- Email: [email protected]
421 COMPARISON OF LIVER STIFFNESS ASSESSMENT BY FIBROSCAN® AND ACOUSTIC RADIATION FORCE IMPULSE IMAGING® FOR THE EVALUATION OF LIVER FIBROSIS AND CIRRHOSIS
POSTERS Aim: To better estimate FT and LSM performances, we assessed the strength of concordance between FT and LSM with FA of surgical samples, according to biopsy length. Methods: Surgical samples, FT and LSM, from 12 consecutive patients with chronic liver diseases and 4 controls, were prospectively studied. From the digitized image (Aperio Scanner, TRIBVN, France), 22,119 virtual biopsies of increasing length (5/10/15/20/25/30 mm) were produced: 5,106 HCV, 4,572 ALD, 3,240 NAFLD, 3,988 HBV, 1,458 PBC and 4,665 controls. The concordance of FT and LSM with FA was assessed using the Spearman correlation coefficient (S), and R2 of best curve fitting. Results: FA reference values were 3.8% (4 subjects METAVIR stage F0), 5.0% (1 F1), 7.1% (3 F2), 9.0% (1 F3) and 18.2% (7 F4) similar to those previously described in HCV. In all liver diseases the coefficient of variation decreased with biopsy length from 0.87 (5 mm) to 0.69 (30 mm) biopsy. FT ranged from 0.13 to 0.98 and LSM from 3.7 to 23.8 kPa. For FT and LSM there was a steady increase in concordance with FA according to biopsy length: FT from 5 mm S = 0.68 (95% CI 0.66–0.70) to 30 mm S = 0.78 (0.76–0.79); FS from 5 mm S = 0.60 (0.57–0.62) to 30 mm S = 0.65 (0.62–0.67). Differences between S were significant between biopsy lengths (p < 0.05) for FT and not for LSM. For FT the best curves fitting was obtained using linear association after logarithmic transformation of FA; R2 steadily increased from 0.51 to 0.69. For LSM the best fitting was obtained using linear association after logarithmic transformation of both FA and LSM; R2 increased from 0.35 to 0.49. S and R2 were all significantly higher for FT vs. LSM (P < 0.01). Conclusion: Both FT and LSM strength of concordance with area of fibrosis increased with length of biopsy, with a significantly higher association for FT than LSM. 419 THE CORRELATION OF LIVER STIFFNESS WITH PORTAL PRESSURE AND FIBROSIS STAGE IS INFLUENCED BY VASOACTIVE TREATMENT AND ETIOLOGY OF LIVER DISEASE T. Reiberger1 , A. Ferltisch1 , M. Pinter1 , M. Homoncik1 , G. Ulbrich2 , M. Peck-Radosavljevic1 . 1 Internal Medicine III, Div. of Gastroenterology & Hepatology, Medical University Vienna, 2 Internal Medicine, Div. of Gastroenterology & Hepatology, Hospital Hietzing, Vienna, Austria E-mail: [email protected] Introduction: Recently published studies support the use of transient elastography (TE) for evaluating patients with portal hypertension since liver stiffness (LS) is significantly correlated with the hepatovenous pressure gradient (HVPG). However, negative (NPV) and positive predictive values (PPV) for diagnosis of clinically significant portal hypertension (CSPH) by TE should be used to evaluate clinical applicability. In addition, certain limitations of TE, e.g. the influence of sex, age, etiology and levels of aminotransferases levels have to be considered. Methods: Retrospective analysis of the 717 measurements of LS performed in 559 patients evaluated at the hepatic hemodynamic laboratory. 88 sequential HVPG measurements with and without vasactive treatment with betablockers were performed. 175 transjugular liver biopsies were obtained. Demographic patient data were documented. Results: A significant correlation of LS and HVPG was noted (R = 0.795; p < 0.0001), which was stronger in patients with viral disease (R = 0.836; p < 0.0001) than in patients with alcoholic disease (R = 0.740; p < 0.0001). The correlation of LS in patients with CSPH was stronger under vasoactive treatment than without (R = 0.451 vs. R = 0.662; p < 0.0001). Analysis of the area under the receiver operating curve (AUROC) indicated that a cutoff at 18 kPa can identify CSPH with a sensivity and specifity of 80% and 77%, respectively. The PPV and NPV for diagnosis of CSPH were 81% and 76% using a TE threshold at 18 kPa. AUROC for diagnosis of F2 was 0.669 (>7.2 kPa; p = 0.03), 0.0694 for F3 (>9.6 kPa; p = 0.004) and
