• Albumin-bilirubin score
• Liver stiffness
• Mean transmitral gradient
• Mitral stenosis
• Mitral valve area
• Systolic pulmonary artery pressure

• Humans
• Mitral Valve Stenosis/diagnostic imaging
• Mitral Valve/diagnostic imaging
• Bilirubin
• Predictive Value of Tests
• Echocardiography/methods
• Albumins

• Elastography
• Heart failure
• Heart transplantation
• Liver fibrosis
• Liver stiffness measurement
• Mechanical circulatory support

• Budd-Chiari Syndrome/diagnostic imaging
• Budd-Chiari Syndrome/therapy
• Elasticity Imaging Techniques
• Humans
• Stents

• ACE, angiotensin-converting enzyme
• AFP, α-fetoprotein
• ALP, alkaline phosphatase
• ALT, alanine aminotransferase
• AST, aspartate amino transferase
• BNP, B-type natriuretic peptide
• Combined heart and liver transplant
• Congestive hepatopathy
• FALD, Fontan-associated liver disease
• FIB-4, Fibrosis-4 index
• Fontan-associated liver disease
• GGT, gamma-glutamyltransferase
• HCC, hepatocellular carcinoma
• INR, international normalised ratio
• MELD, model for end-stage liver disease
• NAFLD, non-alcoholic fatty liver disease
• NFS, NAFLD fibrosis score

Purpose Ultrasound elastography is a noninvasive method for liver stiffness measurement (LSM) with the aim of reflecting approximate liver fibrosis load. Despite minimal evidence, current guidelines recommend 10 min of rest and breath hold prior to measurements and offer no advice concerning recent alcohol consumption, leading to challenges in clinical practice. We aimed to investigate how LSM in healthy adults is influenced by physical exercise, recent alcohol consumption, and respiration.

Materials and Methods 42 healthy subjects aged 21–36 years were included. LSM using point shear wave elastography (pSWE) was performed in five stages: baseline, after physical activity, after registration of alcohol consumption, and during breath hold compared to free breathing.

Results LSM values were significantly increased following physical exercise compared to baseline values (4.1±0.8 vs. 3.8±0.8 kPa, p=0.01). Alcohol consumption during the last 72 h (0–27 alcohol units) did not significantly affect LSM. There was no significant difference between LSM during breath hold and free breathing.

Conclusion In healthy subjects, LSM increased after recent physical exercise, while alcohol consumption 24–72 h prior to examination did not have a significant impact. There was no clinically significant effect of breath hold on LSM. Our study supports present guidelines recommending rest prior to LSM, while indicating that breath hold may not be mandatory. Recent moderate alcohol exposure may affect LSM to a lesser extent than commonly believed.

• Alcohol consumption
• Physical exertion
• Respiration
• Shear wave elastography
• ultrasound, Methods and techniques

Several guidelines have indicated that liver stiffness (LS) assessed by means of shear wave elastography (SWE) can safely replace liver biopsy in several clinical scenarios, particularly in patients with chronic viral hepatitis. However, an increase of LS may be due to some other clinical conditions not related to fibrosis, such as liver inflammation, acute hepatitis, obstructive cholestasis, liver congestion, infiltrative liver diseases. This review analyzes the role that SWE can play in cases of liver congestion due to right-sided heart failure, congenital heart diseases or valvular diseases. In patients with heart failure LS seems directly influenced by central venous pressure and can be used as a prognostic marker to predict cardiac events. The potential role of LS in evaluating liver disease beyond the stage of liver fibrosis has been investigated also in the hepatic sinusoidal obstruction syndrome (SOS) and in the Budd-Chiari syndrome. In the hepatic SOS, an increase of LS is observed some days before the clinical manifestations; therefore, it could allow an early diagnosis to timely start an effective treatment. Moreover, it has been reported that patients that were successfully treated showed a LS decrease, that reached pre-transplantation value within two to four weeks. It has been reported that, in patients with Budd-Chiari syndrome, LS values can be used to monitor short and long-term outcome after angioplasty.

