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Experimental And Clinical Study On The Evaluation Of Liver Fibrosis By CEUS

Posted on:2009-08-09Degree:DoctorType:Dissertation
Country:ChinaCandidate:L M JieFull Text:PDF
GTID:1114360242491520Subject:Medical imaging and nuclear medicine
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PrefaceLiver fibrosis is the middle procedure and critical stage in developing to liver cirrhosis for diffuse liver diseases.Liver fibrosis is the result of misbalanced synthesis and degradation of extracellular matrix.HA,PCⅢ,C-Ⅳ,LN are major components of extracellular matrix,their serum level is useful on diagnosing of liver fibrosis.It is important to evaluate hepatic fibrosis using imaging methods,but no imaging manifestation on liver fibrosis or cirrhosis is specific.Numerous groups have investigated the utility of Doppler ultrasound as a noninvasive method for assessing liver fibrosis or cirrhosis.The measurement of relative flow,velocity or resistive index of hepatic artery,portal vein or hepatic vein was involved.However,the results were still controversy.Some authors created a new method for assessing liver cirrhosis by using the characteristic of microbubble which can enhance Doppler signal.But it is still controversy on assessing liver fibrosis and there are shortcomings such as artifact and complex postprocess.This study is to perform CEUS on liver in rats and patients of different fibrosis stage,observing hepatic artery arrival time(HAAT),portal vein arrival time(PVAT),hepatic vein arrival time(HVAT)and the changing of liver parenchyma time-intensity curve by using phase inversion harmonic with Sonovue,to study if CEUS can be used to evaluate the changing of microcirculation during the development of liver fibrosis,and to assess the value of serum,Doppler and CEUS on diagnosing of liver fibrosis. Materials and Methods1.Experimental study62 rats were randomly selected from seventy male Wistar rats for liver fibrosis mode.60%CCl4 was percutaneously injeced twice a week at 2ml/Kg with the first administration at 4ml/Kg.Other 8 rats in control group were percutaneously injected saline at 2ml/Kg with the first administration at 4ml/Kg.At the 5th,7th,9th,and 11th week,10 rats from liver fibrosis mode group and 2 rats from control group were randomly selected for US.Fistly,rat liver was examined by two-dimensional ultrasound.Switching to CEUS process when hepatic vein and portal vein were shown simultaneously.SonoVue was bolus injected into tail vein at a dose of 0.1ml/Kg.Recording the time from injection. Reviewing the dynamic imaging,recording HAAT,PVAT,HVAT,and calculating VAT (HVAT-HAAT)and VVT(HVAT-PVAT).In TIC analysis,ROI was put on the center of the imaging to obtain the time-intensity curve of liver parenchyma.Recording the time to peak,peak intensity,rising rate and descending rate.Blood samples were obtained from animals' hearts after US examination to observe serum markers of liver fibrosis including HA,PCⅢ,C-Ⅳand LN.The rats were sacrificed and liver samples were fixed in 10%formalin and then for HE staining, Masson staining and reticular fiber staining.Liver fibrosis was staged according to the pathological results.Immunohistochemistry staining was used to perform for C-Ⅳ,LN with Envision.Liver samples was routinely fixed in 2.5%glutaral for electron microscopic examination to observe liver ultrastucture.All rats were grouped according to pathological liver fibrosis stage and performing statistic analysis.The serum,immunohistochemistry staining and CEUS results were compared by one-way ANOVA.Linear correlation analysis was performed between the serum and immunohistochemistry staining results.Linear correlation analysis was performed between the parameters of CEUS,serum and immunohistochemistry results. P<0.05 was taken as significant. 2.Clinical study32 patients with final diagnosis confirmed by puncture biopsy including 18 males and 14 femals,with an average 36.9 years ranging from 18 to 64 years,including 7 patients with non-fibrosis liver(S0),11 patients with mild fibrosis(S1/S2),6 patients with moderate fibrosis(S3)and 8 patients with severe fibrosis(S4).Control group included 6 healthy people with an average 33.5 years.Checking serum of direct markers of liver fibrosis,which were HA,PCⅢ,C-Ⅳ, LN.Calculating serum of indirect markers of liver fibrosis,which were APRI and Forns index.Measuring PVD,PVP,HAP,HARI,SPL by Doppler ultrasound and calculating HAP/PVP.Switching to CEUS processs when hepatic vein and portal vein were shown simultaneously.SonoVue was bolus injected into cubital vein at a dose of 0.03ml/Kg.Recording the time from injection.Reviewing