0.904 for F4 (12.1 kPa; p = 0.0001), respectively. Using a cut-off at 12.1 kPa the PPV and NPV for diagnosis of F4 were 77% and 91%. Conclusions: Poor PPV and NPV limit the diagnostic use of TE for discriminating patients with and without CSPH. The better correlation of LS and HVPG under vasoactive medication may reflect the fact that TE is not assessing the dynamic component of portal hypertension. TE is able to exclude the diagnosis of histological cirrhosis with a NPV of 91%. 420 TRANSIENT ELASTOGRAPHY EARLY PREDICTS PROGRESSIVE RECURRENT HEPATITIS C AFTER LIVER TRANSPLANTATION C. Rigamonti1 , M.F. Donato1 , M. Fraquelli2 , F. Agnelli3 , G. Rossi3 , M. Colombo1 . 1 First Division of Gastroenterology, 2 Second Division of Gastroenterology, 3 Liver Transplant Unit, IRCCS Fondazione Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy E-mail: [email protected] Background and Aims: Early graft damage following liver transplantation (OLT) predicts rapid evolution of recurrent hepatitis C to cirrhosis. We evaluated whether transient elastography (TE) performed early after OLT may help in identifying patients at risk of progressive disease. Methods: 37 consecutive HCV-infected liver recipients transplanted from June 2005 to December 2007 were prospectively submitted to repeated TE examinations at 3, 6, 9 and 12 months after OLT, and to a liver biopsy at month 12. Staging (S) was assessed according to Ishak score. Patients with 12 month S <3 were defined slow fibrosers, compared to rapid fibrosers with S≥3. The linear slope of TE progression for the two groups was assessed using a longitudinal mixed model for repeated measurements. Results: 33 patients completed the follow-up (4 died within 6 months after OLT). 21 (64%) patients were slow fibrosers and 12 (36%) rapid fibrosers including 3 who developed cirrhosis at month 12. Median TE at 3, 6, 9, 12 months were 7.5, 7.0, 6.9, 6.4 kPa in slow fibrosers and 8.9, 10.9, 11.8, 13.0 kPa in rapid fibrosers. TE values were significantly correlated with 12 month-staging at 6 (rho = 0.48, p = 0.006), 9 (rho = 0.78, p < 0.0001) and 12 months (rho = 0.83, p < 0.0001). Rapid fibrosers had significantly higher AST serum levels at 3, 6, 9, 12 months, gamma-GT serum levels at 6, 12 months and TE values at 6, 9, 12 months with respect to slow fibrosers. The slope of TE variations was significantly greater in rapid fibrosers (0.40 kPa/month) than in slow fibrosers (−0.05 kPa/month) (p < 0.0001). Proportion of patients with >7.9 kPa (previous published TE cut-off for S≥3) at 3, 6, 9 and 12 months were 29%, 26%, 31% and 28% in slow fibrosers and 60%, 67%, 100%, 95% in rapid fibrosers (p = 0.22, p = 0.06, p = 0.001 and p = 0.001). The areas under receiver operating characteristic in identifying rapid fibrosers were 0.74 (95% CI 0.53–0.94) at 6 months, 0.92 (95% CI 0.74–0.99) at 9 months and 0.94 (95% CI 0.79–0.99) at 12 months. Conclusions: Repeated TE examinations early after OLT may help identifying HCV-infected recipients at risk of progressive graft disease. 421 COMPARISON OF LIVER STIFFNESS ASSESSMENT BY FIBROSCAN® AND ACOUSTIC RADIATION FORCE IMPULSE IMAGING® FOR THE EVALUATION OF LIVER FIBROSIS AND CIRRHOSIS P. Salzl, T. Reiberger, M. Homoncik, B. Payer, B. Schwengerer, M. Peck-Radosavljevic, A. Ferlitsch, Hepatic Hemodynamic Lab. Internal Medicine III, Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria E-mail: [email protected] Background: Staging of liver fibrosis is an essential part in the management of chronic liver disease. Invasive screening tests like liver biopsy, hepatic venous pressure gradient (HVPG) measurement and Upper-GI-Endoscopy have a significant burden on patients. We compared two different noninvasive methods of liver stiffness
