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Sa1008 20 Years Experience of Percutaneous Echo-Assisted Liver Biopsy Using Menghini Modified Needles
Sa1007
difficult in certain situations including, age, BMI, metabolic syndrome, and ALT levels. Aims: To study the normal reference range for Fibroscan® LSM, and analyze the effect of age, BMI, metabolic syndrome, and ALT level in adult population through a meta-analysis of previously published reports. Methods: We conducted a systematic search of MEDLINE, EMBASE and published proceedings of major liver meetings from January 1980 to November 2014. We identified 10 studies that reported the normal values of LSM in different cohorts, described the demographics, and value ranges including age, gender, BMI, the presence of metabolic syndrome, the presence of abnormal LFTs, and the presence of alcohol consumption. In a meta-analysis, we combined pooled estimates of these values and investigated significant correlations. We used random effect model to analyze our data using Comprehensive Meta Analysis Version 2.0. Results: A total of 3130 patients were available for analysis. The pooled estimate of the mean LSM for all patients was 4.22 ± 0.19 kPa with a substantial heterogeneity (I 2=98%). In a subgroup analysis, the pooled estimates for mean normal male LSM values was 5.07 ± 0.16 kPa whereas for females it was 4.69 ± 0.135 kPa. A head to head p value test application showed a 0.02 value between genders. A regression analysis of the effect of age on mean LSM value showed a statistically significant positive correlation with point estimates for slope and intercept coefficients of 0.09 and 1.3, respectively. A similar analysis of the effect of BMI on mean LSM was also statistically significant, showing a positive correlation with point estimates for slope and intercept coefficients of 0.21 and - 0.11, respectively. A subgroup analysis showed a statistically insignificant increase in LSM with the presence of abnormal LFTs, presence of fatty liver disease, and a statistically insignificant decrease in LSM with the presence of alcohol consumption. Conclusions: Based on a meta-analysis, normal mean LSM value and range have been established. LSM is expected to increase with age and with BMI. A prior presence of fatty liver disease and abnormal LFTs may affect normal ranges, but larger studies are needed to determine a statistically significant correlation. Further investigation of LSM in healthy alcohol-drinking individuals is required to evaluate normal ranges.
Assessment of Liver Stiffness by Shear Wave Elastography in Liver Transplant Recipients Renata Senkerikova, Halima Gottfriedova, Eva Sticova, Sona Frankova, Jiri Fronek, Pavel Trunecka, Julius Spicak, Jan Sperl
AASLD Abstracts
Background and Aims: Shear wave elastography (SWE) is a progressive method for noninvasive assessment of liver fibrosis. SWE results should be validated according to biopsyproven stage of liver fibrosis to be applicable in clinical practice. The number of validation data, specially in hepatitis B and C, is increasing. Validation data concerning fibrosis in the liver transplant recipients are still missing. The aim of the study was to correlate SWEassessed liver stiffness and biopsy-proven fibrosis of the liver graft. Methods: Forty-five consecutive patients (23 males and 22 females, median age 58 years, median follow-up from transplantation 62 months) with an inflammatory injury of the liver graft (recurrent hepatitis B and C, autoimunne hepatitis and allograft hepatitis) underwent protocolar biopsy of the liver graft and SWE on the same day. Patients with recurrence of cholestatic liver diseases and patients with severe steatosis of the graft were excluded. Fibrosis stage was evaluated by one pathologist using the following semiquantitative score: F1-portal fibrosis without septa, F2-portal fibrosis with few septa, F3-septal fibrosis, F4-cirrhosis. Liver stiffness was calculated as mean value of 3 different areas measurements of the liver graft. Results: Results are summarized in the table. A significant difference in SWE liver graft stiffness between the subgroups according to biopsy-proven fibrosis stage was found: F1 vs. F2, F2 vs. F3 or F4, but not F3 vs. F4. The difference between F3 and F4 groups was not statistically significant owing to a small number of patients. Conclusions: SWE may represent a simple and non-invasive method for assessment of liver graft fibrosis, but further validations for different types of liver graft injuries are needed.