the dynamic imaging and recording HAAT,PVAT,HVAT,VAT and VVT.In TIC analysis,ROI was put on the center of the imaging to obtain the time-intensity curve of liver parenchyma.Recording the time to peak,peak intensity,rising rate and descending rate.The parameters of different groups were compared by one-way ANOVA. Spearman correlation was performed between the parameters and liver fibrosis stage. ROC analysis was performed to assess the value of these methods on diagnosing of liver fibrosis.P<0.05 was taken as significant.Results1.Experimental study8 rats in control group were alive.Rats of liver fibrosis mode group began dead from 4thweek.According to pathological staging,3 rats in S0,9 rats in S1,8 rats in S2, 9 rats in S3,11 rats in S4.Degeneration,necrosis appeared and then fiber septa were formed gradually,the structure of hepatic lobules disordered and finally pseudolobules were formed.On electronic microscopy,sinusoidal endothelial cells defenestrated, basement membrane was formed under endothelial cells and amount of collagen fiber appeared peri-endothelial cells.The positive area percentage of C-Ⅳ,LN increased with the severity of liver fibrosis.The serum level of HA,PCⅢ,C-Ⅳ,LN increased with the severity of liver fibrosis.The serum level of HA,PCⅢ,C-Ⅳ,LN was positive correlation with immunohistochemistry of C-Ⅳ,LN.There were no statistical difference of HAAT,PVAT among control group,S1-S4 stage.HVAT,VAT,VVT was shorter in S3 and S4 stage than in control group,S1 and S2 stage.The parenchyma time-intensity curve analysis showed that peak intensity and descending rate was lower in S3 and S4 stage than in control group,S1 and S2 stage.HVAT was negative correlated with serum HA,PCⅢ,C-Ⅳ,LN.VAT,VVT was negative correlated with serum HA,PCⅢ,C-Ⅳ,LN.Peak intensity and descending rate was negative correlated with serum HA,PCⅢ,C-Ⅳ,LN.HVAT,VAT,VVT was negative correlated with the percentage of positive area of C-Ⅳ,LN.Peak intensity and descending rate was negative correlated with the percentage of positive area of C-Ⅳ,LN.2.Clinical studySerum of direct markers of liver fibrosis such as HA,PCⅢ,C-Ⅳ,LN and indirect markers such as APRI,Forns index was positive correlated with the severity of liver fibrosis.ROC analysis showed AUC of HA,PCⅢ,LN for diagnosing early liver cirrhosis(S=4)was 0.733~0.800(P<0.05),AUC of APRI and Forns index for diagnosing early liver cirrhosis(S=4)was 0.765(P<0.05)and 0.900(P<0.05).It was no statistically significant for comparing PVD,PVP,HAP,HAP/PVP,HARI, SPL among the groups.HVAT,VAT,VVT was negative correlated with the severity of liver fibrosis.HVAT, VAT,VVT was shorter in moderate and severe liver fibrosis groups,ROC analysis showed that the AUC of HVAT,VAT,VVT for diagnosing of early liver cirrhosis(S=4) was 0.829~0.835.Time to peak of time-intensity curve was positive correlated with the severity of liver fibrosis,peak intensity,rising rate and decending rate was negative correlated with severity of liver fibrosis.Peak intensity,descending rate was lower in moderate and severe fibrosis groups.Time to peak was prolonged and rising rate was lower in severe fibrosis groups,ROC analysis showed that the AUC of rising rate and descending rate for diagnosing early liver cirrhosis was 0.731(P<0.05)and 0.850(P<0.05).Conclusions1.CEUS is a safe imaging method.By CEUS,we can observe the developing process of hepatic artery,portal vein,hepatic vein an also can observe the characteristic of the liver parenchyma time-intensity curve,to reveal the pattern of hemodynamic changing in liver fibrosis.2.CEUS in the clinical and experimental study showed similiar results.The shortening of HVAT,VAT,VVT,the reducing of peak intensity and decending rate on liver parenchyma time-intensity curve in liver fibrosis of S3,S4 stage were correlated with hepatic sinusoidal capillariztion and intrahepatic circulation changes such as liver arterialization,intrahepatic shunts.3.Parameters of CEUS were helpful for evaluating moderate/severe liver fibrosis. CEUS had a moderate accuracy on diagnosing of early liver cirrhosis(S=4),but had no value on early diagnosing of liver fibrosis(S>1).4.Serum markers had no value on early diagnosing of liver fibrosis(S>1).The direct markers HA,PCⅢ,LN and indirect markers APRI,Forns index had moderate accuracy on diagnosing of early liver cirrhosis(S=4).5.PVD,PVP,HAP,HAP/PVP,HARI measured by Doppler were not useful parameters for assessing liver fibrosis stage.
Keywords/Search Tags:liver fibrosis, liver cirrhosis, contrast enhanced ultrasound (CEUS), arterialization, intrahepatic shunts, hepatic sinusoidal capillariztion
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