Carcinoembryonic antigen in the diagnosis,treatment,and follow-up of focal liver lesions

In this editorial review,we comment on the article published in the recent issue of the World Journal of Gastrointestinal Surgery.Carcinoembryonic antigen(CEA)is a fetal glycoprotein and can be secreted in very small amounts from healthy adults after birth.CEA is widely used not only for diagnostic tumor markers but also importantly for the management of some gastrointestinal tumors.The most common clinical use is surveillance for the monitoring of colorectal carcinoma.However,CEA can become elevated in several malign or benign characterized pathologies.Serum CEA level may vary depending on the location of the lesion,whether it metastasizes or not,and its histopathological characteristics.It has been determined that cases with high preoperative CEA have a more aggressive course and the risk of metastasis to the lymph tissue and liver increases.In this editorial review,we focused on evaluating the role of CEA in clinical practice with a holistic approach,including the diagnostic and prognostic significance of CEA in patients with focal liver lesions,the role of CEA in follow-up after definitive surgery,and also hepatic resection for metastasis,and the management of all patients with raised CEA.

Endoscopic ultrasound-guided tissue acquisition for the diagnosis of focal liver lesion

In patients with liver tumors,the histopathology examination can assist in diagnosis,staging,prognosis,and therapeutic management strategy.Endoscopic ultrasound(EUS)-guided tissue acquisition using fine needle aspiration(FNA)or more newly fine needle biopsy(FNB)is a well-developed technique in order to evaluate and differentiate the liver masses.The goal of the EUS-FNA or EUS-FNB is to provide an accurate sample for a histopathology examination.Therefore,malignant tumors such as hepatocarcinoma,cholangiocarcinoma and liver metastasis or benign tumors such as liver adenoma,focal hyperplastic nodular tumors and cystic lesions can be accurately diagnosed using EUS-guided tissue acquisition.EUS-FNB using 19 or 22 Ga needle provide longer samples and a higher diagnostic accuracy in patients with liver masses when compared with EUS-FNA.Few data are available on the diagnostic accuracy of EUS-FNB when compared with percutaneously,ultrasound,computer tomography or transjugulary-guided liver biopsies.This review will discuss the EUS-guided tissue acquisition options in patients with liver tumors and its efficacy and safety in providing accurate samples.The results of the last studies comparing EUS-guided liver biopsy with other conventional techniques are presented.The EUS-guided tissue acquisition using FNB can be a suitable technique in suspected liver lesions in order to provide an accurate histopathology diagnosis,especially for those who require endoscopy.

Imaging features and management of focal liver lesions

Notably,the number of incidentally detected focal liver lesions(FLLs)has increa-sed dramatically in recent years due to the increased use of radiological imaging.The diagnosis of FLLs can be made through a well-documented medical history,physical examination,laboratory tests,and appropriate imaging methods.Although benign FLLs are more common than malignant ones in adults,even in patients with primary malignancy,accurate diagnosis of incidental FLLs is of utmost clinical significance.In clinical practice,FLLs are frequently evaluated non-invasively using ultrasound(US),computed tomography(CT),and magnetic resonance imaging(MRI).Although US is a cost-effective and widely used imaging method,its diagnostic specificity and sensitivity for FLL characterization are limited.FLLs are primarily characterized by obtaining enhancement patterns through dynamic contrast-enhanced CT and MRI.MRI is a problem-solving method with high specificity and sensitivity,commonly used for the evaluation of FLLs that cannot be characterized by US or CT.Recent technical advancements in MRI,along with the use of hepatobiliary-specific MRI contrast agents,have significantly improved the success of FLL characterization and reduced unnece-ssary biopsies.The American College of Radiology(ACR)appropriateness criteria are evidence-based recommendations intended to assist clinicians in selecting the optimal imaging or treatment option for their patients.ACR Appropriateness Criteria Liver Lesion-Initial Characterization guideline provides recommend-ations for the imaging methods that should be used for the characterization of incidentally detected FLLs in various clinical scenarios.The American College of Gastroenterology(ACG)Clinical Guideline offers evidence-based recommend-ations for both the diagnosis and management of FLL.American Association for the Study of Liver Diseases(AASLD)Practice Guidance provides an approach to the diagnosis and management of patients with hepatocellular carcinoma.In this article,FLLs are reviewed with a comprehensive analysis of ACR Appropri-ateness Criteria,ACG Clinical Guideline,AASLD Practice Guidance,and current medical literature from peer-reviewed journals.The article includes a discussion of imaging methods used for the assessment of FLL,current recommended imaging techniques,innovations in liver imaging,contrast agents,imaging features of common nonmetastatic benign and malignant FLL,as well as current management recommendations.

