EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis – 2021 update

Non-invasive tests are increasingly being used to improve the diagnosis and prognostication of chronic liver diseases across aetiologies. Herein, we provide the latest update to the EASL Clinical Practice Guidelines on the use of non-invasive tests for the evaluation of liver disease severity and prognosis, focusing on the topics for which relevant evidence has been published in the last 5 years

Studies related to portal hypertension

Cirrhosis of the liver is a chronic disorder resulting from a variety of known and unknown aetiological factors, which lead to hepatocyte damage and death, regeneration of remaining hepatocytes and progressive fibrosis in a sequential manner. This ultimately leads to distortion of the architecture of the liver lobules. The net result is liver cell dysfunction and an increase in the intrahepatic resistance to blood flow. The latter, combined with alteration of portal blood flow and of extrahepatic splanchnic vascular responsiveness characterizes portal hypertension.Systemic and splanchnic vasodilatation seem to be prominent features of decompensated hepatic cirrhosis and lead to a fall in the effective circulating blood volume. This results in the activation of a cascade of compensatory events, which include the RAS, release of AVP and heightened sympathetic nervous system activity. Neuronal and humoral mechanisms, therefore, seem to be central to the sodium and water retention, which occurs in cirrhosis of the liver. These pathophysiological changes contribute to fluid retention and ascites.The regulation of arterial tone in cirrhosis of the liver is complex and a multitude of factors seem to be playing a part. The areas which have been explored in the past include the role of endothelial-derived vasodilator agents, circulating vasodilator agents which act on the vascular smooth muscle, and lack of response of the vascular smooth muscle to vasoconstrictor agents.The last could in fact be a result of the first two factors. There is a paucity of data on human tissues in the literature because of difficulty in acquiring larger distributory arteries from cirrhotic patients for experimentation. Blood vessels acquired at OLT offer the opportunity to study donor (normal) and recipient (cirrhotic) blood vessels invitro under controlled standardized conditions (organ bath experiments).The development of portal hypertension itself is followed by clinically important sequelae. Enlargement of the spleen is an early and cardinal sign of portal hypertension and it is difficult to make a diagnosis of portal hypertension without the demonstration of splenomegaly. Factors which participate in the development of splenomegaly include increase in portal pressure and splanchnic blood flow, and RE cell hyperplasia. However, the correlation of spleen size to these factors is not entirely clear. The difficulty in interpreting the results of different studies in this area of medicine is partly due to the lack of information about the accuracy of methods used for determining spleen size and partly due to the paucity of data comparing the different methods of measuring spleen size including ultrasonography, CT scanning, MRI and radionuclide studies. Radionuclides have also been used to quantify splanchnic blood flows as well as liver function in the normal and patients with chronic liver disease but there is again a scarcity of data in this regardThe development of portal hypertension is associated with the opening up of portasystemic collateral shunts at different sites in order to decompress the portal circulation. Clinically important shunt vessels develop in the oesophagus, stomach and the duodenum. These assume varicose proportions and can rupture when the intravascular pressures rise above a threshold value. This can lead to potentially life threatening haemorrhage. Shunting of blood to the systemic circulation is also a contributory factor in hepatic encephalopathyImpairment of glucose tolerance and even the development of diabetes mellitus are also consequences of cirrhosis and portal hypertension occurring in 10-40% of patients. The prevalence of these abnormalities of glycaemic control increases as the duration and severity of liver disease increases. Although, it is generally believed to be a result of insulin resistance at the peripheral receptor sites, the pattern of insulin secretion from the P cells of the pancreas is also believed to be altered in this form of diabetes, particularly in the later stages. However, there are obvious problems in quantifying insulin secretion from the endocrine pancreas as it undergoes significant extraction during first pass through the normal liver and the pulse mass is lost to a large extent. Measurements done at the peripheral vein site are therefore not an accurate reflection of the quantum of insulin secretion over a period of time. TIPSS used to treat complications of portal hypertension are reviewed at portographic examinations and can be used to study the pattern of insulin secretion directly from the portal vein. Although this complex investigation could only be done in a few patients with relatively stable liver function, this human model can be used to study the pattern of insulin secretion in the patients with different grades of severity of liver disease and normal as well as abnormal glucose tolerance in hepatic cirrhosisA number of treatment strategies have been devised for prevention of bleeding and control active bleeding from varices in the gastro-intestinal tract. These include endoscopic sclerotherapy, endoscopic variceal ligation, pharmacological measures including ß adrenoreceptor blocking agents and nitrates, surgical decompressive shunts and TIPSS.TIPSS is the most recent addition to the armamentarium of treatment modalities. Although it is a highly effective of treatment, there are obvious problems in that procedure related and short and long-term complications limit its acceptability. Procedure related complications include intraperitoneal bleeding and subcapsular haematoma in the liver. The main longer-term problems relate to sepsis, precipitation of hepatic encephalopathy and SI and occlusion. A number of shunt and patient related factors have been assessed as predictors of SI and these include, age and sex of patients, the liver functions, pre- and post-stent insertion portal pressures and the diameter of the stent. The role of diabetes mellitus, which has been shown to encourage stenosis in vascular stents placed elsewhere in the body, has not been assessed in TIPSS.Accordingly, the aim of this thesis was to explore the following aspects of hepatic cirrhosis and portal hypertension.1.1 TO STUDY THE PATHOPHYSIOLOGIC MECHANISM OF VASCULAR HYPORESPONSIVENESS IN HEPATIC CIRRHOSIS. • The aim in these experiments was to investigate the role of NO release in modulating a-adrenoceptor mediated contraction in hepatic cirrhosis.1.2 TO STUDY CLINICAL SEQUELAE OF PORTAL HYPERTENSION DUE TO HEPATIC CIRRHOSIS. These were the areas of study in relation to clinical sequelae: • The clinical aspects of splenomegaly and its relation to portal haemodynamic factors in portal hypertension due to hepatic cirrhosis. • The role of radionuclides in measuring spleen size and assessing liver function in hepatic cirrosis and portal hypertension.1.3 TO STUDY THE PATTERN OF INSULIN SECRETION IN CIRRHOTIC PATIENTS WITH TIPSS AND THE IMPACT OF DIABETES MELLITUS ON TIPSS FUNCTION. • The pattern of pulsatile insulin secretion in portal vein in patients suffering from hepatic cirrhosis using a TIPSS inserted model was studied. This model should help study pattern of insulin secretion in different stages of hepatogenous diabetes mellitus, ie., impaired glucose tolerance and frank diabetes mellitus. • The effect of diabetes mellitus on the efficacy of TIPSS in the treatment of patients suffering from portal hypertension has been studie

