use of elastography in portal hypertension - bmus · institute for liver and digestive health use...

Institute for Liver and Digestive Health

Use of Elastography in Portal Hypertension

Dr. Davide Roccarina Specialist in General Medicine Specialist Doctor in Clinical Ultrasound and non-invasive liver assessment Hepatology Department Division of Medicine Royal Free Hospital

1. Pre-hepatic pre-sinusoidal

2. Intra-hepatic pre-sinusoidal

3. Intra-hepatic sinusoidal

4. Intra-hepatic post-sinusoidal

5. Post-hepatic post-sinusoidal

Cirrhosis

?

“Decompensating

Event” Stage 3

Bleeding

Stage 4 First non

bleeding

decompensation

Stage 5

Second

decompensation

Death or

OLT

SEPSIS

Renal

Failure

Decompensated Cirrhosis

Stage 1

No Varices

No Ascites

Varices

No Ascites

Stage 2 Years

Months

Compensated Cirrhosis

Portal Hypertension

Cirrhosis

Liver Cirrhosis: natural history

Portal Hypertension: pathogenesis

OHM’S LAW

ΔP = Q × R

Dynamic Component

Static Component

https://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=0ahUKEwiVmdWSgOPSAhVKC8AKHcifCj4QjRwIBw&url=https://en.wikipedia.org/wiki/Georg_Ohm&psig=AFQjCNH7sCIILOHU-oo9Mzo_4VnbgB33xA&ust=1490027773635635

OLTx DEATH

SBP

ASCITES

ESOPHAGEAL VARICES

RAPTURE

BLEEDING

HEPATO-RENAL SYNDROME

CSPH is an independent predictor of clinical decompensation

HVPG

Upper GI endoscopy

Portal Hypertension: reference standard

Procopet B and Berzigotti A, Gastroenterology Report, Volume 5, Issue 2, 1 May 2017,

Portal Hypertension: non-invasive techniques


Liver Transient Elastography/Fibroscan


Liver Transient Elastography for detection of CSPH

Detection of CSPH: pre-Baveno VI

Auguatin, Journal of Hepatology 2014

Journal of Hepatology 2015

Detection of CSPH: Baveno VI Identification of Low Risk Patients not Immediately Requiring

Endoscopic Surveillance

Journal of Hepatology 2015

Study N Viral

%

ALD

%

Varices VNT Varices

missed

VNT

missed

OGD

spared

OGD

unneeded

Perazzo 97 - - 54% - 6% 0 22% 29%

Tossetti 146 100 - 45% 8% 6% 0 27% 34%

Chang* 173 55 - 31% 8% - 1.7% 20% -

Thabut* 790 100 - - - 10% 0 20% -

Paternostro* 135 47 30 65% 24% 3% 0 7% 30%

Silva* 112 80 7 48% 15% 1.8% 0 11% 43%

Cales* 287 26 64 44% 17% 2% 0 16.5% 41.5%

Ahmed* 478 33 36 - 11% - 0.5% 23% -

Maurice 310 55 13 23% 5% 3.5% 0.6% 33% 48%

TOTAL 2528 12% 0.3% 20% 38%

Perazzo, J Hepatol 2015; Tossetti, DLD 2016; *EASL 2016; Maurice, J Hepatol 2016

Validation of Baveno VI Criteria for Avoiding Screening Endoscopy

N=499

Spared endoscopies

VNT missed

Platelets >150 + LSM <20 kPa

(Baveno VI) 68 (14%) 2/68 (3%) (0.8-10%)§

Platelets >110 + LSM <25 kPa (Expanded-Baveno VI) 158 (32%) 3/158 (1.9%) (0.6-5.4%)

Study cohort Spared endoscopies VNT missed/

Expanded-Baveno VI* VNT missed/

All patients§

Anticipate 158/499 (32%) 3/158 (1.9%) (0.6-5.4%)¥ 3/499 (0.6%) (0.1-1.9%)

London 161/309 (52%) 3/161 (1.9%) (0.6-5.3%) 3/309 (1%) (0.3-2.8%)

Vall d’Hebron 48/117 (41%) 0/48 (0%) (0.7-9.2%) 0/117 (0%) (0-3.1%)