• Liver stiffness
• Shear wave elastography
• Heart failure
• Liver congestion
• Hepatic sinusoidal obstruction syndrome
• Fontan circulation
• Budd Chiari syndrome
• Valvular diseases

• Budd-Chiari Syndrome/diagnostic imaging
• Budd-Chiari Syndrome/therapy
• Elasticity Imaging Techniques
• Humans
• Liver/diagnostic imaging
• Liver Cirrhosis/complications
• Liver Cirrhosis/diagnostic imaging
• Ultrasonography

Alcohol‐related liver disease (ALD) represents a major cause of death worldwide, and unfortunately, most patients are diagnosed at an advanced stage of the disease, which is related to poorer outcomes. Liver biopsy has historically been the gold standard for identifying advanced hepatic fibrosis, but this approach has several limitations, including invasiveness, low applicability, sampling variability, and cost.

In order to detect earlier features of advanced liver fibrosis, surrogate biomarkers and techniques have been developed. While these were initially developed for chronic liver diseases such as viral hepatitis and nonalcoholic fatty liver disease (NAFLD), their performance in ALD has also been recently studied. Among the noninvasive surrogate markers and techniques used to detect liver fibrosis, the Enhanced Liver Fibrosis test, FibroTest, and Transient Elastography are the most accurate and validated techniques. In this review, we summarize the current status of the noninvasive assessment of liver disease in ALD and provide a synthesis of how these noninvasive tools can be used in clinical practice. Finally, we briefly outline novel biomarkers that are currently being investigated and discuss future directions and new opportunities in the noninvasive diagnosis of ALD.

• alcohol‐related liver disease
• biomarkers
• fibrosis
• noninvasive diagnosis
• transient elastography

Elastography-based liver stiffness measurement (LSM) is a non-invasive tool for estimating liver fibrosis but also provides an estimate for the severity of portal hypertension in patients with advanced chronic liver disease (ACLD). The presence of varices and especially of varices needing treatment (VNT) indicates distinct prognostic stages in patients with compensated ACLD (cACLD). The Baveno VI guidelines suggested a simple algorithm based on LSM < 20 kPa (by transient elastography, TE) and platelet count > 150 G/L for ruling-out VNT in patients with cACLD. These (and other) TE-based LSM cut-offs have been evaluated for VNT screening in different liver disease etiologies. Novel point shear-wave elastography (pSWE) and two-dimensional shear wave elastography (2D-SWE) methodologies for LSM have also been evaluated for their ability to screen for “any” varices and for VNT. Finally, the measurement of spleen stiffness (SSM) by elastography (mainly by pSWE and 2D-SWE) may represent another valuable screening tool for varices. Here, we summarize the current literature on elastography-based prediction of “any” varices and VNT. Finally, we have summarized the published LSM and SSM cut-offs in clinically useful scale cards.

• Elastography
• Liver stiffness
• Spleen stiffness
• Shear wave
• Magnetic resonance elastography
• Varices
• Portal hypertension
• Cirrhosis
• Advanced chronic liver disease

• Clinical Protocols/standards
• Echo-Planar Imaging/methods
• Echo-Planar Imaging/standards
• Elasticity Imaging Techniques/methods
• Elasticity Imaging Techniques/standards
• Esophageal and Gastric Varices/diagnosis
• Esophageal and Gastric Varices/etiology
• Humans
• Hypertension, Portal/diagnosis
• Hypertension, Portal/etiology
• Liver/diagnostic imaging
• Liver/pathology
• Liver Cirrhosis/complications
• Liver Cirrhosis/diagnostic imaging
• Liver Cirrhosis/pathology
• Mass Screening/methods
• Mass Screening/standards
• Practice Guidelines as Topic
• Prognosis

• Decongestion
• Doppler ultrasonography
• heart failure (HF)
• organ congestion

• algorithm
• chronic hepatitis B
• controlled attenuation parameter
• fibrosis
• liver stiffness measurement
• steatosis

• Abdominal organs
• Circulatory support devices
• Heart failure
• Liver

• Cardiomyopathy, Hypertrophic/diagnostic imaging
• Cardiomyopathy, Hypertrophic/physiopathology
• Cardiomyopathy, Hypertrophic/therapy
• Echocardiography
• Elasticity Imaging Techniques
• Female
• Heart Failure/diagnostic imaging
• Heart Failure/physiopathology
• Heart Failure/therapy
• Heart Transplantation
• Heart-Assist Devices
• Humans
• Liver/diagnostic imaging
• Liver/physiology
• Male
• Middle Aged
• Perioperative Care/methods
• Retrospective Studies
• Stroke Volume/physiology
• Treatment Outcome
• Ventricular Dysfunction, Right/diagnostic imaging
• Ventricular Dysfunction, Right/physiopathology
• Ventricular Dysfunction, Right/therapy
• Ventricular Function, Right/physiology