Sa1008 20 Years Experience of Percutaneous Echo-Assisted Liver Biopsy Using Menghini Modified Needles Ioan Sporea, Felix Bende, Alina Popescu, Roxana Sirli, Ruxandra Mare Background and aims: Liver biopsy (LB) is the most accurate method for staging diffuse chronic liver disease. There are 3 methods for performing LB: percutaneous, trans-jugular and laparoscopic. The percutaneous LB can be performed: blinded, echo-guided and echoassisted. The aim of our study was to assess the quality of the liver sample obtained by percutaneous LB in diffuse liver disease, during an extensive experience, by a single senior operator, as well as the complications rate during the procedure. Methods: We performed a retrospective study that included the echo-assisted LBs in our Department during a period of 20 years (1994- 2013), using 1.4 or 1.6 mm Menghini modified needle with 2 liver passages. From a total of 2967 liver biopsies performed in our Department, 2139 biopsies performed by a single senior operator were included in the study. Complete data was recovered regarding 1128 patients (42.3% male, 57.7% female) with mean age of 46 ± 12 years who were evaluated by 1162 procedures. The following parameters were investigated: number of inconclusive biopsies, length of tissue specimen, number of portal tracts and complications. Results: From the total of 1162 liver biopsies only 1 %( 11/1162) were inconclusive (insufficient tissue for histological assessment). The mean length of tissue specimen was 3.3 ± 1.4 cm and the mean number of portal tracts was 22 ± 10. 88% of the LBs provided more than 11 portal tracts, 92% more than 8, while 2% less than 6. The severe complications rate was 0.13% (3/2208) and the mortality rate 0%. Besides mild pain or local discomfort, from the total of 2208 procedures only 3 major complications occurred: 1 arteriovenous fistula with liver hematoma, that was treated by surgical intervention and 2 patients that developed hemoperitoneum and were successfully managed by conservative treatment (blood transfusion). Starting from 1994 we observed that the number of procedures increased during the years, with a maximum of LBs in 2008 (249 LBs). The elastographic methods were validated in 2010 for the non-invasive assessment of liver fibrosis and afterwards the number of procedures started to decrease and in 2013 only 59 LBs were performed.Figure 1 Conclusions: Percutaneous echo-assisted LB using modified Menghini needles using 2 liver passages is a very good method for obtaining high quality liver specimens, with a very low complications rate, in experienced hands. The actual trend of LB is in decreasing numbers, being replaced by elastographic methods.
Figure 1. Mean Liver stiffness measurement (LSM) in pooled studies Sa1010 The Role of Transient Elastography in Assessing Significant Liver Fibrosis and Cirrhosis in Patients With Chronic Liver Disease: An Evaluation of MRE and FibroScan in Hepatology Clinics Idrees Suliman, Yaseen Kady, Roukaya Hassanein, Thomas Couturier, Anna Marie Hefner, Russell Low, Tarek I. Hassanein Introduction: Assessment of liver fibrosis using indirect measures is gaining popularity because they are non-invasive, provide immediate results, and are cost effective. More data is required to evaluate the effectiveness of these measures compared to the current gold standard. Magnetic Resonance Elastography (MRE) and the Echosens Fibroscan are currently the most widely used transient elastography measures. Aim: The purpose of this study was to evaluate MRE and Fibroscan as initial diagnostic tests to detect significant fibrosis (F>2) and cirrhosis (F4) and compare them to liver biopsy. Subjects: Patients were selected by utilizing electronic medical records to identify patients who have had a Fibroscan, MRE, liver biopsy, and contemporary blood tests (CBC, BMP). 