Noninvasive Evaluation of Clinically Significant Portal Hypertension in Patients with Liver Cirrhosis: The Role of Contrast-Enhanced Ultrasound Perfusion Imaging and Elastography

Abstract

Background Hepatic venous pressure gradient (HVPG) is the gold standard for assessing the degree of portal hypertension (PH), but it is not suitable for routine clinical use. The recently developed ultrasonography techniques, dynamic contrast-enhanced ultrasound (D-CEUS) and liver stiffness (LS), have expanded the possibilities for noninvasive evaluation.

Aims To investigate the usefulness of D-CEUS and elastographic parameters in assessing the presence and degree of PH.

Methods This is a prospective monocentric study. Patients with liver cirrhosis referred for HVPG measurements underwent hepatic Doppler ultrasound, LS measurement, and D-CEUS with a second-generation contrast agent. Pearson’s correlation and a receiver operating characteristic (ROC) curve analysis were performed to assess the role of noninvasive findings in predicting clinically significant PH (CSPH) and severe PH (SPH).

Results 46 consecutive patients (31 men; mean age±SD: 57±11 years) were enrolled. A significant positive correlation was noted between LS and HVPG (r = 0.809, p<0.0001) with an area under the ROC curve of 0.923. A cut-off value of 24.2 kPa best predicted CSPH with a positive predictive value of 85%. Among the D-CEUS features, the area under the ROC curves of liver parenchyma peak intensity (PI-LP) was greater than the other indices both for CSPH and SPH (1.000 and 0.981, respectively). A PI-LP under 23.3 arbitrary units indicated the presence of CSPH with a sensitivity and a specificity of 100%.

Conclusion A multimodal ultrasound approach based on D-CEUS and LS might become a reliable predictor of CSPH and SPH and a useful alternative to HVPG.

Zusammenfassung

Hintergrund Der hepatische Venendruckgradient (HVPG) ist der Goldstandard zur Beurteilung des Schweregrads der portalen Hypertonie (PH), eignet sich jedoch nicht für den Einsatz in der klinischen Praxis. Die kürzlich entwickelten Ultraschalltechniken, der dynamische kontrastverstärkte Ultraschall (D-CEUS) und die Lebersteifigkeit (LS), haben die Möglichkeiten der nicht invasiven Untersuchung erweitert.

Ziel Untersuchung des Nutzens von D-CEUS und elastografischen Parametern bei der Diagnose einer PH und Beurteilung ihres Schweregrads.

Methoden Dies ist eine prospektive monozentrische Studie. Bei Patienten mit Leberzirrhose, die zur HVPG-Messung überwiesen wurden, wurden hepatischer Doppler-Ultraschall, LS-Messung und D-CEUS mit einem Kontrastmittel der 2. Generation durchgeführt. Es wurden eine Pearson-Korrelation und eine ROC-Kurvenanalyse (Receiver Operating Characteristic) durchgeführt, um die Rolle nicht invasiver Befunde bei der Vorhersage einer klinisch signifikanten PH (CSPH) und der schweren PH (SPH) zu bewerten.

Ergebnisse Es wurden 46 konsekutive Patienten (31 Männer; Durchschnittsalter ±SD: 57 ±11 Jahre) eingeschlossen. Eine signifikante positive Korrelation wurde zwischen LS und HVPG (r = 0,809, p<0,0001) mit einer Fläche unter der ROC-Kurve von 0,923 festgestellt. Ein Cut-Off-Wert von 24,2 kPa erlaubte die beste Vorhersage für CSPH mit einem positiven Vorhersagewert von 85%. Unter den D-CEUS-Merkmalen war die Fläche unter den ROC-Kurven der Peak-Intensität des Leberparenchyms (PI-LP) sowohl für CSPH als auch für SPH größer (1,000 bzw. 0,981) als die anderen Indizes. Eine PI-LP unter 23,3 arbiträren Einheiten sprach für eine CSPH mit einer Sensitivität und einer Spezifität von 100%.

Schlussfolgerung Ein multimodaler Ultraschallansatz, basierend auf D-CEUS und LS, könnte ein zuverlässiger Prädiktor für CSPH und SPH sowie eine nützliche Alternative zum HVPG werden.

Keywords

liver stiffness - clinically significant portal hypertension - liver cirrhosis - dynamic contrast-enhanced ultrasound

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