• Fibroscan
• Insulin resistance
• NAFLD
• Normal value

• Adult
• Case-Control Studies
• Cross-Sectional Studies
• Elasticity Imaging Techniques
• Female
• Humans
• Insulin Resistance
• Italy
• Liver/diagnostic imaging
• Liver/pathology
• Liver Cirrhosis/diagnostic imaging
• Liver Cirrhosis/pathology
• Logistic Models
• Male
• Middle Aged
• Multivariate Analysis
• Non-alcoholic Fatty Liver Disease/complications
• Non-alcoholic Fatty Liver Disease/diagnostic imaging

• Doppler ultrasonography
• Liver stiffness
• Portal hypertension
• Resistive index
• Splenomegaly

• Area Under Curve
• Female
• Humans
• Hypertension, Portal/complications
• Hypertension, Portal/diagnostic imaging
• Hypertension, Portal/physiopathology
• Liver/diagnostic imaging
• Liver/physiopathology
• Liver Cirrhosis/complications
• Liver Cirrhosis/physiopathology
• Male
• ROC Curve
• Reproducibility of Results
• Retrospective Studies
• Spleen/diagnostic imaging
• Spleen/physiopathology
• Ultrasonography, Doppler/methods
• Vascular Resistance/physiology

Magnetic resonance elastography (MRE) is an innovative imaging technique for the non-invasive quantification of the biomechanical properties of soft tissues via the direct visualization of propagating shear waves in vivo using a modified phase-contrast magnetic resonance imaging (MRI) sequence. Fundamentally, MRE employs the same physical property that physicians utilize when performing manual palpation - that healthy and diseased tissues can be differentiated on the basis of widely differing mechanical stiffness. By performing “virtual palpation”, MRE is able to provide information that is beyond the capabilities of conventional morphologic imaging modalities. In an era of increasing adoption of multi-parametric imaging approaches for solving complex problems, MRE can be seamlessly incorporated into a standard MRI examination to provide a rapid, reliable and comprehensive imaging evaluation at a single patient appointment. Originally described by the Mayo Clinic in 1995, the technique represents the most accurate non-invasive method for the detection and staging of liver fibrosis and is currently performed in more than 100 centers worldwide. In this general review, the mechanical properties of soft tissues, principles of MRE, clinical applications of MRE in the liver and beyond, and limitations and future directions of this discipline -are discussed. Selected diagrams and images are provided for illustration.

• Magnetic resonance elastography
• Elasticity imaging techniques
• Liver disease
• Fibrosis
• Emerging applications

Liver fibrosis represents the repair mechanism in liver injury and is a feature of most chronic liver diseases. The degree of liver fibrosis in chronic viral hepatitis infections has major clinical implications and presence of advanced fibrosis or cirrhosis determines prognosis. Treatment initiation for viral hepatitis is indicated in most cases of advanced liver fibrosis and diagnosis of cirrhosis entails hepatology evaluation for specialized clinical care. Liver biopsy is an invasive technique and has been the standard of care of fibrosis assessment for years; however, it has several limitations and procedure related complications. Recently, several methods of noninvasive assessment of liver fibrosis have been developed which require either serologic testing or imaging of liver. Imaging based noninvasive techniques are reviewed here and their clinical use is described. Some of the imaging based tests are becoming widely available, and collectively they are shown to be superior to liver biopsy in important aspects. Clinical utilization of these methods requires understanding of performance and quality related parameters which can affect the results and provide wrong assessment of the extent of liver fibrosis. Familiarity with the strengths and weaknesses of each modality is needed to correctly interpret the results in appropriate clinical context.

• biomarker
• fibrosis
• hepatobiliary
• macromolecular proton fraction
• magnetization transfer
• quantification

• Algorithms
• Biomarkers/metabolism
• Feasibility Studies
• Humans
• Liver/metabolism
• Liver/pathology
• Liver Cirrhosis/metabolism
• Liver Cirrhosis/pathology
• Macromolecular Substances/metabolism
• Magnetic Resonance Imaging/methods
• Molecular Imaging/methods
• Proton Magnetic Resonance Spectroscopy/methods
• Reproducibility of Results
• Sensitivity and Specificity

• R21 EB016135 NIBIB NIH HHS
• R21EB016135 NIBIB NIH HHS

Unidimensional transient elastography (TE) is a noninvasive technique, which has been increasingly used in the assessment of diffuse liver diseases. This paper focuses on reviewing the existing data on the use of TE in the diagnosis of fibrosis and in monitoring disease progression in alcoholic liver disease, on the factors that may influence the result of fibrosis prediction, and last but not least, on its potential use in assessing the steatosis degree. Therefore, this field is far from being exhausted and deserves more attention. Further studies are required, on large groups of biopsied patients, in order to find answers to all the remaining questions in this field.