Liver Biopsy

Liver biopsy is recommended as the gold standard method to determine diagnosis, fibrosis staging, prognosis and therapeutic indications in patients with chronic liver disease. However, liver biopsy is an invasive procedure with a risk of complications which can be serious. This book provides the management of the complications in liver biopsy. Additionally, this book provides also the references for the new technology of liver biopsy including the non-invasive elastography, imaging methods and blood panels which could be the alternatives to liver biopsy. The non-invasive methods, especially the elastography, which is the new procedure in hot topics, which were frequently reported in these years. In this book, the professionals of elastography show the mechanism, availability and how to use this technology in a clinical field of elastography. The comprehension of elastography could be a great help for better dealing and for understanding of liver biopsy

Diseases of the Abdomen and Pelvis 2018-2021: Diagnostic Imaging - IDKD Book

Gastrointestinal disease; PET/CT; Radiology; X-ray; IDKD; Davo

Current knowledge in pathophysiology and management of Budd-Chiari syndrome and non-cirrhotic non-tumoral splanchnic vein thrombosis

Budd-Chiari Syndrome (BCS) and non-cirrhotic non-tumoral portal vein thrombosis (NCPVT) are two rare disorders, with several similarities that are categorized under the term splanchnic vein thrombosis. Both disorders are frequently associated with an underlying pro-thrombotic disorder. They can cause severe portal hypertension and usually affect oung patients, negatively influencing life expectancy when the diagnosis and treatment is not done at an early stage. Yet, they have specific features that require individual considerations. The current review will focus on the available knowledge on pathophysiology, diagnosis and management of both entities. BCS is defined as the obstruction of hepatic venous outflow regardless of its causative mechanism or level of obstruction. This obstruction can be traced to the small hepatic venules up to the entrance of the inferior vein cava (IVC) into the right atrium. Hepatic outflow obstruction related to cardiac disease, pericardial disease or sinusoidal obstruction syndrome have different pathophysiological and clinical implications and are excluded from this definition. BCS is classified as primary when the obstruction originates in the vein and thrombosis is the main cause, or secondary when the vein is externally compressed (abscess, tumor). The focus of this review is on primary BCS. NCPVT refers to the presence of a thrombus in the main portal vein trunk and/or the left or right intrahepatic portal vein branches that may extend to the splenic vein and/or the superior or inferior mesenteric veins. Isolated splenic or mesenteric vein thrombosis are out of the scope of this review.Copyright © 2019. Published by Elsevier B.V

Colour Doppler Evaluation of Common Adult Hepatic Tumors more than 2 Cm with HPE and CECT Correlation.