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POSTERS measurement (LSM), Transient Elastography (TE; FibroScan® ) and Acoustic Radiation Force Impulse Imaging (ARFI; ACUSON Siemens 2000® ), with HVPG and histology. Methods: Forty-eight patients (mean age 53±13) with different etiologies of chronic liver diseases were included. Liver cirrhosis and fibrosis was histologically diagnosed in 75.0% and 22.9%, respectively. Clinically significant portal hypertension (CSPH; HVPG≥10 mmHg) was present in 56.2%. Results: Invalid results of TE and ARFI were obtained in 14 patients (29.2%) and 1 patient (2.1%), respectively, because of ascites and obesity (BMI 29.00 vs. BMI 25.57; p < 0.05) HVPG correlated significantly with TE (r = 0.754; p < 0.01) and ARFI (r = 0.709; p < 0.01). TE correlated significantly to ARFI (r = 0.757, p < 0.01). Patients with CSPH had significantly higher LSM via TE (47.03 kPa vs. 15.92 kPa; r = 0.649; p < 0.01) and via ARFI (2.92 m/s vs. 1.91 m/s; r = 0.497; p < 0.01) Area under the receiver operating curve (AUROC) for CSPH was 0.896 (CI 0.791–1.001; p < 0.01) for TE and 0.874(CI 0.7480.999; p < 0.01) for ARFI. Patients with cirrhosis had significantly higher LSM with TE (42.6 kPa vs. 8.0 kPa; r = 0.806; p < 0.01) and with ARFI (2.75 m/s vs. 1.48 m/s; r = 0.536; p < 0.01) than patients with fibrosis. AUROC for cirrhosis was 0.955 (CI 0.891–1.018; p < 0.01) for TE and 0.849 (CI 0.703–0.995; p < 0.01) for ARFI. Mean HVPG in cirrhosis was 16.32±8.81 mmHg compared to 3.00±1.63 mmHg in non-cirrhotic patients. For diagnosing cirrhosis, a cut-off value of 16.0 kPa for TE shows a sensitivity of 86%, a specificity of 100% (PPV 100%; NPV 69%). A cut-off value of 1.71 m/s for ARFI shows a sensitivity of 91%, a specificity of 82% (PPV 94%; NPV 80%). Conclusion: Both TE and ARFI correlated with HVPG and showed a similar performance for the evaluation of CSPH. TE may be superior to ARFI for the diagnosis of liver cirrhosis. Possible advantages of ARFI are superior feasibility in obese patients and patients with ascites. 422 IDIOPATHIC PORTAL HYPERTENSION: IMPACT OF HEPATIC VEIN CATHETERIZATION AND TRANSIENT ELASTOGRAPHY ON ITS DIAGNOSIS S. Seijo, E. Reverter, A. Berzigotti, J.G. Abraldes, M. Bruguera, J. Bosch, J.C. Garcia-Pagan. Hospital Clinic i Provincial de Barcelona, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain E-mail: [email protected] Background: Idiopathic portal hypertension (IPH) is a rare cause of hepatic presinusoidal portal hypertension frequently misdiagnosed as liver cirrhosis because they may present with similar clinical complications and the finding of minimal alterations in liver biopsy may be interpreted as sampling error. This study evaluates whether there are specific findings at hepatic vein catheterization or transient elastography (FibroScan ® ) that may led to a high suspicion of IPH. Methods: 44 patients with confirmed IPH were included. Hepatic vein catheterization was performed in 40 patients; cardiopulmonary catheterization in 25 and transient elastography (TE) measurements in 31. Results: All patients had clinical portal hypertension (varices, ascites and/or splenomegaly). In all patients cirrhosis and splenoportal thrombosis were ruled out by adequate size biopsies, biochemical and imaging tests and clinical follow-up. 26 (59%) were males; mean age was 40 years. Hepatic vein catheterization revealed the presence of venous-venous communications in 19/40 (43%) patients. These communications prevented to obtain a proper wedged pressure in 12 cases while this was finally achieved in the remaining 7 patients by advancing the catheter to a more distal position not showing communications. In the 28 patients with proper wedged measurements, median hepatic venous pressure gradient (HVPG) was 7 mmHg (2–14.5). In 6 (21%) the HVPG was S172
