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422 IDIOPATHIC PORTAL HYPERTENSION: IMPACT OF HEPATIC VEIN CATHETERIZATION AND TRANSIENT ELASTOGRAPHY ON ITS DIAGNOSIS
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
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