Complementary comments on metastatic liver lesions with exceptional and rare cases

Liver metastases can appear in different forms in magnetic resonance imaging.Contrary to popular belief,while radiologists report hypovascular or hypervascular metastatic lesions,exceptional examples may be detected in various tumors.The aim of this article is to improve this review by presenting rare and atypical examples of liver metastasis,as well as cases that might potentially be misdiagnosed as metastases during the process of differential diagnosis.

Hepatic cystic lesions mimicking liver abscess on imaging: A report oftwo cases

Hepatic cystic lesions include congenital dysplasia,inflammatory cystic lesions,neoplastic cystic lesions and parasitic cystic lesions.As different treatment modalities can be chosen for these lesions,differential diagnosis is particularly important[1].Clinical features or imaging findings of cystic lesions of the liver are typical;for instance,liver abscess often shows thick-walled enhancement on contrast-enhanced CT.

Liver as a new target organ in Alzheimer's disease:insight from cholesterol metabolism and its role in amyloid-beta clearance

Alzheimer's disease,the primary cause of dementia,is characterized by neuropathologies,such as amyloid plaques,synaptic and neuronal degeneration,and neurofibrillary tangles.Although amyloid plaques are the primary characteristic of Alzheimer's disease in the central nervous system and peripheral organs,targeting amyloid-beta clearance in the central nervous system has shown limited clinical efficacy in Alzheimer's disease treatment.Metabolic abnormalities are commonly observed in patients with Alzheimer's disease.The liver is the primary peripheral organ involved in amyloid-beta metabolism,playing a crucial role in the pathophysiology of Alzheimer's disease.Notably,impaired cholesterol metabolism in the liver may exacerbate the development of Alzheimer's disease.In this review,we explore the underlying causes of Alzheimer's disease and elucidate the role of the liver in amyloid-beta clearance and cholesterol metabolism.Furthermore,we propose that restoring normal cholesterol metabolism in the liver could represent a promising therapeutic strategy for addressing Alzheimer's disease.

Characterization of focal liver lesions with SonoVue~-enhanced sonography: International multicenter-study in comparison to CT and MRI

AIM： To evaluate in a multicenter study whether the sonographic characterization of focal liver lesions can be improved using SonoVue-enhancement; and to compare this method with computed tomography （CT） and magnetic resonance imaging （MRI）. METHODS： One hundred and thirty four patients withone focal liver lesion detected in baseline ultrasound （US） were examined with conventional US, contrastenhanced US （n = 134）, contrast-enhanced CT （n = 115） and/or dynamic contrast-enhanced MRI （n = 70）. The lesions were classified as malignant, benign or indeterminate and the type of lesion was determined. The final diagnosis based on the combined information of all imaging examinations, clinical information and histology （n = 32） was used. Comparisons were made to see whether the addition of contrast-enhanced US led to the improvement of the characterization of doubtful focal liver lesions.RESULTS： In comparison with unenhanced US, SonoVue markedly improves sensitivity and specificity for the characterization （malignant/benign） of focal liver lesions. In comparison with CT and/or dynamic MRI, SonoVue -enhanced sonography applied for characterization of focal liver lesions was 30.2% more sensitive in the recognition of malignancy and 16.1% more specific in the exclusion of malignancy and overall 22.9% more accurate. In the subgroup with confirmative histology available （n = 30）, sensitivity was 95.5% （CEUS）, 72.2% （CT） and 81.8% （MRI）, and specificity was 75.0% （CEUS）, 37.5% （CT） and 42.9% （MRI）. The sensitivity and specificity of CEUS for the identification of focal nodular hyperplasia （FNH） and hemangiomas was 100% and 87%, resulting in an accuracy of 94.5%.CONCLUSION： SonoVue-enhanced sonography emerges as the most sensitive, ost specific and thus most accurate imaging modality for the characterization of focal liver lesions.