normal (≤5 mmHg), in 7 (25%) ≥10 mmHg and in the remaining 15 (54%) was increased but without reaching the threshold value of 10 mmHg. Three patients had portopulmonary hypertension. 41% of patients had a hyperdynamic circulatory syndrome with reduced systemic vascular resistance. Median TE was 9.2 KPa (1.6–23.8). Only 3 patients had a TE >13.6 KPa (the cut-off that has been shown to predict the presence of significant portal hypertension in liver cirrhosis). Conclusions: The presence of venous-venous communications is a common feature of IPH patients. IPH patients, despite having unequivocal signs of portal hypertension, have HVPG and TE values usually abnormal but in most cases below the published cut-off for clinically significant portal hypertension in cirrhosis. These findings, during the evaluation of a patient with portal hypertension, oblige to discard IPH. 423 LIVER STIFFNESS VALUES ARE INFLUENCED BY RESPIRATION Y.S. Seo1 , K.G. Lee1 , J.H. Kim1 , H.J. Yim1 , J.E. Yeon1 , K.S. Byun1 , S.H. Um1,2 , C.D. Kim1 , H.S. Ryu1 . 1 Internal Medicine, Korea University Medical College, 2 Liver Cirrhosis Clinical Research Center, Seoul, Republic of Korea E-mail: [email protected] Background and Aims: Liver stiffness (LS) values using transient elastography have recently been the widely used methods for predicting the fibrosis stage in patients with chronic hepatitis. Several studies suggested that LS values could be influenced by factors other than the fibrosis stage, including increased portal flow by diet, or hepatic congestion as well as hepatic necroinflammation. Because respiration affects the hepatic venous return and intrahepatic pressure, LS values might be influenced by respiration. This study was performed to evaluate the influence of respiration on the LS values. Methods: Consecutive patients who performed liver biopsy were enrolled. Patients were requested to breathe freely. LSMs were performed during the patient’s free inspiration and then, during free expiration. The median values obtained during inspiration and those obtained during expiration were defined as iLS and eLS, respectively. Significant difference between iLS and eLS was defined as P < 0.05 by Wilcoxon test. Results: A total of 80 patients were enrolled. Mean age was 50 years and 45 patients (56.3%) were men. Most common causes of liver disease were chronic hepatitis B (48.8%) and chronic hepatitis C (31.3%). In overall, eLS (11.8±9.1 kPa) was significantly higher than iLS (10.9±8.3 kPa) (P < 0.001 by Wilcoxon signed ranks test). eLS was significantly higher than iLS in 31 patients (38.8%) and lower than iLS in 5 (6.3%), while there was no significant differences in 44 (55.0%). Significantly high eLS than iLS was more frequently noted in patients with no significant fibrosis (F0 or F1) (P = 0.046). AUROCs of iLS for predicting ≥F2, ≥F3, and F4 [0.768 (0.655–0.880), 0.809 (0.713–0.906), and 0.903 (0.820–0.986), respectively] were superior to those of iLS [0.735 (0.616–0.854), 0.806 (0.706–0.905), and 0.886 (0.794–0.9790), respectively]. Conclusions: Because respiration could affect the LS values, patients’ respiration should be considered when transient elastography is performed. Examination at the end of free inspiration is recommended to avoid the effect of hepatic congestion during expiration.
