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array:23 [ "pii" => "S217351071830020X" "issn" => "21735107" "doi" => "10.1016/j.rxeng.2018.03.003" "estado" => "S300" "fechaPublicacion" => "2018-05-01" "aid" => "1020" "copyright" => "SERAM" "copyrightAnyo" => "2017" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Radiologia. 2018;60:183-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 4 "HTML" => 4 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0033833817301911" "issn" => "00338338" "doi" => "10.1016/j.rx.2017.11.002" "estado" => "S300" "fechaPublicacion" => "2018-05-01" "aid" => "1020" "copyright" => "SERAM" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Radiologia. 2018;60:183-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1226 "formatos" => array:2 [ "HTML" => 809 "PDF" => 417 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Actualización</span>" "titulo" => "Elastografía hepática: ¿qué es, cómo se hace y cómo se interpreta?" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "183" "paginaFinal" => "189" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Liver elastography: what it is, how it is done, and how it is interpreted" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1613 "Ancho" => 2917 "Tamanyo" => 364598 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Elastografías de hígado en diferentes pacientes. a) Mujer de 23 años con elevación de las enzimas hepáticas, sin otros factores de riesgo. Por los valores obtenidos se considera una paciente con bajo riesgo de fibrosis clínicamente significativa. El resultado de patología fue de esteatosis leve. b) Varón de 23 años con sospecha de cirrosis hepática e hipertensión portal. Por los valores obtenidos se considera un paciente con riesgo moderado de fibrosis clínicamente significativa. El resultado de patología fue concordante con cambios por fibrosis sinusoidal mínima sin evidencia de cirrosis ni enfermedad necroinflamatoria. c) Varón de 45 años con hepatopatía en estudio. Por los valores obtenidos se considera un paciente con riesgo alto de fibrosis clínicamente significativa. El resultado de patología fue concordante con enfermedad necroinflamatoria crónica en estadio de cirrosis temprana.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "V. Murad Gutiérrez, J.A. Romero Enciso" "autores" => array:2 [ 0 => array:2 [ "nombre" => "V." "apellidos" => "Murad Gutiérrez" ] 1 => array:2 [ "nombre" => "J.A." "apellidos" => "Romero Enciso" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S217351071830020X" "doi" => "10.1016/j.rxeng.2018.03.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217351071830020X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0033833817301911?idApp=UINPBA00004N" "url" => "/00338338/0000006000000003/v1_201805040430/S0033833817301911/v1_201805040430/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2173510718300211" "issn" => "21735107" "doi" => "10.1016/j.rxeng.2018.03.004" "estado" => "S300" "fechaPublicacion" => "2018-05-01" "aid" => "1023" "copyright" => "SERAM" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Radiologia. 2018;60:190-207" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 17 "formatos" => array:2 [ "HTML" => 12 "PDF" => 5 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Update in Radiology</span>" "titulo" => "Diagnostic imaging in neuro-ophthalmology" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "190" "paginaFinal" => "207" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Diagnóstico por la imagen en neuroftalmología" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1894 "Ancho" => 2500 "Tamanyo" => 335579 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Orbital trauma. Axial slice with bone window (a) and sagittal reformatting with soft tissue algorithm (b and c) in a 26-year-old woman with facial trauma after a recent traffic accident. She had multiple fractures in her left maxillary sinus and orbit, with multi-fragmented fracture in her orbital roof, revealing one fragment (arrow) in the optic foramen that caused an irreversible lesion of the optic nerve despite urgent treatment. Orbital trauma. Axial slice (d) and sagittal reformatting (e) of CT scan performed on an 80-year-old woman after falling down the stairs, with periorbital hematoma and limitation of ocular motility. Thickening and fraying of retrobulbar and perineural fat compatible with hematoma, which was immediately drained.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A.C. Vela Marín, P. Seral Moral, C. Bernal Lafuente, B. Izquierdo Hernández" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A.C." "apellidos" => "Vela Marín" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Seral Moral" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Bernal Lafuente" ] 3 => array:2 [ "nombre" => "B." "apellidos" => "Izquierdo Hernández" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0033833817302151" "doi" => "10.1016/j.rx.2017.11.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0033833817302151?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173510718300211?idApp=UINPBA00004N" "url" => "/21735107/0000006000000003/v1_201805050431/S2173510718300211/v1_201805050431/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Update in Radiology</span>" "titulo" => "Liver elastography: What it is, how it is done, and how it is interpreted" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "183" "paginaFinal" => "189" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "V. Murad Gutiérrez, J.A. Romero Enciso" "autores" => array:2 [ 0 => array:4 [ "nombre" => "V." "apellidos" => "Murad Gutiérrez" "email" => array:1 [ 0 => "murad.vanessa@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.A." "apellidos" => "Romero Enciso" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Radiología e Imágenes Diagnósticas, Hospital Universitario de la Fundación Santa Fe de Bogotá, Bogotá, Colombia" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Elastografía hepática: ¿qué es, cómo se hace y cómo se interpreta?