Gd-EOB-DTPA-enhanced magnetic resonance imaging for focal liver lesions in Chinese patients:a multicenter,open-label,phase Ⅲ study

BACKGROUND:Contrast agents help to improve visibility in magnetic resonance(MR)imaging.However,owing to the large interstitial spaces of the liver,there is a reduction in the natural contrast gradient between lesions and healthy tissue.This study was undertaken to evaluate the efficacy and safety of the liverspecific MR imaging contrast agent gadoxetate disodium(GdEOB-DTPA)in Chinese patients.METHODS:This was a single-arm,open-label,multicenter study in patients with known or suspected focal liver lesions referred for contrast-enhanced MR imaging.MR imaging was performed in 234 patients before and after a single intravenous bolus of Gd-EOB-DTPA(0.025 mmol/kg body weight).Images were evaluated by clinical study investigators and three independent,blinded radiologists.The primary efficacy endpoint was sensitivity in lesion detection.RESULTS:Gd-EOB-DTPA improved sensitivity in lesion detection by 9.46%compared with pre-contrast imaging for the average of the three blinded readers(94.78%vs 85.32%for Gd-EOB-DTPA vs pre-contrast,respectively).Improvements in detection were more pronounced in lesions less than 1cm.Gd-EOB-DTPA improved diagnostic accuracy in lesion classification.CONCLUSIONS:This open-label study demonstrated that Gd-EOB-DTPA improves diagnostic sensitivity in liver lesions,particularly in those smaller than 1 cm.Gd-EOB-DTPA also significantly improves the diagnostic accuracy in lesion classification,and furthermore,Gd-EOB-DTPA is safe in Chinese patients with liver lesions.

Application of superb microvascular imaging in focal liver lesions

AIM To explore the ability of superb microvascular imaging(SMI) in differential diagnosis of focal liver lesions(FLLs) and to compare SMI morphology findings to those of color Doppler ultrasound and enhanced imaging.METHODS Twenty-four patients with 31 FLLs were included in our study,with diagnoses of hemangioma(HE)(n = 17),hepatocellular carcinoma(HCC)(n = 5),metastatic lesions(n = 5),primary hepatic lymphoma(n = 1),focal nodular hyperplasia(FNH)(n = 2),and adenoma(n = 1). Nine lesions were pathologically diagnosed,and 22 lesions were radiologically confirmed,all of which were evaluated by at least two types of enhanced imaging techniques. All patients had undergone SMI. Patients were divided into subgroups based on pathological and radiological diagnoses to analyze SMI manifestations. We also compared the SMI manifestations of the most common malignant FLLs(HCCs and metastatic lesions) with those of the most common benign FLLs(HEs).RESULTS HEs were classified into three SMI subgroups: diffuse dot-like type(n = 6),strip rim type(n = 8),and nodular rim type(n = 3). The sizes of the three types of HEs were significantly different(P = 0.00,< 0.05). HCCs were classified into two subgroups: diffuse honeycomb type(n = 2) and non-specific type(n = 3). Four of the metastatic lesions were the strip rim type,and the other metastatic lesion was the thick rim type,which is the same as that of lymphoma. FNH was described as a spoke-wheel type,and adenoma as a diffuse honeycomb type. The SMI types of HCCs and metastatic lesions were significantly different from those of HEs(P = 0.048,< 0.05).CONCLUSION SMI technology enables microvascular evaluation of FLLs without using any contrast agent. For HEs,lesion size may affect SMI performance. SMI is able to provide useful information for differential diagnosis of HCCs and metastatic lesions from HEs.