Liver Is A Large, Homogenous Organ And Therefore Is Well Suited For Evaluation By Many Imaging Techniques. Liver Tumors In The Adults Are One Of The Common Lesions In Day Today Practice. Common Adult Hepatic Tumors Include Hepatocellular Carcinoma, Metastases And Hemangiomas. 45 Hepatocellular Carcinoma (HCC) Represents 5% Of All Cancers And Is The Dominant Cause Of Death In Compensated Cirrhosis. HCC Incidence Is Increasing Worldwide Because Of Increasing HBV And HCV Infection. HCC Accounts For 85% Of Primary Liver Cancer. Most Patients Die Within One Year After Diagnosis. Survival Is Dependent On Tumor Size And Associated Disease At The Time Of Diagnosis. So, Early Detection Of HCC Is Very Important To Prolong The Survival. HCC Is More Common In` Males In The Age Group 30 To 60 Years.7 Liver Provides Fertile Soil In Which Metastases Can Establish, Not Only Because Of Rich, Dual Blood Supply But Also Because Of Humoral Factors That Promote Cell Growth. (The Blood Supply Of Liver Is Exceeded Only By That Of The Lung, In Terms Of Blood Flow Per Minute). Liver Is The Most Commonly Involved Organ By Metastatic Disease, After The Lymphnodes. The Liver May Be The Site Of Metastases For Virtually Any Primary Neoplasm. So, Patients With Any Malignant Neoplasm Especially With Primary Tumors Of Colon, Stomach, Pancreas, Breast, Lung And Eye Should Be Intensely Followed Up With Ultrasound And If Any Lesion Is Detected, Colour Doppler Can Be Utilized For Early Diagnosis And Treatment.22 Hemangiomas Are The Most Common Benign Liver Tumors. Reported Incidence Of Hepatic Hemangiomas Is 2%. The Prevalence At Necropsy Is As High As 7.4%. Most Hepatic Hemangiomas Are Diagnosed At 30 To 50 Years With Females More Affected Than Males.45 The Study Of Liver Tumor Is Particularly Challenging. In Many Cases, A Preoperative Diagnosis May Be Achieved With Appropriate Combination Of Imaging Techniques In A Purely Noninvasive Fashion. This Is Important Because Many Adults Have Benign Nonsurgical Hepatic Lesions Such As Hemangiomas.45 There Are Several Imaging Modalities To Evaluate Focal Liver Lesions Starting From Plain Radiograph, USG And Doppler, CT, MRI, Angiography And Nuclear Medicine Techniques. Ultrasound And Doppler Is The Initial, Noninvasive, Easily Available Modality To Characterize Focal Liver Lesions Followed By CECT Or MRI. Scintigraphy Done For Selected Cases. Angiogram Is Done Prior To Embolization.3

Equilibrium Contrast Imaging for Extracellular Volume Quantification

In disease and senescence, the balance between cells and the surrounding interstitium is altered. Cell injury and inflammation induce fibrosis, with collagen deposition leading to expansion of the interstitium. When diffuse, this expansion can affect the structure and function of the whole organ. Examples of diffuse fibrosis include liver cirrhosis and myocardial fibrosis, which are becoming more prevalent as the population ages. Traditional assessment of such diseases involves invasive biopsy, but for many tissues, biopsy is poorly tolerated and carries a significant complication risk. Recently our group has developed a new technique (equilibrium imaging) that utilises the extracellular contrast agents employed widely in MRI and CT to quantify tissue fractional extracellular volume (ECV). Early work demonstrated a significant elevation in myocardial ECV in hypertrophic cardiomyopathy and aortic stenosis. Equilibrium contrast imaging potentially offers a powerful new non-invasive tissue biomarker for ‘extracellular disease’, and promises new insights into the biology of these conditions. In this thesis I develop the equilibrium imaging technique, beginning with an evaluation of the basic principles of extracellular volume estimation by EQ-MRI - using a 3-dimensional engineered tissue model. I show an association between ECV quantified during construction of six engineered models with ECV measured using EQ-MRI (R2=0.77, p=0.02). I then explore the use of equilibrium imaging in quantifying two disease processes that alter the extracellular volume – diffuse fibrosis and amyloidosis. EQ-MRI is used in systemic amyloidosis to demonstrate significant elevation in ECV within the liver (0.32) and spleen (0.39) compared with healthy volunteers (p<0.01). I then translate the basic EQ method to a new modality – computed tomography, a potentially simpler and more widely available imaging platform. EQ-CT is used to show an association between ECV and a histological comparator in cardiac valve disease (r=0.71); and in liver cirrhosis (r=0.64). EQ-MRI is also used as a reference test to investigate diffuse 99mTc-DPD skeletal muscle uptake in systemic ATTR amyloidosis. Using a novel scoring system to quantify uptake, I show that skeletal muscle ECV increases with 99mTc-DPD soft tissue score (R2=0.34) - suggesting that skeletal muscle is a significant target organ for amyloid deposition. Technical development of the CT technique required the optimisation of image acquisition and processing for quantitative attenuation measurement within tissues, and advancement of the contrast protocol to allow rapid ECV estimation using a bolus only dynamic equilibrium technique. In summary, this research thesis presents methological development and validation of EQ imaging for tissue extracellular volume fraction quantification

Propaedeutics of internal medicine. Collection of clinical lectures: the educational and visual guide: in two parts. Part 1

A textbook designed for the training of specialists of the second (master's) level of higher education, educational qualification "Master of Medicine", professional qualification "Doctor" for English speaking students. Учбово-наочний посібник «Propaedeutics of internal medicine. Collection of clinical lectures» є виданням «Курсу лекцій з пропедевтики внутрішньої медицини» в авторській редакції, призначений для підготовки фацівців другого (магістерського) рівня вищої освіти, освітньої кваліфікації «Магістр медицини» професійної кваліфікації «Лікар», які навчаються на англійській мові