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3138 "Ancho" => 2405 "Tamanyo" => 379840 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(a) Correct measurement in one portion of the blood vessel-free hepatic parenchyma no more than 2<span class="elsevierStyleHsp" style=""></span>cm away from the hepatic capsule. (b) Ten (10) different measurements taken in the region of interest expressed as average kPa and m/s, and an IQR below 0.30.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hepatic fibrosis is the scarring response of the liver to lesions of different nature that when they become persistent, can generate changes in the architecture of the liver. Damage starts with the subendothelial deposit of fibrous tissue that becomes panlobular with the corresponding formation of nodes in advanced stages such as cirrhosis.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1–3</span></a> Around 20–30% of all patients with chronic hepatopathy develop cirrhosis at one time or another—a situation that significantly increases the risk of developing hepatocellular carcinoma and other complications such as portal hypertension, ascites, encephalopathy, and metabolic dysfunction.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Little by little we have become to accept the fact that once it has started, fibrosis is an irreversible process of variable progression based on factors that are specific of every patient such as age, alcohol consumption, and co-infection due to the human immunodeficiency virus, or other viruses.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">4</span></a> However, during the last few years, we have been able to see that we have the possibility of reverting it or, at least, stopping the changes associated with fibrosis, especially if detected and treated in the early stages of the disease.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Traditionally, alcoholic hepatopathy has been one of the leading causes of fibrosis and cirrhosis such as hepatitis B. However, today the incidence of cirrhosis is on the rise since the cases of hepatitis C and non-alcoholic steatohepatitis have been growing (the latter one has a prevalence of 3% among the worldwide population).<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">5,6</span></a> Other causes include drugs and toxins such as methotrexate and vitamin A; infections such as schistosomiasis, brucellosis, and syphilis; autoimmune conditions; metabolic conditions (Wilson's disease and hemochromatosis), and chronic biliary obstructions. Also, cases of idiopathic hepatic fibrosis have been reported.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Diagnosis of hepatic fibrosis</span><p id="par0020" class="elsevierStylePara elsevierViewall">Determining the extension and severity of hepatic fibrosis is essential for the management of patients, the follow-up of complications, and the assessment of the response to treatment.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">1</span></a> To date, the hepatic biopsy (percutaneous, laparoscopic, surgical or transjugular) with selective staining of connective tissue molecules is still the most accurate way to determine the degree of fibrosis, the severity of damage caused, and all concomitant conditions.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">5,7</span></a> At least, today there are three (3) histologically validated systems for the stratification of hepatic fibrosis: the Ishak score, the Desmet/Scheur system and the METAVIR system—which is the one most widely used today.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">3</span></a> The METAVIR system includes five (5) different categories: F0 is a completely normal liver; F1 shows the presence of periportal fibrosis; F2 shows additional formation of incomplete fibrous septa; F3 shows complete fibrous septa; and F4 shows nodes that are consistent with cirrhotic state.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Although it is the method of choice for diagnostic purposes, the hepatic biopsy is a non-invasive method with associated possible complications that can go from pain, mild hemorrhages, and transient hypotension to severe hemorrhages, peritonitis, sepsis, and perforation of neighboring organs, among others, and whose mortality rate is 1 for every 10,000 patients.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">9,10</span></a> Also, there is an inter-observer variability of up to 20%, being the main error the sampling errors, that amount to 33–50% of all cases and, given the diffuse non-homogeneous distribution of the disease, the size of the sample is only representative of 1/50,000 of the total mass of the liver.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,7,9</span></a> On the other hand, it increases hospital costs, since 2–3% of all patients need to be hospitalized due to associated complications.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">It is for this reason that several efforts have been made looking for serological markers that may show an altered hepatic function (indirect markers), or the activity of the enzymes involved in the production of the extracellular matrix, which may be predictive of the degree of fibrosis (direct markers).<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">7,9,12</span></a> However, indirect markers have been associated with the degree of inflammation rather than the degree of fibrosis and, same as it happen with direct markers, they are expensive and are not available everywhere.