Use of second generation contrast-enhanced ultrasound in the assessment of focal liver lesions

Ultrasound (US) is often the first imaging modality employed in patients with suspected focal liver lesions. The role of US in the characterisation of focal liver lesions has been transformed with the introduction of specific contrast media and the development of specialized imaging techniques. Ultrasound now can fully characterise the enhancement pattern of hepatic lesions, similar to that achieved with contrast enhanced multiphasic computed tomography (CT) and magnetic resonance imaging (MRI). US contrast agents are safe, well-tolerated and have very few contraindications. Furthermore, real-time evaluation of the vascularity of focal liver lesions has become possible with the use of the newer microbubble contrast agents. This article reviews the enhancement pattern of the most frequent liver lesions seen, using the second generation US contrast media. The common pitfalls for each type of lesion are discussed. The recent developments in US contrast media and specific imaging techniques have been a major advance and this technique, in view of the intrinsic advantages of US, will undoubtedly gain popularity in the years to come.

Ultrasound elastographic techniques in focal liver lesions

Elastographic techniques are new ultrasound-based imaging techniques developed to estimate tissue deformability/stiffness. Several ultrasound elastographic approaches have been developed, such as static elastography, transient elastography and acoustic radiation force imaging methods, which include point shear wave and shear wave imaging elastography. The application of these methods in clinical practice aims at estimating the mechanical tissues properties. One of the main settings for the application of these tools has been liver stiffness assessment in chronic liver disease, which has been studied mainly using transient elastography. Another field of application for these techniques is the assessment of focal lesions, detected by ultrasound in organs such as pancreas, prostate, breast, thyroid, lymph nodes. Considering the frequency and importance of the detection of focal liver lesions through routine ultrasound, some studies have also aimed to assess the role that elestography can play in studying the stiffness of different types of liver lesions, in order to predict their nature and thus offer valuable non-invasive methods for the diagnosis of liver masses.

Combination of acoustic radiation force impulse imaging, serological indexes and contrast-enhanced ultrasound for diagnosis of liver lesions

AIM To assess the value of combined acoustic radiation force impulse(ARFI) imaging, serological indexes and contrast-enhanced ultrasound(CEUS) in distinguishing between benign and malignant liver lesions. METHODS Patients with liver lesions treated at our hospital were included in this study. The lesions were divided into either a malignant tumor group or a benign tumor group according to pathological or radiological findings. ARFI quantitative detection, serological testing and CEUS quantitative detection were performed and compared. A comparative analysis of the measured indexes was performed between these groups. Receiver operating characteristic(ROC) curves were constructed to compare the diagnostic accuracy of ARFI imaging, serological indexes and CEUS, alone or in different combinations, in identifying benign and malignant liver lesions. RESULTS A total of 112 liver lesions in 43 patients were included, of which 78 were malignant and 34 were benign. Shear wave velocity(SWV) value, serum alpha-fetoprotein(AFP) content and enhancement rate were significantly higher in the malignant tumor group than in the benign tumor group(2.39 ± 1.20 m/s vs 1.50 ± 0.49 m/s, 18.02 ± 5.01 ng/m L vs 15.96 ± 4.33 ng/m L, 2.14 ± 0.21 d B/s vs 2.01 ± 0.31 d B/s; P < 0.05). The ROC curve analysis revealed that the areas under the curves(AUCs) of SWV value alone, AFP content alone, enhancement rate alone, SWV value + AFP content, SWV value + enhancement rate, AFP content + enhancement rate and SWV value + AFP content + enhancement rate were 85.1%, 72.1%, 74.5%, 88.3%, 90.4%, 82.0% and 92.3%, respectively. The AUC of SWV value + AFP content + enhancement rate was higher than those of SWV value + AFP content and SWV value + enhancement rate, and significantly higher than those of any single parameter or the combination of any two of parameters.CONCLUSION The combination of SWV, AFP and enhancement rate had better diagnostic performance in distinguishing between benign and malignant liver lesions than the use of any single parameter or the combination of any two of parameters. It is expected that this would provide a tool for the differential diagnosis of benign and malignant liver lesions.