19 patients meeting these criteria were identified. The mean age was 55.3 ± 13.2 years of which 63% of the subjects were female and 42% Caucasian. Chronic liver disease etiology included hepatitis C (47.3%), NASH (57.9%), and Hepatitis B (5.3%). Methods: Using the liver biopsy as the gold standard, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for MRE, Fibroscan, and APRI. With regard to MRE the values of > 4.5 kPa and > 6.0 kPa were used for significant fibrosis (>F2) and cirrhosis respectively. For the Fibroscan 7.76kPa and 13.01kPa were used as cutoffs for significant fibrosis and cirrhosis, respectively. For the APRI the cutoff values were > 1 for and >0.7 for significant fibrosis. Results: Compared to the liver biopsy, the sensitivity, specificity, PPV, and NPV of MRE, Fibroscan and APRI are displayed in the table below for both significant fibrosis and cirrhosis. In detecting significant fibrosis MRE obtained vales of 82.0% sensitivity, 63.0% specificity, 75.0% PPV, and 71.0% NPV while Fibroscan obtained 69.2% sensitivity, 50% specificity, 75.0% PPV, and 42.9% NPV. With regard to cirrhosis MRE obtained 83.3% Sensitivity, 77.0% specificity, 63.0% PPV, and 91.0% NPV when compared to the liver biopsy while the Fibroscan obtained 83.0% sensitivity, 77.0% specificity, 63.0%PPV, and 91.0%NPV. APRI (>1) in detecting significant fibrosis ARI was associated with 46.2% sensitivity, 33.3%
Sa1009 Normal Values of Liver Stiffness Measurement in Healthy Adults - A Systematic Review and Meta-Analysis of Observational Studies Fateh Bazerbachi, Sushil Kumar Garg, Samir Haffar, John R. Lake Background: Liver stiffness measurement (LSM) is a non-invasive method designed to diagnose liver fibrosis. It evaluates the velocity of propagation of a shock wave within liver tissue. Normal liver tissue is viscous and unfavorable to wave propagation, and fibrosis favors more rapid progression. LSM in healthy subjects has been studied in different cohorts and several limitations have been raised in the literature suggestinginterpretation may be
S-1005
AASLD Abstracts
difficult in certain situations including, age, BMI, metabolic syndrome, and ALT levels. Aims: To study the normal reference range for Fibroscan® LSM, and analyze the effect of age, BMI, metabolic syndrome, and ALT level in adult population through a meta-analysis of previously published reports. Methods: We conducted a systematic search of MEDLINE, EMBASE and published proceedings of major liver meetings from January 1980 to November 2014. We identified 10 studies that reported the normal values of LSM in different cohorts, described the demographics, and value ranges including age, gender, BMI, the presence of metabolic syndrome, the presence of abnormal LFTs, and the presence of alcohol consumption. In a meta-analysis, we combined pooled estimates of these values and investigated significant correlations. We used random effect model to analyze our data using Comprehensive Meta Analysis Version 2.0. Results: A total of 3130 patients were available for analysis. The pooled estimate of the mean LSM for all patients was 4.22 ± 0.19 kPa with a substantial heterogeneity (I 2=98%). In a subgroup analysis, the pooled estimates for mean normal male LSM values was 5.07 ± 0.16 kPa whereas for females it was 4.69 ± 0.135 kPa. A head to head p value test application showed a 0.02 value between genders. A regression analysis of the effect of age on mean LSM value showed a statistically significant positive correlation with point estimates for slope and intercept coefficients of 0.09 and 1.3, respectively. A similar analysis of the effect of BMI on mean LSM was also statistically significant, showing a positive correlation with point estimates for slope and intercept coefficients of 0.21 and - 0.11, respectively. A subgroup analysis showed a statistically insignificant increase in LSM with the presence of abnormal LFTs, presence of fatty liver disease, and a statistically insignificant decrease in LSM with the presence of alcohol consumption. Conclusions: Based on a meta-analysis, normal mean LSM value and range have been established. LSM is expected to increase with age and with BMI. A prior presence of fatty liver disease and abnormal LFTs may affect normal ranges, but larger studies are needed to determine a statistically significant correlation. Further investigation of LSM in healthy alcohol-drinking individuals is required to evaluate normal ranges.