• Transient elastography
• Alcoholic liver disease
• Fibrosis
• Steatosis
• Liver stiffness
• Controlled attenuation parameter

• Animals
• Comorbidity
• Disease Progression
• Elasticity
• Elasticity Imaging Techniques
• Humans
• Liver/pathology
• Liver Diseases, Alcoholic/mortality
• Liver Diseases, Alcoholic/pathology
• Liver Diseases, Alcoholic/therapy
• Predictive Value of Tests
• Prognosis
• Reproducibility of Results
• Risk Factors
• Severity of Illness Index

• Fatty Liver/diagnostic imaging
• Female
• Humans
• Liver Cirrhosis
• Male
• Middle Aged
• Non-alcoholic Fatty Liver Disease/diagnostic imaging
• Severity of Illness Index
• Ultrasonography

• ARFI
• LVAD
• acoustic radiation force impulse imaging
• heart failure
• left ventricular assist device
• liver congestion
• liver elastography
• liver stiffness
• ultrasound

• HVPG
• Liver biopsy
• Non-invasive tests
• Oesophageal varices
• Serological scores
• Transient elastography

• congestive hepatopathy
• extracellular matrix
• mechanical stretch
• hepatic stellate cell
• fibronectin fibril assembly

• Cirrhosis
• Fibrosis
• Hepatitis
• Liver Disease
• Nonalcoholic Fatty Liver Disease

• Cirrhosis
• Evaluation
• Fibroscan®
• Non-invasive
• Ultrasound

Chronic infection with hepatitis C virus (HCV) is a leading cause of liver-related morbidity and mortality worldwide and predisposes to liver fibrosis and end-stage liver complications. Liver fibrosis is the excessive accumulation of extracellular matrix proteins, including collagen, and is considered as a wound healing response to chronic liver injury. Its staging is critical for the management and prognosis of chronic hepatitis C (CHC) patients, whose number is expected to rise over the next decades, posing a major health care challenge. This review provides a brief update on HCV epidemiology, summarizes basic mechanistic concepts of HCV-dependent liver fibrogenesis, and discusses methods for assessment of liver fibrosis that are routinely used in clinical practice. Liver biopsy was until recently considered as the gold standard to diagnose and stage liver fibrosis. However, its invasiveness and drawbacks led to the development of non-invasive methods, which include serum biomarkers, transient elastography and combination algorithms. Clinical studies with CHC patients demonstrated that non-invasive methods are in most cases accurate for diagnosis and for monitoring liver disease complications. Moreover, they have a high prognostic value and are cost-effective. Non-invasive methods for assessment of liver fibrosis are gradually being incorporated into new guidelines and are becoming standard of care, which significantly reduces the need for liver biopsy.

• Hepatitis C virus
• Liver fibrosis
• Cirrhosis
• Biopsy
• Fibroscan

• Algorithms
• Animals
• Biomarkers/blood
• Biopsy
• Critical Pathways
• Elasticity
• Elasticity Imaging Techniques
• Hepacivirus/pathogenicity
• Hepatitis C, Chronic/diagnosis
• Hepatitis C, Chronic/epidemiology
• Hepatitis C, Chronic/therapy
• Hepatitis C, Chronic/virology
• Humans
• Liver/metabolism
• Liver/pathology
• Liver/virology
• Liver Cirrhosis/blood
• Liver Cirrhosis/diagnosis
• Liver Cirrhosis/epidemiology
• Liver Cirrhosis/therapy
• Liver Cirrhosis/virology
• Predictive Value of Tests
• Prognosis

An important aspect of managing chronic liver disease is assessing for evidence of fibrosis. Historically, this has been accomplished using liver biopsy, which is an invasive procedure associated with risk for complications and significant sampling and observer error, limiting the accuracy for determination of fibrosis stage. Hence, several serum biomarkers and imaging methods for noninvasive assessment of liver fibrosis have been developed. In this article, we review the current literature on an important noninvasive imaging modality to measure tissue elastography (FibroScan^®). This ultrasound-based technique is now increasingly available in many countries and has been shown to be a reliable and safe noninvasive means of assessing disease severity in chronic liver disease of varying etiology.