All cohorts 367/925 (40%) 6/367 (1.6%) (0.7-3.5%) 6/925 (0.6%) (0.3-1.4%)

Augustin, Hepatology 2017

Expanded Baveno VI Criteria are Safe and Effective

LS≥21.1 kPa

AUROC 0.845

(0.767-0.923)

HVPG≥10 mmHg

AUROC 0.830

(0.751-0.910)

Prognostic Capacity of Liver Stiffness Values

Risk of Decompensation

Robic, Journal of Hepatology 2011

Prognostic Capacity of Liver Stiffness Values

Risk of Death

Verniol, Gastroenterology 2011


Liver


Spleen Elastography

Transient Elastography/Fibroscan

1. – Sufficient intercostal space width

2. - Splenic parenchymal thickness > 4 cm (by US)

3. – Success rate > 60% and IQR < 30% of median value 4. – Intra-observer reproducibility 96%, inter-observer

reproducibility 94%

5. – Probe upper limit 75 kPa

Measurement of Spleen Stiffness by Liver Transient Elastography/Fibroscan

P = 0.0000

R2 = 0,78

5

10

15

20

25

30

35

0

20 30 70 80 40 50 60

Spleen Stiffness (kPa)

P = 0.0000

R² = 0,70

0

5

10

15

20

25

30

35

10 20 50 60 70 30 40

Liver Stiffness (kPa)

HVPG

(m

m H

g)

Esophageal Varices: NO Esophageal Varices: YES

Colecchia A. et al., Gastroenterology 2012 ; 143(3):646-54

Cirrhosis

HVPG

(m

m H

g)

Compensated Cirrhosis

Spleen Stiffness vs. Liver Stiffness for the detection of Esophageal Varices

EV: YES EV: NO EV: YES EV: NO

Colecchia A. et al., Gastroenterology 2012 ; 143(3):646-54

Spleen Stiffness vs. Liver Stiffness for the detection of Esophageal Varices

Colecchia, Journal of Hepatology 2014

Prognostic Value of Spleen Stiffness in Cirrhosis

• 260 patients: with Chronic Liver Disease due to HCV, HBV or Alcoholic Liver Disease were

prospectively enrolled.

An upper GI-endoscopy for EV grading, liver (LSM) and spleen (SSM) stiffness measurements performed within 6 months.

SSM measured according to 2 parameters :

1) standard FS technical settings used for LSM: SSM-50Hz

2) new settings specifically dedicated to the spleen: SSM-100Hz

Only cases with at least 8 valid SSM-100Hz were kept in the analysis.

SSM-50Hz SSM-100Hz

SSM-50Hz vs SSM-100Hz

SSM-100Hz HVPG

SSM-100 Hz vs HVPG

TARGET SSM-100 Hz HVPG P value

AUC 0,835 (0,757-

0,913) 0,749 (0,643-

0,854) <0,001

SSM-100 Hz vs HVPG

216 patients

Baveno VI criteria : LSM < 20 kPa and platelet count > 150 x 109 cells/L (De Franchis J Hepatol 2015)

• SSM-100Hz cut-off value of 38.3 kPa was calculated in the population excluding Baveno VI criteria (n = 193) with a sensitivity of 95 %.

Expanded-Baveno VI criteria : LSM < 25 kPa and platelet count > 110 x 109 cells/L (Augustin & Pons Hepatology 2017)

• SSM-100Hz cut-off value of 38.3 kPa was calculated in the population excluding Expanded-Baveno VI criteria (n = 154) with a sensitivity of 95 %.

(*) McNemar test (**) ² test

Baveno VI Baveno VI + SSM p

Missed HREV / number of HREV (*) 1 / 51 (2 %) 3 / 51 (5.9 %) 0.48

Missed HREV / number of spared endoscopy (**) 1 / 22 (4.5 %) 3 / 69 (4.3 %) 1

Missed HREV / all patients (*) 1 / 216 (0.5 %) 3 / 216 (1.4 %) 0.48

Spared endoscopy (*) 22 / 216 (10.2 %) 69 / 216 (31.9 %) <0.001

Expanded-Baveno VI Expanded-Baveno VI + SSM p

Missed HREV / number of HREV (*) 7 / 51 (13.7 %) 9 / 51 (17.6 %) 0.48

Missed HREV / number of spared endoscopy (**) 7 / 55 (12.7 %) 9 / 83 (10.8 %) 0.947