Assessment of Liver Stiffness by Shear Wave Elastography in Liver Transplant Recipients Renata Senkerikova, Halima Gottfriedova, Eva Sticova, Sona Frankova, Jiri Fronek, Pavel Trunecka, Julius Spicak, Jan Sperl
AASLD Abstracts
Background and Aims: Shear wave elastography (SWE) is a progressive method for noninvasive assessment of liver fibrosis. SWE results should be validated according to biopsyproven stage of liver fibrosis to be applicable in clinical practice. The number of validation data, specially in hepatitis B and C, is increasing. Validation data concerning fibrosis in the liver transplant recipients are still missing. The aim of the study was to correlate SWEassessed liver stiffness and biopsy-proven fibrosis of the liver graft. Methods: Forty-five consecutive patients (23 males and 22 females, median age 58 years, median follow-up from transplantation 62 months) with an inflammatory injury of the liver graft (recurrent hepatitis B and C, autoimunne hepatitis and allograft hepatitis) underwent protocolar biopsy of the liver graft and SWE on the same day. Patients with recurrence of cholestatic liver diseases and patients with severe steatosis of the graft were excluded. Fibrosis stage was evaluated by one pathologist using the following semiquantitative score: F1-portal fibrosis without septa, F2-portal fibrosis with few septa, F3-septal fibrosis, F4-cirrhosis. Liver stiffness was calculated as mean value of 3 different areas measurements of the liver graft. Results: Results are summarized in the table. A significant difference in SWE liver graft stiffness between the subgroups according to biopsy-proven fibrosis stage was found: F1 vs. F2, F2 vs. F3 or F4, but not F3 vs. F4. The difference between F3 and F4 groups was not statistically significant owing to a small number of patients. Conclusions: SWE may represent a simple and non-invasive method for assessment of liver graft fibrosis, but further validations for different types of liver graft injuries are needed.
Sa1008 20 Years Experience of Percutaneous Echo-Assisted Liver Biopsy Using Menghini Modified Needles Ioan Sporea, Felix Bende, Alina Popescu, Roxana Sirli, Ruxandra Mare Background and aims: Liver biopsy (LB) is the most accurate method for staging diffuse chronic liver disease. There are 3 methods for performing LB: percutaneous, trans-jugular and laparoscopic. The percutaneous LB can be performed: blinded, echo-guided and echoassisted. The aim of our study was to assess the quality of the liver sample obtained by percutaneous LB in diffuse liver disease, during an extensive experience, by a single senior operator, as well as the complications rate during the procedure. Methods: We performed a retrospective study that included the echo-assisted LBs in our Department during a period of 20 years (1994- 2013), using 1.4 or 1.6 mm Menghini modified needle with 2 liver passages. From a total of 2967 liver biopsies performed in our Department, 2139 biopsies performed by a single senior operator were included in the study. Complete data was recovered regarding 1128 patients (42.3% male, 57.7% female) with mean age of 46 ± 12 years who were evaluated by 1162 procedures. The following parameters were investigated: number of inconclusive biopsies, length of tissue specimen, number of portal tracts and complications. Results: From the total of 1162 liver biopsies only 1 %( 11/1162) were inconclusive (insufficient tissue for histological assessment). The mean length of tissue specimen was 3.3 ± 1.4 cm and the mean number of portal tracts was 22 ± 10. 88% of the LBs provided more than 11 portal tracts, 92% more than 8, while 2% less than 6. The severe complications rate was 0.13% (3/2208) and the mortality rate 0%. Besides mild pain or local discomfort, from the total of 2208 procedures only 3 major complications occurred: 1 arteriovenous fistula with liver hematoma, that was treated by surgical intervention and 2 patients that developed hemoperitoneum and were successfully managed by conservative treatment (blood transfusion). Starting from 1994 we observed that the number of procedures increased during the years, with a maximum of LBs in 2008 (249 LBs). The elastographic methods were validated in 2010 for the non-invasive assessment of liver fibrosis and afterwards the number of procedures started to decrease and in 2013 only 59 LBs were performed.Figure 1 Conclusions: Percutaneous echo-assisted LB using modified Menghini needles using 2 liver passages is a very good method for obtaining high quality liver specimens, with a very low complications rate, in experienced hands. The actual trend of LB is in decreasing numbers, being replaced by elastographic methods.