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,5,10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">For the last few decades, imaging modalities have been included in the protocols for the assessment of patients with hepatic fibrosis. Mainly, the ultrasound, the computed tomography, and the MRI have been used for the identification of the morphological changes derived from the normal progression of the disease, such as an altered echogenicity, lobullated hepatic contours, the appearance of fibrotic nodes, the reduced size of the right hepatic lobe with an increased size of the caudate lobe, and changes due to portal hypertension, among others. However, all these imaging modalities have limitations, and the major morphological changes occur in more advanced stages of the disease, which is why during the early stages, when identifying this condition can completely change the course of the disease, the aforementioned imaging modalities have low sensitivity and poor specificity.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">7,13,14</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">To fight the limitations of hepatic biopsy, the aforementioned serological markers and imaging modalities have been very popular during the last decade in a search for new non-invasive methods for the quantification of fibrosis. New techniques have been born such as the magnetic resonance elastography, and the ultrasound elastography including the quantitative elastography and the semi-quantitative elastography, which estimate the degree of fibrosis by measuring the tissue stiffness variation relative to how fast the sound waves propagate inside such tissue. The stiffness or elasticity of a tissue is described based on Young's modulus (<span class="elsevierStyleItalic">E</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleItalic">qV</span><span class="elsevierStyleSup">2</span>), where <span class="elsevierStyleItalic">q</span> represents the tissue density, and <span class="elsevierStyleItalic">V</span> expresses how fast the shear waves propagate—expressed as kilopascals (kPa) and meters per second (m/s).<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1,9,10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Elastography-based imaging techniques</span><p id="par0045" class="elsevierStylePara elsevierViewall">Elastography techniques are used in order to determine the mechanical properties of a tissue such as its stiffness. This is something that can be done by applying forces that deform the tissue and cause measurable changes in it. The forces applied can be the manual static compression or the movement of the organs (semi-quantitative elastography), the dynamic compression induced by vibrations or compression mediated by mechanical impulses or generated by ultrasound (quantitative elastography). The latter are the ones most widely used today in elastography methods; the semi-quantitative elastography uses external mechanical forces, and the quantitative elastography uses internal acoustic radiation foces.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1,15</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Static elastography is a semi-quantitative technique where data on tissue stiffness are acquired and compared before and after applying pressure and manual external compression. The indirect measurement of the tissue elasticity is obtained by measuring its deformity after compression, which is inversely proportional to its stiffness. The displacement of the deformed tissue is shown on gray or color scale maps.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1,16,17</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Transition elastography (another semi-quantitative technique) – most widely used as FibroScan<span class="elsevierStyleSup">®</span>, consists of one unidimensional ultrasonic transducer not incorporated to a conventional ultrasound machine that is capable of generating vibrations with a wave of moderate amplitude and low frequency, whose speed of propagation is measured in order to determine the tissue elasticity in a cylinder of parenchyma with a depth of approximately 25–65<span class="elsevierStyleHsp" style=""></span>mm.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">10,9,18</span></a> In this modality there is no associated image, which is a setback compared to quantitative techniques. Recent studies confirm sensitivities of around 91% and 87%, and specificities of around 91% and 85% for the diagnosis of fibrosis and cirrhosis, respectively.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">13,19</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Acoustic radiation force impulse (ARFI) elastography is one typical type of quantitative elastography. Same as it occurs with transition elastography, it uses one unidimensional transducer to measure tissue elasticity, but it also allows us to view the studied area (1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>0.5<span class="elsevierStyleHsp" style=""></span>cm) in two-dimensional B mode, since it is incorporated to a conventional ultrasound machine. The low-frequency pulse generated by the transducer simultaneously produces the axial displacement of both the tissue and the shear waves, while the measurement of the shear wave speed perpendicular to the transducer expresses the tissue stiffness.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1,4,17</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Shear wave elastography (quantitative technique) was first introduced back in the year 2005 and its main advantage is that it allows us to perform real time tissue stiffness measurements without it being affected by the patient's moves. It does not need an external generator for the formation of the shear wave, instead the same transducer produces internal radiation forces (ARFI-like) that induce its formation and propagation inside the tissue. The measurement, that can also be done retrospectively, is presented in color maps that provide the anatomical reference, and additionally in kPa, including the average value with standard deviations.