Clinical value of contrast-enhanced ultrasonography in the characterization of focal liver lesions:a prospective multicenter trial

BACKGROUND: Contrast-enhanced ultrasonography (CEUS) is increasingly accepted in clinical settings for diagnostic imaging of focal liver lesions (FLLs). This study aimed to assess the efficacy of CEUS in the characterization of FLLs in comparison with final diagnosis based on gold standard assessment. METHODS: The study was approved by the local ethics committee and participating patients provided written informed consent. A total of 148 patients with 164 FLLs were studied. Unenhanced ultrasonography (US) and CEUS were performed using fundamental and harmonic imaging, respectively. Contrast enhancement was assessed during the arterial, portal and late vascular phases after intravenous administration of contrast (SonoVue (R), Bracco, Italy). Sensitivity, specificity and diagnostic accuracy of US and CEUS were compared in identifying the lesion as benign, malignant or indeterminate and its actual tumor type. Final diagnosis was established by biopsy (129/164), MR imaging (11/164) or medical history (24/164). RESULTS: When compared to the gold standard, the number of indeterminate diagnoses was reduced from 56.7% (93/164) as assessed by fundamental imaging to 6.1% (10/164) after SonoVue (R) enhanced US examination. Sensitivity and specificity improved from 49% and 25% at baseline US to 93% and 75% with CEUS, respectively (P<0.01). Diagnostic accuracy of CEUS was 88% in contrast to 41% of baseline US. CONCLUSION: SonoVue (R) enhanced US improves the characterization of FLLs and may limit the need for further investigations.

Application of acoustic radiation force impulse imaging for the evaluation of focal liver lesion elasticity

BACKGROUND: Acoustic radiation force impulse (ARFI) imaging is a new elastography method for the evaluation of tissue stiffness. This study aims to evaluate the performance of ARFI in noninvasive assessment of the tissue stiffness of focal liver lesion (FLL) and to explore its potential value in the differential diagnosis of FLL. METHODS: ARFI was performed in 140 patients with 154 FLLs, which included 28 hemangiomas (ANGIs), 14 focal nodular hyperplasias (FNHs), 61 hepatocellular carcinomas (HCCs), 39 metastases and 12 cholangiocellular carcinomas (CCCs). Virtual touch tissue quantification (VTTQ) values were obtained, analyzed and compared. The area under the receiver operating characteristic curve (AUROC) and optimal cut-off values were obtained using a receiver operating characteristic (ROC) curve analysis to assess diagnostic performance. All cases were definitively diagnosed using histopathology, CT, MRI or contrast-enhanced ultrasound. RESULTS: The VTTQ median values of ANGI, FNH, HCC metastasis and CCC were 1.30, 1.80, 2.52, 3.08 and 3.89 m/s respectively. A significant increase in the VTTQ values of different lesions was observed: ANGI【FNH【HCC【metastasis 【CCC (P【0.001). The AUROC (95% CI) of VTTQ values was 0.94 (0.90-0.98) for ANGI, 0.91 (0.87-0.96) for malignant lesions and 0.87 (0.79-0.94) for CCC. The sensitivity and specificity for ANGI (86.5%, 89.3%, respectively), malignancy (81.3% 92.9%, respectively), and CCC (91.7%, 72.5%, respectively) were associated with VTTQ cut-off values of 1.76, 2.22 and 3.00 m/s respectively.CONCLUSIONS: ARFI can accurately and objectively assess the elasticity of lesions by obtaining the shear wave elastic value of FLL with VTTQ. Therefore, ARFI is a novel, simple, noninvasive and useful diagnostic method for the characterization of FLL.

