Part 1 The biliary tree and gall bladder: removal of retained biliary calculi, Eugene Y. Yeung percutaneous transhepatic cholangiography and biliary drainage, Robert N. Gibson biliary endoprosthesis, Andy Adam interventional radiology for benign biliary strictures, Robert N. Gibson and Andy Adam percutaneous gall-bladder procedures, Eugene Y. Yeung endoscopic and combined management of biliary strictures, Anthony G. Speer and Robert N. Gibson. Part 2 Biopsy and abscess drainage: computed tomographic-guided and ultrasound-guided intra-abdominal biopsy and abscess drainage, Eugene Y. Yeung liver biopsy in patients with abnormal coagulation - alternatives to the transjugular approach, Andy Adam. Part 3 Oesophageal and gastrointestinal intervention: oesophageal strictures, Steven G. Meranze and Gordon K. McLean. Part 4 Angiography: embolization of the liver, Goetz Richter vascular stents in liver disease, Goetz Richter.
Objective: To investigate whether the change in Acoustic Radiation Force Impulse (ARFI) readings over time has value in assessing the clinical trajectory of patients with chronic liver disease.Design: All chronic liver disease patients with at least two ARFI liver stiffness measurements between August 2012-March 2016 were included in our study.Demographics, etiology of liver disease, BMI, blood test results, presence of cirrhosis and liver complications were obtained at baseline and follow up.The percentage change in ARFI scores per year was calculated for each patient.Initiation of any treatment likely to improve liver disease, and clinical features of decompensation of the liver disease, between ARFI measurements were documented.Patients with less than 6 months between baseline and follow up ARFI, or an IQR: Median velocity ratio > 0.30 (indicative of unreliable readings) were excluded from the study.Results: one hundred and twelve (112) patients met the inclusion criteria and were analyzed in the study.Patients who developed new varices (median % ARFI change 17.3, p = 0.01) or experienced a new drug-induced liver injury (median % ARFI change 21.6, p = 0.01) had significant increases in percent change in ARFI/ yr, while new HCV treatment (median % ARFI change -19.1, p = 0.04) was associated with significant decrease.There was no statistically significant difference with new HBV treatment (median % ARFI change -17.2, p = 0.14) and alcohol cessation (median % ARFI change -0.67, p = 0.71). Conclusion:Percentage change in ARFI may be a better clinical indicator of disease prognosis or regression than absolute values, as it may account for individual confounding variables.
Targeted ultrasound of the liver (TUSL) has been proposed as a new approach in chronic liver disease to meet the increasing demands on ultrasound services in this patient population. This study analyses the impact of TUSL on examination time.Retrospective cohort analysis of time taken to perform liver ultrasound on consecutive chronic liver disease patients pre- (n = 230) and post- (n = 147) introduction of TUSL. Within each cohort, patients were subdivided into three categories based on the clinical indication: Group 1. hepatocellular carcinoma (HCC) surveillance; Group 2. detection of cirrhosis, fibrosis or fatty liver; Group 3. detection of portal hypertension. The primary outcome was difference in examination time in the pre- and post-intervention groups.Introduction of TUSL led to 49% reduction in examination time (median (Q1-Q3) 23.7 (16.7-36.2) min in pre-TUSL period vs 12.1 (6.4-19.5) min in post, P < 0.001) and it was consistent across all three clinical indication groups (gr1: median 23.1 minutes vs 8.1 minutes (P < 0.001), gr2: 23.0 minutes vs 14.3 minutes (P < 0.001), gr3: 32.2 minutes vs 15.3 minutes (P = 0.006)). After the adjustment for clinical indication and sonographer's experience, impact of TUSL on time reduction remained significant with a 66.6% time reduction (95% CI 53.6 to 79.5).Targeted ultrasound of the liver improves efficiency of chronic liver disease ultrasound with halving of examination times and consequently has the potential to greatly improve resource utilization.
Cardiac hepatopathy is the liver injury resulting from congestion and ischaemia associated with acute or chronic heart failure. The improved longevity of adults with operated congenital heart disease who develop heart failure as an increasingly late event makes this form of liver injury increasingly clinically relevant. Patients with congenital heart disease with a single ventricle anomaly, who require creation of a Fontan circulation, are particularly vulnerable as they have elevated venous filling pressures with chronic liver congestion. Progression to liver fibrosis and eventually cirrhosis may occur, with its associated risks of liver failure and hepatocellular carcinoma. This risk likely increases over the patient's lifetime, related to the duration post-surgical repair and reflects the chronicity of congestion. Liver biopsy is rarely performed due to a higher risk of complications in the setting of elevated venous pressures, and the frequent use of anticoagulation. Non-invasive methods of liver assessment are poorly validated and different factors require consideration compared to other chronic liver diseases. This review discusses the current understanding of cardiac hepatopathy in congenital heart disease patients with a Fontan circulation. This entity has recently been called Fontan Associated Liver Disease in the literature, with the term useful in recognising that the pathophysiology is incompletely understood, and that long-standing venous pressure elevation and hypoxaemia are presumed to play an additional significant role in the pathogenesis of the liver injury.
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