Anselme Konate

A novel panel of blood markers to assess the degree of liver fibrosis

The objective was to develop new blood tests to characterize different fibrosis parameters in viral and alcoholic chronic liver diseases. Measurements included 51 blood markers and Fibrotest, Fibrospect, ELFG, APRI, and Forns scores. The clinically significant fibrosis was evaluated via Metavir staging (F2‐F4), and image analysis was used to determine the area of fibrosis. In an exploratory step in 383 patients with viral hepatitis, the area under the receiving operator characteristic (AUROC) curve for stages F2‐F4 in a test termed the “Fibrometer” test combining platelets, prothrombin index, aspartate aminotransferase, α2‐macroglobulin (A2M), hyaluronate, urea, and age was 0.883 compared with 0.808 for the Fibrotest (P = .01), 0.820 for the Forns test (P = .005), and 0.794 for the APRI test (P < 10−4). The Fibrometer AUROC curve was 0.892 in the validating step in 120 patients. The AUROC curve for stages F2‐F4 in a test combining prothrombin index, A2M, hyaluronate, and age was 0.962 in 95 patients with alcoholic liver diseases. The area of fibrosis was estimated in viral hepatitis by testing for hyaluronate, γ‐glutamyltransferase, bilirubin, platelets, and apolipoprotein A1 (aR2 = 0.645), and in alcoholic liver diseases by testing for hyaluronate, prothrombin index, A2M, and platelets (aR2 = 0.836). In conclusion, the pathological staging and area of liver fibrosis can be estimated using different combinations of blood markers in viral and alcoholic liver diseases. Whereas the Fibrometer has a high diagnostic accuracy for clinically significant fibrosis, blood tests for the area of liver fibrosis provide a quantitative estimation of the amount of fibrosis, which is especially useful in cirrhosis. (HEPATOLOGY 2005.)

The combination of a blood test and Fibroscan improves the non‐invasive diagnosis of liver fibrosis

Background and aims: Blood tests and liver stiffness evaluation (LSE) by ultrasonographic elastometry are accurate tools for diagnosing liver fibrosis. We evaluated whether their synchronous combination in new scores could improve the diagnostic accuracy and reduce liver biopsy requirement in algorithm.

Reproducibility of liver stiffness measurement by ultrasonographic elastometry.

BACKGROUND & AIMS Fibroscan is a noninvasive device that assesses liver fibrosis by liver stiffness evaluation (LSE) with ultrasonographic elastometry. We evaluated LSE reproducibility and its influencing factors. METHODS LSE was performed by 4 experienced physicians (>100 LSEs) in 46 patients with chronic liver disease at 4 different anatomic sites. Additional LSEs were performed for ancillary aims, so that 534 LSEs were available. RESULTS Overall interobserver agreement for LSE results was considered as excellent, with intraclass coefficient correlation (Ric) of 0.93. Low LSE level, nonrecommended sites, LSE interquartile range >25%, and body mass index > or =25 independently decreased agreement. Thus, agreement was fair (Ric = 0.53) for LSE <9 kilopascals and excellent (Ric = 0.90) beyond. The best measurement site for LSE reproducibility was the median axillary line on the first intercostal space under the liver dullness upper limit, with the patient lying in dorsal decubitus. When LSE results were categorized into fibrosis Metavir stages, interobserver discordance was noticed in about 25% of the cases and was the highest for F2 and F3 stages and the lowest for F4. Intraobserver (Ric = 0.94), intersite (Ric = 0.92-0.98), and interequipment (Ric = 0.92) agreements for LSE results were excellent. Preliminary standard ultrasonography or probe pressure changes did not improve interobserver agreement. CONCLUSIONS The best measurement site for LSE is the one generally used for liver biopsy. Reproducibility of LSE is globally excellent but is fair in patient with low liver stiffness. The fibrosis diagnosis by ultrasonographic elastometry in low stages or categorized into fibrosis Metavir stages must be interpreted with caution.