Journal of Hepatology 2010 vol. 52 | S59–S182
0.904 for F4 (12.1 kPa; p = 0.0001), respectively. Using a cut-off at 12.1 kPa the PPV and NPV for diagnosis of F4 were 77% and 91%. Conclusions: Poor PPV and NPV limit the diagnostic use of TE for discriminating patients with and without CSPH. The better correlation of LS and HVPG under vasoactive medication may reflect the fact that TE is not assessing the dynamic component of portal hypertension. TE is able to exclude the diagnosis of histological cirrhosis with a NPV of 91%. 420 TRANSIENT ELASTOGRAPHY EARLY PREDICTS PROGRESSIVE RECURRENT HEPATITIS C AFTER LIVER TRANSPLANTATION C. Rigamonti1 , M.F. Donato1 , M. Fraquelli2 , F. Agnelli3 , G. Rossi3 , M. Colombo1 . 1 First Division of Gastroenterology, 2 Second Division of Gastroenterology, 3 Liver Transplant Unit, IRCCS Fondazione Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy E-mail: [email protected] Background and Aims: Early graft damage following liver transplantation (OLT) predicts rapid evolution of recurrent hepatitis C to cirrhosis. We evaluated whether transient elastography (TE) performed early after OLT may help in identifying patients at risk of progressive disease. Methods: 37 consecutive HCV-infected liver recipients transplanted from June 2005 to December 2007 were prospectively submitted to repeated TE examinations at 3, 6, 9 and 12 months after OLT, and to a liver biopsy at month 12. Staging (S) was assessed according to Ishak score. Patients with 12 month S <3 were defined slow fibrosers, compared to rapid fibrosers with S≥3. The linear slope of TE progression for the two groups was assessed using a longitudinal mixed model for repeated measurements. Results: 33 patients completed the follow-up (4 died within 6 months after OLT). 21 (64%) patients were slow fibrosers and 12 (36%) rapid fibrosers including 3 who developed cirrhosis at month 12. Median TE at 3, 6, 9, 12 months were 7.5, 7.0, 6.9, 6.4 kPa in slow fibrosers and 8.9, 10.9, 11.8, 13.0 kPa in rapid fibrosers. TE values were significantly correlated with 12 month-staging at 6 (rho = 0.48, p = 0.006), 9 (rho = 0.78, p < 0.0001) and 12 months (rho = 0.83, p < 0.0001). Rapid fibrosers had significantly higher AST serum levels at 3, 6, 9, 12 months, gamma-GT serum levels at 6, 12 months and TE values at 6, 9, 12 months with respect to slow fibrosers. The slope of TE variations was significantly greater in rapid fibrosers (0.40 kPa/month) than in slow fibrosers (−0.05 kPa/month) (p < 0.0001). Proportion of patients with >7.9 kPa (previous published TE cut-off for S≥3) at 3, 6, 9 and 12 months were 29%, 26%, 31% and 28% in slow fibrosers and 60%, 67%, 100%, 95% in rapid fibrosers (p = 0.22, p = 0.06, p = 0.001 and p = 0.001). The areas under receiver operating characteristic in identifying rapid fibrosers were 0.74 (95% CI 0.53–0.94) at 6 months, 0.92 (95% CI 0.74–0.99) at 9 months and 0.94 (95% CI 0.79–0.99) at 12 months. Conclusions: Repeated TE examinations early after OLT may help identifying HCV-infected recipients at risk of progressive graft disease. 421 COMPARISON OF LIVER STIFFNESS ASSESSMENT BY FIBROSCAN® AND ACOUSTIC RADIATION FORCE IMPULSE IMAGING® FOR THE EVALUATION OF LIVER FIBROSIS AND CIRRHOSIS P. Salzl, T. Reiberger, M. Homoncik, B. Payer, B. Schwengerer, M. Peck-Radosavljevic, A. Ferlitsch, Hepatic Hemodynamic Lab. Internal Medicine III, Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria E-mail: [email protected] Background: Staging of liver fibrosis is an essential part in the management of chronic liver disease. Invasive screening tests like liver biopsy, hepatic venous pressure gradient (HVPG) measurement and Upper-GI-Endoscopy have a significant burden on patients. We compared two different noninvasive methods of liver stiffness