Figure 1. Mean Liver stiffness measurement (LSM) in pooled studies Sa1010 The Role of Transient Elastography in Assessing Significant Liver Fibrosis and Cirrhosis in Patients With Chronic Liver Disease: An Evaluation of MRE and FibroScan in Hepatology Clinics Idrees Suliman, Yaseen Kady, Roukaya Hassanein, Thomas Couturier, Anna Marie Hefner, Russell Low, Tarek I. Hassanein Introduction: Assessment of liver fibrosis using indirect measures is gaining popularity because they are non-invasive, provide immediate results, and are cost effective. More data is required to evaluate the effectiveness of these measures compared to the current gold standard. Magnetic Resonance Elastography (MRE) and the Echosens Fibroscan are currently the most widely used transient elastography measures. Aim: The purpose of this study was to evaluate MRE and Fibroscan as initial diagnostic tests to detect significant fibrosis (F>2) and cirrhosis (F4) and compare them to liver biopsy. Subjects: Patients were selected by utilizing electronic medical records to identify patients who have had a Fibroscan, MRE, liver biopsy, and contemporary blood tests (CBC, BMP). 19 patients meeting these criteria were identified. The mean age was 55.3 ± 13.2 years of which 63% of the subjects were female and 42% Caucasian. Chronic liver disease etiology included hepatitis C (47.3%), NASH (57.9%), and Hepatitis B (5.3%). Methods: Using the liver biopsy as the gold standard, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for MRE, Fibroscan, and APRI. With regard to MRE the values of > 4.5 kPa and > 6.0 kPa were used for significant fibrosis (>F2) and cirrhosis respectively. For the Fibroscan 7.76kPa and 13.01kPa were used as cutoffs for significant fibrosis and cirrhosis, respectively. For the APRI the cutoff values were > 1 for and >0.7 for significant fibrosis. Results: Compared to the liver biopsy, the sensitivity, specificity, PPV, and NPV of MRE, Fibroscan and APRI are displayed in the table below for both significant fibrosis and cirrhosis. In detecting significant fibrosis MRE obtained vales of 82.0% sensitivity, 63.0% specificity, 75.0% PPV, and 71.0% NPV while Fibroscan obtained 69.2% sensitivity, 50% specificity, 75.0% PPV, and 42.9% NPV. With regard to cirrhosis MRE obtained 83.3% Sensitivity, 77.0% specificity, 63.0% PPV, and 91.0% NPV when compared to the liver biopsy while the Fibroscan obtained 83.0% sensitivity, 77.0% specificity, 63.0%PPV, and 91.0%NPV. APRI (>1) in detecting significant fibrosis ARI was associated with 46.2% sensitivity, 33.3%
Sa1009 Normal Values of Liver Stiffness Measurement in Healthy Adults - A Systematic Review and Meta-Analysis of Observational Studies Fateh Bazerbachi, Sushil Kumar Garg, Samir Haffar, John R. Lake Background: Liver stiffness measurement (LSM) is a non-invasive method designed to diagnose liver fibrosis. It evaluates the velocity of propagation of a shock wave within liver tissue. Normal liver tissue is viscous and unfavorable to wave propagation, and fibrosis favors more rapid progression. LSM in healthy subjects has been studied in different cohorts and several limitations have been raised in the literature suggestinginterpretation may be
S-1005
AASLD Abstracts