for all techniques, as the median value of 10 measurements with an interquartile range/median(IQR/MED) Results Reliable liver stiffness measurements were obtained in 93% (114/122) of cases by means of TE, 88% (107/122) of cases by means of VTQ and 87% (106/122) of cases by means of 2D-SWE.GE. In the final analysis we included 93 patients which had reliable stiffness measurements with all methods.The AUROCS were calculated considering TE as the reference method. The optimal cutoff of VTQ for cirrhosis was 1.77m/s(SE:83%; SP:88%; AUC:0.89) and for 2D-SWE.GE was 10.2 kPa(SE:86%; SP:77%; AUC:0.89). No statistical differences were found between both methods(p Conclusion Both methods have similar performance for diagnosing liver cirrhosis and seem to be a promising alternative to Transient Elastography in evaluating patients with liver fibrosis.

What is new in liver elastography

Abstract: In daily practice, many hepatological conditions, such as chronic viral hepatitis, non-alcoholic and alcoholic fatty liver disease (NAFLD and ALD, respectively) need evaluation. This evaluation can be made invasively (by liver biopsy) or non-invasively (by biological tests or by elastographic methods). Elastographic methods can be divided into ultrasound based or magnetic resonance based (MR-Elastography). According to the latest guidelines, (EFSUMB 2017 and WFUMB 2018) ultrasound based elastographic methods can be sub-divided into: Strain Elastography and Shear Wave Elastography (SWE). In hepatological field, SWE is mainly used for liver fibrosis assessment. According to the type of tissue stimulation, SWE can be divided into Transient Elastography (TE) and ARFI technologies (point SWE and 2D-SWE). Transient Elastography (TE) is the oldest elastographic method used in hepatology. Many guidelines and meta-analyses presented its value and limitations (mainly the presence of ascites), including the confounding factors. This method has been proven valuable in HCV and HBV chronic hepatitis, in NAFLD, ALD, post-transplant and in other conditions. The accuracy is increasing with the severity of fibrosis. The New FibroScan system includes a software for spleen stiffness assessment and has a supplementary ultrasound probe for the inspection of the liver, before stiffness evaluation. Point SWE (pSWE) is a quite simple method, working in real time. After the ultrasound examination of the liver, a box of 10/5 mm is placed at more than 1 cm bellow the liver capsule and a button is pressed to measure liver stiffness. The values are expressed in m/s or kPa. The first pSWE system was VTQ (Virtual Touch Quantification) from Siemens, and many papers and meta-analysis proved its good value to predict fibrosis severity in HCV, HBV or NAFLD patients. Later, ElastPQ from Philips was developed and showed a good predictive value in chronic liver disease. Other pSWE techniques were developed by Hitachi, Samsung and other companies. 2D-SWE is a real time elastographic technique, in which liver stiffness is expressed as a colour coded elastogram and also in numeric values. Studies demonstrated that some ultrasound experience is needed for quality measurements. The Aixplorer system from Supersonic Imagine, (SSI) was the first system on the market to use 2D-SWE, and good results of this method were published in several studies and meta-analyses. Other 2D-SWE technologies were developed by GE and Canon, showing good values for clinical practice. Comparative studies were performed in patients with chronic viral hepatitis or NAFLD, evaluating TE, pSWE and 2D-SWE, with liver biopsy as the gold standard. These studies demonstrated that comparable accuracies of al these methods. Studies have been made evaluating TE, pSWE and 2D-SWE as predictors of portal hypertension, but the results are still under discussion regarding pSWE and 2D-SWE. TE has been accepted as a tool to stratify patients at risk for clinically significant portal hypertension. The most recent topic in the field on the non-invasive assessment of liver diseases is the quantification of liver fat. CAP (Controlled Attenuation Parameter) from EchoSens implemented into the FibroScan device, was the first used for liver steatosis quantification. The correlation with histology is quite good (AUROC 0.80-0.85) and CAP is implemented into both the M and XL probes. More recently, other companies such as Hitachi or Canon implemented this type of quantification (attenuation) in their systems (ATT and ATI, respectively), both with interesting results. The same companies included in their latest machines algorithms evaluating the viscosity as a marker of the inflammation in the liver. In this respect, we go now in the direction of a multi-parametric elastographic approach of liver diseases, which quantifies stiffness, steatosis and inflammation. Confounding factors must be known regarding ultrasound based liver elastography to avoid clinical mistakes. In addition, the cut-offs values, which are ultrasound machine specific should be known. Finally, published papers showed the good predictive value of TE, pSWE and 2D-SWE for predicting liver fibrosis severity in daily practice. In conclusion, the body of evidence for ultrasound based elastography is enough strong to recommend this methods for liver diseases assessment. Liver elastography replaced in many cases liver biopsy.

Quantification of Liver Steatosis

Abstract: The prevalence of non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) is increasing in themodernworld. Fatty infiltration of the liver can be assessed by standard ultrasound, by controlled attenuation parameter (CAP) using the FibroScan device or, more recently, by ultrasound systems that evaluate the attenuation in the liver. Standard ultrasound (US) for steatosis evaluation was used for a long time as a semi-quantitativemethod for steatosis assessment in the liver. A “bright liver”with “posterior attenuation” is the typical US sign of liver steatosis. Considering the attenuation severity, steatosis is subjectively graded as mild, moderate or severe. Using the kidney/liver ratio, a more accurate evaluation can bemade. Controlled attenuation parameter (CAP) was developed by EchoSens, France, and implemented into the FibroScan device. CAPmanages an objective assessment of steatosis severity with rather good accuracy. More recently, ultrasound companies such as Hitachi, General Electric and Canon, implemented in their system algorithms which allow an objective assessment of liver steatosis, using the attenuation of the ultrasound beams.