title: Ultrasonographic evaluation of liver surface and transient elastography in clinically doubtful cirrhosis.
abstract: OBJECTIVE
  Both transient elastography (TE) and left lobe liver surface (LLS) ultrasound may non-invasively detect cirrhosis (LC). We aimed to examine the diagnostic value of these methods in patients with a suspicion but not a definite diagnosis of cirrhosis.
  
  
  METHODS
  We enrolled 90 patients with clinical suspicion of cirrhosis and a strong co-existing differential diagnosis requiring further invasive evaluation. They underwent hepatic venous pressure gradient (HVPG) measurement+/-transjugular liver biopsy, LLS and TE. Images of LLS were digitally post-processed to obtain a numerical value (quantitative LLS, qLLS). TE<12kPa was considered to exclude LC, 18kPa diagnosed LC, and 12-18kPa indeterminate. Technical failures were considered 'indeterminate'. Diagnosis of cirrhosis was confirmed by histology (84%) or by clinical data and HVPG10mm Hg. Diagnostic accuracy was evaluated by positive and negative likelihood ratios (+LR and -LR).
  
  
  RESULTS
  Cirrhosis was diagnosed in 44 patients. There were 14 technical failures with TE and 1 with LLS (p=0.001). TE and LLS had similar diagnostic accuracy but gave complementary information: TE was mildly more accurate than LLS to rule out LC (-LR: 0.08 vs. 0.10), while it was less accurate to rule it in (+LR 5.05 vs. 11.15). Their combination offered the best diagnostic performance (+LR 9.15; -LR 0.06).
  
  
  CONCLUSIONS
  LLS is more technically applicable than TE. In patients with clinical suspicion of cirrhosis, LLS is the best non-invasive method to diagnose cirrhosis, while TE is preferable to rule it out. The combination of both holds the best diagnostic accuracy.
authors.affiliation: Hepatic Hemodynamic Laboratory, Liver Unit, Barcelona, Spain.
authors.forename: Annalisa
authors.initials: A
authors.lastname: Berzigotti
authors.forename: Juan G
authors.initials: JG
authors.lastname: Abraldes
authors.forename: Puneeta
authors.initials: P
authors.lastname: Tandon
authors.forename: Eva
authors.initials: E
authors.lastname: Erice
authors.forename: Rosa
authors.initials: R
authors.lastname: Gilabert
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: García-Pagan
authors.forename: Jaime
authors.initials: J
authors.lastname: Bosch
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D001706:Biopsy; D054459:Elasticity Imaging Techniques / Q000379:methods* / Q000592:standards*; D005260:Female; D006801:Humans; D008099:Liver / Q000000981:diagnostic imaging / Q000473:pathology; D008103:Liver Cirrhosis / Q000000981:diagnostic imaging* / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012015:Reference Standards; D015203:Reproducibility of Results; D014463:Ultrasonography / Q000379:methods* / Q000592:standards*