Journal of Hepatology 2010 vol. 52 | S59–S182
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POSTERS measurement (LSM), Transient Elastography (TE; FibroScan® ) and Acoustic Radiation Force Impulse Imaging (ARFI; ACUSON Siemens 2000® ), with HVPG and histology. Methods: Forty-eight patients (mean age 53±13) with different etiologies of chronic liver diseases were included. Liver cirrhosis and fibrosis was histologically diagnosed in 75.0% and 22.9%, respectively. Clinically significant portal hypertension (CSPH; HVPG≥10 mmHg) was present in 56.2%. Results: Invalid results of TE and ARFI were obtained in 14 patients (29.2%) and 1 patient (2.1%), respectively, because of ascites and obesity (BMI 29.00 vs. BMI 25.57; p < 0.05) HVPG correlated significantly with TE (r = 0.754; p < 0.01) and ARFI (r = 0.709; p < 0.01). TE correlated significantly to ARFI (r = 0.757, p < 0.01). Patients with CSPH had significantly higher LSM via TE (47.03 kPa vs. 15.92 kPa; r = 0.649; p < 0.01) and via ARFI (2.92 m/s vs. 1.91 m/s; r = 0.497; p < 0.01) Area under the receiver operating curve (AUROC) for CSPH was 0.896 (CI 0.791–1.001; p < 0.01) for TE and 0.874(CI 0.7480.999; p < 0.01) for ARFI. Patients with cirrhosis had significantly higher LSM with TE (42.6 kPa vs. 8.0 kPa; r = 0.806; p < 0.01) and with ARFI (2.75 m/s vs. 1.48 m/s; r = 0.536; p < 0.01) than patients with fibrosis. AUROC for cirrhosis was 0.955 (CI 0.891–1.018; p < 0.01) for TE and 0.849 (CI 0.703–0.995; p < 0.01) for ARFI. Mean HVPG in cirrhosis was 16.32±8.81 mmHg compared to 3.00±1.63 mmHg in non-cirrhotic patients. For diagnosing cirrhosis, a cut-off value of 16.0 kPa for TE shows a sensitivity of 86%, a specificity of 100% (PPV 100%; NPV 69%). A cut-off value of 1.71 m/s for ARFI shows a sensitivity of 91%, a specificity of 82% (PPV 94%; NPV 80%). Conclusion: Both TE and ARFI correlated with HVPG and showed a similar performance for the evaluation of CSPH. TE may be superior to ARFI for the diagnosis of liver cirrhosis. Possible advantages of ARFI are superior feasibility in obese patients and patients with ascites. 422 IDIOPATHIC PORTAL HYPERTENSION: IMPACT OF HEPATIC VEIN CATHETERIZATION AND TRANSIENT ELASTOGRAPHY ON ITS DIAGNOSIS S. Seijo, E. Reverter, A. Berzigotti, J.G. Abraldes, M. Bruguera, J. Bosch, J.C. Garcia-Pagan. Hospital Clinic i Provincial de Barcelona, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain E-mail: [email protected] Background: Idiopathic portal hypertension (IPH) is a rare cause of hepatic presinusoidal portal hypertension frequently misdiagnosed as liver cirrhosis because they may present with similar clinical complications and the finding of minimal alterations in liver biopsy may be interpreted as sampling error. This study evaluates whether there are specific findings at hepatic vein catheterization or transient elastography (FibroScan ® ) that may led to a high suspicion of IPH. Methods: 44 patients with confirmed IPH were included. Hepatic vein catheterization was performed in 40 patients; cardiopulmonary catheterization in 25 and transient elastography (TE) measurements in 31. Results: All patients had clinical portal hypertension (varices, ascites and/or splenomegaly). In all patients cirrhosis and splenoportal thrombosis were ruled out by adequate size biopsies, biochemical and imaging tests and clinical follow-up. 26 (59%) were males; mean age was 40 years. Hepatic vein catheterization revealed the presence of venous-venous communications in 19/40 (43%) patients. These communications prevented to obtain a proper wedged pressure in 12 cases while this was finally achieved in the remaining 7 patients by advancing the catheter to a more distal position not showing communications. In the 28 patients with proper wedged measurements, median hepatic venous pressure gradient (HVPG) was 7 mmHg (2–14.5). In 6 (21%) the HVPG was S172