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">20</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Several studies have been conducted worldwide showing the utility of the shear wave elastography in the diagnosis of hepatic fibrosis in its different stages with an 83% correlation with the histopathological study (the reference method), which is superior to other methods. Similarly, its superiority determining the F2 and F3 stages has been confirmed, whose early detection can change the course of the disease, with an average sensitivity of 84.7% and 78.3%, and a 92.1% and 80.9% specificity, respectively.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">15,21–23</span></a> For the determination of advanced fibrosis or cirrhosis and associated complications, its sensitivity is up to 91.2%, and its specificity stays at around 79.7–80%.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">24,25</span></a> When it comes to its reproducibility, the intra-observer correlation is 0.95 (with a 0.93–0.98 confidence interval) and the inter-observer correlation is 0.88 (with a 0.83–0.94 confidence interval).<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">26</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Indications</span><p id="par0075" class="elsevierStylePara elsevierViewall">The clinical indications accepted today for the hepatic elastography include the stratification of the degree of fibrosis in patients with chronic hepatic disease in order to determine the presence or absence of advanced fibrosis (F4), the follow-up of patients with already diagnosed fibrosis, the assessment of patients with portal hypertension of unclear causes, and the assessment of the response to treatment in patients with established fibrosis.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conducting the technique</span><p id="par0080" class="elsevierStylePara elsevierViewall">Measurements should be conducted with the patient in the decubitus supine position or with a 30° rotation toward the left side, and with elevation of the right arm in order to increase the intercostal acoustic window. The transducer should be placed while the patient remains in the intercostal position, and 2<span class="elsevierStyleHsp" style=""></span>cm away from the hepatic capsule, and once the B mode parameters have been adjusted and the blood vessel-free portion of the hepatic parenchyma has been identified, the measurements are taken with suspended breathing on the exhale<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">8,27</span></a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">At least 10 measurements should be taken in the region of interest, and the mean and median should be expressed as both kilopascals (kPa) and meters per second (m/s). At least 60% of these measurements should be good quality measurements, meaning that they should be measurements with a numeric value different from 0, interquartile range (IQR) and a median below 0.30.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Interpreting the findings</span><p id="par0090" class="elsevierStylePara elsevierViewall">The interpretation of the findings should be based on the consensus recommendations established the Society of Radiologists in Ultrasound and conducted in October 2014 and published in June 2015.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">It is important to remember that although studies show an adequate correlation between the value in kPa of hepatic stiffness and the METAVIR stages, the value of hepatic stiffness per se is not powerful enough to be able to achieve a diagnosis of hepatic fibrosis. The correlation between these findings and the specific characteristics of the patient is essential, since there are many sources of variability as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, that should be taken into consideration, and no specific studies on this issue have been conducted yet.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">8,28</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The values of the measurements in kPa should be interpreted according to 2 cut-off values as shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>, and also taking into consideration the machine used, and the fact that we should be dealing with patients with compensated disease.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a> Consequently, there are two (2) different groups: patients without clinically significant fibrosis, and patients with clinically significant fibrosis.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Also, based on these values and depending on the clinical setting, the patients can be categorized into one of the following three (3) risk categories for developing clinically significant fibrosis: low, intermediate, and high. The first category is that of patients with normal elastography values equivalent to F0–F1 (<7<span class="elsevierStyleHsp" style=""></span>kPa), without any risk factors and low chances of developing clinically significant hepatic fibrosis. These patients do not require follow-up or any additional tests. The second category is that of patients with abnormal elastography values equivalent to F2–F3 (7–15<span class="elsevierStyleHsp" style=""></span>kPa), with risk factors to develop hepatic fibrosis, or progression of the disease if they have already been diagnosed. These patients, representative of the intermediate group, require additional tests (following medical criterion) in order to determine the need for therapy and follow-up. The third category is that of patients with really abnormal elastography values equivalent to F4 (>15<span class="elsevierStyleHsp" style=""></span>kPa), with established risk factors to develop fibrosis or cirrhosis. In this group, the elastography procedure is considered