Learning curve and interobserver reproducibility evaluation of liver stiffness measurement by transient elastography

Background/Aims Fibroscan allows liver stiffness examination (LSE) that is well correlated with fibrosis stages. Our main objective was to evaluate LSE learning curve. Methods LSE results of five novice observers with different medical status were compared with those of five expert observers (physicians with >100 examinations) in 250 patients with chronic liver disease. Each novice–expert pair had to blindly examine 50 consecutive patients divided into five consecutive subgroups of 10 patients. Results In each observer group, novice–expert agreement [intraclass correlation coefficient (Ric)] for LSE results was excellent from the first to the last subgroup. Novice–expert agreement for LSE results varied with liver stiffness level: <9 kPa: Ric=0.49; ≥9 kPa: Ric=0.87. Relative difference (%) between novice and expert LSE results was independently associated with the number of valid LSE measurements, and stabilizes around 20–30% after the fourth valid measurement. In each observer group, novice–expert agreement (Ric) for LSE success rate progressively increased as a function of time. Conclusion LSE requires no learning curve: a novice is able to obtain a reliable result after a single training session, whatever the professional status. However, success rate will progressively increase. An LSE with less than four valid measurements should not be considered as reliable.

Diagnostic non invasif de l’hypertension portale au cours de la cirrhose: Application à la stratégie de la prévention primaire des varices

One of the major complications of cirrhosis is the occurrence of portal hypertension and esophageal varices. At present, universal endoscopic screening of esophageal varices is recommended in association to primary prophylaxis in patients at high risk of variceal bleeding. But this screening is invasive and could be not cost-effective. Besides, pre-primary phrophylaxis is not effective and hampared by side effects. So, non invasive diagnosis of portal hypertension might be useful. This one could depend on non invasive measurement of hepatic venous pressure gradient, but its application to screening is not well-documented and its use in treatment monitoring is debated. A second way could be non invasive diagnosis of large esophageal varices because of prognostic and economic issues. Indirect echographic markers of portal hypertension and esophageal varices (ascites, portal vein diameter > or = 13 mm, spleen length, maximal and mean velocimetry of portal vein flow, respectively < 20 cm/s and < 12 cm/s) could be useful. Among this parameters, spleen length is an independent predictive marker of esophageal varices. Besides, several direct or indirect blood markers of fibrosis have been tested. Platelet count is repeatedly a predictive marker of esophageal varices in multivariate analysis. The other predictive factors of esophageal varices could be: prothrombin time, splenomegaly, spider naevi, Child-Pugh class, bilirubinemia, platelet count/spleen diameter ratio and Fibrotest, but these data require validation. In summary, in regard to actual results, non invasive diagnosis of portal hypertension might be useful in esophageal varices screening, but the substitutes to endoscopy have limited place actually in clinical practice, and exclusive non invasive diagnosis of portal hypertension is not applicable; the only test that seems to be useful in clinical practice is conventional endoscopy awaiting the results of videocapsule.

Embolisation de varices stomiales par injection percutanée de colle biologique

Resume Les varices stomiales presentes chez les malades avec cirrhose et stomies digestives peuvent saigner. Il s’agit d’un evenement rare mais souvent recidivant et assez difficile a traiter de maniere efficace. Dans certains cas les consequences de l’hemorragie peuvent etre severes. Nous rapportons 2 cas de varices stomiales hemorragiques traites par embolisation percutanee par injection de colle biologique. Chez chacun des malades, apres echec des traitements pharmacologique classique (propranolol) de l’hypertension portale, un traitement par injection percutanee de colle biologique a permis de traiter de maniere efficace les varices hemorragiques. Apres un suivi respectif de 8 et 16 mois, aucun effet secondaire, ni de recidive hemorragique n’etait note. Le traitement des hemorragies stomiales par injection de colle biologique apparait etre un traitement efficace, aise, et sans complication.