normal (≤5 mmHg), in 7 (25%) ≥10 mmHg and in the remaining 15 (54%) was increased but without reaching the threshold value of 10 mmHg. Three patients had portopulmonary hypertension. 41% of patients had a hyperdynamic circulatory syndrome with reduced systemic vascular resistance. Median TE was 9.2 KPa (1.6–23.8). Only 3 patients had a TE >13.6 KPa (the cut-off that has been shown to predict the presence of significant portal hypertension in liver cirrhosis). Conclusions: The presence of venous-venous communications is a common feature of IPH patients. IPH patients, despite having unequivocal signs of portal hypertension, have HVPG and TE values usually abnormal but in most cases below the published cut-off for clinically significant portal hypertension in cirrhosis. These findings, during the evaluation of a patient with portal hypertension, oblige to discard IPH. 423 LIVER STIFFNESS VALUES ARE INFLUENCED BY RESPIRATION Y.S. Seo1 , K.G. Lee1 , J.H. Kim1 , H.J. Yim1 , J.E. Yeon1 , K.S. Byun1 , S.H. Um1,2 , C.D. Kim1 , H.S. Ryu1 . 1 Internal Medicine, Korea University Medical College, 2 Liver Cirrhosis Clinical Research Center, Seoul, Republic of Korea E-mail: [email protected] Background and Aims: Liver stiffness (LS) values using transient elastography have recently been the widely used methods for predicting the fibrosis stage in patients with chronic hepatitis. Several studies suggested that LS values could be influenced by factors other than the fibrosis stage, including increased portal flow by diet, or hepatic congestion as well as hepatic necroinflammation. Because respiration affects the hepatic venous return and intrahepatic pressure, LS values might be influenced by respiration. This study was performed to evaluate the influence of respiration on the LS values. Methods: Consecutive patients who performed liver biopsy were enrolled. Patients were requested to breathe freely. LSMs were performed during the patient’s free inspiration and then, during free expiration. The median values obtained during inspiration and those obtained during expiration were defined as iLS and eLS, respectively. Significant difference between iLS and eLS was defined as P < 0.05 by Wilcoxon test. Results: A total of 80 patients were enrolled. Mean age was 50 years and 45 patients (56.3%) were men. Most common causes of liver disease were chronic hepatitis B (48.8%) and chronic hepatitis C (31.3%). In overall, eLS (11.8±9.1 kPa) was significantly higher than iLS (10.9±8.3 kPa) (P < 0.001 by Wilcoxon signed ranks test). eLS was significantly higher than iLS in 31 patients (38.8%) and lower than iLS in 5 (6.3%), while there was no significant differences in 44 (55.0%). Significantly high eLS than iLS was more frequently noted in patients with no significant fibrosis (F0 or F1) (P = 0.046). AUROCs of iLS for predicting ≥F2, ≥F3, and F4 [0.768 (0.655–0.880), 0.809 (0.713–0.906), and 0.903 (0.820–0.986), respectively] were superior to those of iLS [0.735 (0.616–0.854), 0.806 (0.706–0.905), and 0.886 (0.794–0.9790), respectively]. Conclusions: Because respiration could affect the LS values, patients’ respiration should be considered when transient elastography is performed. Examination at the end of free inspiration is recommended to avoid the effect of hepatic congestion during expiration.
Journal of Hepatology 2010 vol. 52 | S59–S182