diagnostic and no confirmation biopsy is required; also, it can be used as a follow-up and assessment method of the response to therapy (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> and <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall">The hepatic elastography is a non-invasive method widely used today for the diagnosis of fibrosis. Although there are different methods of elastography so far, the shear wave elastography has proven superior to other elastography procedures for the diagnosis of clinically significant fibrosis. Although studies show an adequate correlation between the value, in kPa, of hepatic stiffness and the METAVIR stages, there are multiple sources of measurement variability, which is why the value of hepatic stiffness per se is not powerful enough to be able to establish the diagnosis of fibrosis, meaning that establishing a correlation between these findings and the specific characteristics of the patient and the clinical setting is essential. Normal elastography values in patients without any defined risk factors rule out any diagnoses of clinically significant fibrosis, while really abnormal elastography values in patients at risk confirm diagnoses of advanced fibrosis or cirrhosis. However, in the group of patients with intermediate risk, additional tests such as serological markers, other imaging modalities, and hepatic biopsies to establish accurate diagnoses are still needed.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Authors</span><p id="par0115" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0120" class="elsevierStylePara elsevierViewall">Manager of the integrity of the study: VM and JAR.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0125" class="elsevierStylePara elsevierViewall">Study idea: VM and JAR.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0130" class="elsevierStylePara elsevierViewall">Study design: VM and JAR.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0135" class="elsevierStylePara elsevierViewall">Data mining: N/A.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0140" class="elsevierStylePara elsevierViewall">Data analysis and interpretation: N/A.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6.</span><p id="par0145" class="elsevierStylePara elsevierViewall">Statistical analyses: N/A.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7.</span><p id="par0150" class="elsevierStylePara elsevierViewall">Reference: VM and JAR.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8.</span><p id="par0155" class="elsevierStylePara elsevierViewall">Writing: VM.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9.</span><p id="par0160" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant remarks: VM and JAR.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10.</span><p id="par0165" class="elsevierStylePara elsevierViewall">Approval of final version: VM and JAR.</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflict of interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest associated with this article whatsoever.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres1022311" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec980491" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1022312" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec980492" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Diagnosis of hepatic fibrosis" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Elastography-based imaging techniques" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Indications" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conducting the technique" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Interpreting the findings" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusions" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Authors" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interest" ] 13 => array:2 [ "identificador" => "xack345202" "titulo" => "Acknowledgements" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-05-15" "fechaAceptado" => "2017-11-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec980491" "palabras" => array:4 [ 0 => "Ultrasound elastography" 1 => "Liver" 2 => "Hepatic fibrosis" 3 => "Metavir" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec980492" "palabras" => array:4 [ 0 => "Elastografía por ultrasonido" 1 => "Hígado" 2 => "Fibrosis hepática" 3 => "Metavir" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Liver elastography is a noninvasive method for diagnosing fibrosis that has been developed over the last decade in response to the limitations of liver biopsies, blood markers, and traditional imaging modalities. There are different methods of measuring tissue stiffness through ultrasound; thus far, shear wave elastography has proven superior for diagnosing clinically significant liver fibrosis, where early detection modifies the approach to treatment and improves prognosis.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This article aims to provide a brief review of the different methods for performing elastography with ultrasound, focusing especially on shear wave elastography and on technical aspects for carrying out the procedure and key points for interpreting the findings.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La elastografía hepática representa un método no invasivo de uso actual para el diagnóstico de fibrosis desarrollado a partir de las limitaciones encontradas con la biopsia hepática, los marcadores serológicos y las modalidades de imagen tradicionales durante la última década. Existen diferentes métodos de elastografía por ultrasonido, de los cuales hasta el momento la elastografía por ondas de choque ha demostrado superioridad para el diagnóstico de fibrosis clínicamente significativa, en la que la detección temprana de la enfermedad modifica el tratamiento y mejora el pronóstico. Se pretende realizar una corta revisión de los diferentes métodos de elastografía mediante ultrasonido, haciendo énfasis en la elastografía por ondas de choque, así como los aspectos técnicos para su realización y los puntos clave para su interpretación.