Missed HREV / all patients (*) 7 / 216 (3.2 %) 9 / 216 (4.2 %) 0.48

Spared endoscopy (*) 55 / 216 (25.5 %) 83 / 216 (38.4 %) <0.001

Baveno ± SSM -100 Hz


Liver


Spleen Elastography

Shear Wave Elastography

ARFI (Siemens) ElastPQ (Philips) Epiq, Supersonic

Point Shear Wave Elastography

2D Shear Wave Elastography

RT-SWE

Newer US Elastography: Visual Control of Stiffness Measurement

EXPERT REVIEW OF GASTROENTEROLOGY & HEPATOLOGY, 2018

Liver stiffness Reference standard: HVPG


Spleen stiffness Reference standard: HVPG

Spleen stiffness Reference standard: Upper GI


ARFI (Siemens) ElastPQ (Philips) Epiq, Supersonic

Point Shear Wave Elastography

2D Shear Wave Elastography

RT-SWE

Newer US Elastography: Visual Control of Stiffness Measurement

Few studies although results are promising!!!

0

10

20

30

40

50

60

70

80

noPH NCSPH SPH CSPH

HVPG

Sple

en

-SW

E

0

5

10

15

20

25

30

35

40

45

50

noPH NCSPH SPH CSPH

HVPG

Live

r-SW

E

P<0.0001 P<0.0001

78 patients with CLD admitted for HVPG measurement were recruited into the study

Our preliminary data…

Matteo Rosselli et all, Royal Free Hospital, London

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

HVPG noPH NCSPH CSPH SPH

LSP

S

P<0.0001

Non invasive assessment of CSPH LSPS = LS * (spleen length/Plt count)



0

20

40

60

80

100

120

noPH NCSPH CSPH SPH

SSP

SA

HVPG

P<0.0001

Our preliminary data… Non invasive assessment of CSPH

SSPSA = SS * (spleen area/Plt count)


SSWE 0.918 LSWE 0.895 LSPS 0.911 SSPSA 0.895

AUROC for CSPH (HVPG>10 mmHg)



AUROC for SPH (HVPG>12 mmHg)

SSWE 0.922 LSWE 0.869 LSPS 0.899 SSPSA 0.869



LSWE PORTAL PRESSURE HVPG 6-9 HVPG 10-11 HVPG ≥12

AUC 95% CI 0.918 (0.851-0.986) 0.895 (0.820-0.970) 0.869 (0.785-0.952)

Cut-off (kPa) 11.8 18.6 19.9 Sensitivity (%) 82 85 87 Specificity (%) 91 84 83

PPV (%) 81.6 84.6 89 NPV (%) 91 84.1 83

SSWE PORTAL PRESSURE HVPG 6-9 HVPG 10-11 HVPG ≥12

AUC 95% CI 0.898 (0.825-0.971) 0.918 (0.853-0.983) 0.922 (0.861-0.983)

Cut-off (kPa) 30.2 42.7 50 Sensitivity (%) 84 96 87 Specificity (%) 86 84 83

PPV (%) 83.7 78.1 89 NPV (%) 85.7 97.4 83



Our preliminary data…PSC

Davide Roccarina et all, Royal Free Hospital, London

P<0,0001

P<0,0001

Our preliminary data…PSC

Davide Roccarina et all, Royal Free Hospital, London

Combination of Liver and Spleen Stiffness

Berzigotti A, J Hepatol 2017

CPH NCPH p value

LSWE (kPa) 24 5.8 <0.0001

SSWE (kPa) 55.6 93.3 <0.0001

SA (cm2) 72.4 116 <0.009

Platelets/mm3 124 180 <0.001

SS/LS (kPa) 2.3 14.2 <0.0001

0

5

10

15

20

25

30

35

NCPH CPH

Live

r-p

SWE

P<0.0001

0

20

40

60

80

100

120

140

160

NCPH CPH

Sple

en

-pSW

E P<0.0001



LIVER SPLEEN

LIVER

LIVER stiffness SPLEEN stiffness

NON-CIRRHOTIC PH

THANK YOU

use of elastography in portal hypertension - bmus · institute for liver and digestive health use...

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