• cirrhosis
• elastography
• fibrosis
• ultrasound

Liver congestion due to heart failure in patients with valvular heart disease (VHD) can result in an overestimate of the liver stiffness (LS) as assessed by transient elastography (TE). This prospective pilot study investigated the dynamics of LS during the perioperative valve operation period.

Thirty-two patients who underwent a valve operation (case) and 12 who underwent a varicose vein operation (control) were prospectively enrolled. LS and cardiologic parameters at three time points [baseline, post-operative day (POD)7, and POD90] were collected.

LS at three time points were consistently higher in the case group than those in the control group, although all participants did not show evidence of underlying chronic liver disease (all P<0.05). In the case group, LS at POD7 increased slightly from the LS at baseline (median 7.9→8.4 kPa, P = 0.816), whereas LS at POD90 decreased significantly from the LS at POD7 (median 8.4→6.0 kPa; P = 0.026). LS was significantly correlated with N-terminal-pro brain natriuretic peptide (NT-proBNP) (ρ = 0.412), left ventricular ejection fraction (ρ = −0.494), and central venous pressure during the operation (ρ = 0.555) at baseline (all P<0.05). LS was significantly correlated with NT-proBNP (ρ = 0.526) and right ventricular pressure (ρ = 0.572) at POD7, whereas LS was significantly correlated with NT-proBNP (ρ = 0.590) at POD90 (all P<0.05).

LS can be overestimated in patients with VHD due to hepatic congestion. However, LS can be dynamically reversed during the perioperative period reflecting the restoration of cardiac function after a successful operation.

• Autotaxin
• Hepatocellular carcinoma
• Liver fibrosis
• Lysophosphatidic acid

• HVPG
• MR elastography
• liver stiffness

• Congenital Heart Disease
• Fontan
• Transient Elastography

• Acoustic radiation force impulse imaging elastography
• Liver fibrosis
• Liver stiffness
• Non-alcoholic fatty liver disease
• Non-alcoholic steatohepatitis
• Shear wave

• Diagnosis, Differential
• Elasticity Imaging Techniques/methods
• Fatty Liver/diagnostic imaging
• Female
• Humans
• Male
• Middle Aged
• Non-alcoholic Fatty Liver Disease
• Reproducibility of Results
• Sensitivity and Specificity

Assessment of liver fibrosis and steatosis is crucial in chronic liver diseases in order to determine the prognosis, the need of treatment, as well as monitor disease progression and response to treatment. Liver biopsy is limited by its invasiveness and patient acceptability. Transient elastography (TE, Fibroscan^®) is a non-invasive tool with satisfactory accuracy and reproducibility to estimate liver fibrosis and steatosis. TE has been well validated in major liver diseases including chronic hepatitis B and C, non-alcoholic fatty liver disease, alcoholic liver disease, primary biliary cirrhosis, and primary sclerosing cholangitis. As alanine aminotransferase (ALT) is one of the major confounding factors of liver stiffness in chronic hepatitis B, an ALT-based algorithm has been developed and higher liver stiffness measurements (LSM) cutoff values for different stages of liver fibrosis should be used in patients with elevated ALT levels up to 5 times of the upper limit of normal. Otherwise falsely-high LSM results up to cirrhotic range may occur during ALT flare. TE is also useful in predicting patient prognosis such as development of hepatocellular carcinoma (HCC), portal hypertension, post-operative complications in HCC patients, and also survival. Unfortunately, failed acquisition of TE is common in obese patients. Furthermore, obese patients may have higher LSM results even in the same stage of liver fibrosis. The new XL probe, a larger probe with lower ultrasound frequency and deeper penetration, increases the success rate of TE in obese patients. The median LSM value with XL probe was found to be lower than that by the conventional M probe, hence cutoff values approximately 1.2 to 1.3 kPa lower than those of M probe should be adopted. Recent studies revealed a novel ultrasonic controlled attenuation parameter (CAP) of the machine is a useful parameter to detect even low-grade steatosis noninvasively. CAP may also be used to quantify liver steatosis by applying different cutoff values. As both LSM and CAP results are instantly available at same measurement, this makes TE a very convenient tool to assess any patients who are suspected or confirmed to suffer from chronic liver diseases.

• Biopsy
• Cirrhosis
• Fibrosis
• Hepatitis
• Fatty liver
• Steatosis of liver