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Murad Gutiérrez V, Romero Enciso JA. Elastografía hepática: ¿qué es, cómo se hace y cómo se interpreta? Radiología. 2018;60:183–189.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3138 "Ancho" => 2405 "Tamanyo" => 379840 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(a) Correct measurement in one portion of the blood vessel-free hepatic parenchyma no more than 2<span class="elsevierStyleHsp" style=""></span>cm away from the hepatic capsule. (b) Ten (10) different measurements taken in the region of interest expressed as average kPa and m/s, and an IQR below 0.30.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1613 "Ancho" => 2917 "Tamanyo" => 361713 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Liver elastography procedures in different patients. (a) Twenty-three-year-old woman with elevated hepatic enzymes and no other risk factors. The values obtained confirm that the patient is at low risk of developing clinically significant fibrosis. The pathology findings were mild steatosis. (b) Twenty-three-year-old male with suspicion of hepatic cirrhosis and portal hypertension. The values obtained confirm that the patient is at moderate risk of developing clinically significant fibrosis. The pathology findings were consistent with changes due to minimal sinusoidal fibrosis without evidence of cirrhosis or necro-inflammatory disease. (c) Forty-five-year-old male with hepatopathy under study. The values obtained confirm that the patient is at high risk of developing clinically significant fibrosis. The pathology findings were consistent with chronic necro-inflammatory disease in early cirrhotic stage.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Cause of hepatic condition (hepatitis C, steatohepatitis, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Patient's comorbidity (acute or decompensated disease, congestive heart failure, cholestatis) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Modality used \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Factors specific to the machine used \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Measurement variability (technique, location inside the liver, operator) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Factors specific to the patient (sex, obesity, ascites, postprandial state) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Study indication \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Prevalence of the disease (accuracy and predictive values) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1737394.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Possible sources of variability in elastography procedures.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinically non-significant hepatic fibrosis: METAVIR grade ≤F2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinically significant hepatic fibrosis: METAVIR grade F4 and F3 in selected patients \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><7<span class="elsevierStyleHsp" style=""></span>kPa (<1.5<span class="elsevierStyleHsp" style=""></span>m/s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>15<span class="elsevierStyleHsp" style=""></span>kPa (>2.2<span class="elsevierStyleHsp" style=""></span>m/s) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Machines approved: SuperSonic Imagine, Toshiba and GE.</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1737395.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Consensus recommendations established by the Society of Radiologists in Ultrasound for the interpretation of shear wave elastograhy findings.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Elastography findings \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical setting \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Risk of clinically significant fibrosis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention suggested \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Normal values equivalent to F0–F1 (<7<span class="elsevierStyleHsp" style=""></span>kPa) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No risk factors: low chances of developing hepatic fibrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No additional tests or follow-up required \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abnormal values equivalent to F2–F3 (7–15<span class="elsevierStyleHsp" style=""></span>kPa) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Risk factors to develop hepatic fibrosis or risk factors of progression of the disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intermediate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Additional tests (following medical criterion) required to determine the need for therapy or follow-up \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abnormal values equivalent to F4 (>15<span class="elsevierStyleHsp" style=""></span>kPa) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Risk factors established to develop fibrosis or cirrhosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Elastography is considered diagnostic here \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1737396.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Risk categories for clinically significant fibrosis based on the elastography findings, the clinical setting, and the intervention suggested.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0145" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultrasound elastography in liver" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N. 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