Focal liver lesions:Practical magnetic resonance imaging approach

With the widespread of cross-sectional imaging, a growth of incidentally detected focal liver lesions(FLL) has been observed. A reliable detection and characterization of FLL is critical for optimal patient management. Maximizing accuracy of imaging in the context of FLL is paramount in avoiding unnecessary biopsies, which may result in post-procedural complications. A tremendous development of new imaging techniques has taken place during these last years. Nowadays, Magnetic resonance imaging(MRI) plays a key role in management of liver lesions, using a radiation-free technique and a safe contrast agent profile. MRI plays a key role in the non-invasive correct characterization of FLL. MRI is capable of providing comprehensive and highly accurate diagnostic information, with the additional advantage of lack of harmful ionizing radiation. These properties make MRI the mainstay for the noninvasive evaluation of focal liver lesions. In this paper we review the state-of-the-art MRI liver protocol, briefly discussing different sequence types, the unique characteristics of imaging non-cooperative patients and discuss the role of hepatocyte-specific contrast agents. A review of the imaging features of the most common benign and malignant FLL is presented, supplemented by a schematic representation of a simplistic practical approach on MRI.

Signal transducer and activator of transcription 3 promotes the Warburg effect possibly by inducing pyruvate kinase M2 phosphorylation in liver precancerous lesions

BACKGROUND Study shows that signal transducer and activator of transcription 3(STAT3) can increase the Warburg effect by stimulating hexokinase 2 in breast cancer and upregulate lactate dehydrogenase A and pyruvate dehydrogenase kinase 1 in myeloma. STAT3 and pyruvate kinase M2(PKM2) can also be activated and enhance the Warburg effect in hepatocellular carcinoma. Precancerous lesions are critical to human and rodent hepatocarcinogenesis. However, the underlying molecular mechanism for the development of liver precancerous lesions remains unknown. We hypothesized that STAT3 promotes the Warburg effect possibly by upregulating p-PKM2 in liver precancerous lesions in rats.AIM To investigate the mechanism of the Warburg effect in liver precancerous lesions in rats.METHODS A model of liver precancerous lesions was established by a modified Solt-Farber method. The liver pathological changes were observed by HE staining and immunohistochemistry. The transformation of WB-F344 cells induced with Nmethyl-N'-nitro-N-nitrosoguanidine and hydrogen peroxide was evaluated by the soft agar assay and aneuploidy. The levels of glucose and lactate in the tissue and culture medium were detected with a spectrophotometer. The protein levels of glutathione S-transferase-π, proliferating cell nuclear antigen(PCNA), STAT3,and PKM2 were examined by Western blot and immunofluorescence.RESULTS We found that the Warburg effect was increased in liver precancerous lesions in rats. PKM2 and p-STAT3 were upregulated in activated oval cells in liverprecancerous lesions in rats. The Warburg effect, p-PKM2, and p-STAT3 expression were also increased in transformed WB-F344 cells. STAT3 activation promoted the clonal formation rate, aneuploidy, alpha-fetoprotein expression,PCNA expression, G1/S phase transition, the Warburg effect, PKM2 phosphorylation, and nuclear translocation in transformed WB-F344 cells.Moreover, the Warburg effect was inhibited by stattic, a specific inhibitor of STAT3, and further reduced in transformed WB-F344 cells after the intervention for PKM2.CONCLUSION The Warburg effect is initiated in liver precancerous lesions in rats. STAT3 activation promotes the Warburg effect by enhancing the phosphorylation of PKM2 in transformed WB-F344 cells.

Contrast-enhanced ultrasonography in the evaluation of incidental focal liver lesions: A cost-effectiveness analysis

AIM To determine whether contrast-enhanced ultrasonography(CEUS) as the first-line method is more costeffective in evaluating incidentally discovered focal liver lesions(FLLs) than is computed tomography(CT) and magnetic resonance imaging(MRI). METHODS Between 2010 and 2015, our prospective study enrolled 459 patients with incidentally found FLLs. The biological nature of FLLs was assessed by CEUS in all patients. CT or MRI examinations were added in unclear cases. The sensitivity and specificity of CEUS were calculated. The total costs of CEUS examinations and of the added examinations performed in inconclusive cases were calculated. Afterwards, the theoretical expenses for evaluating incidentally discovered FLLs using CT or MRI as the first-line method were calculated. The resultswere compared. RESULTS The total cost of the diagnostic process using CEUS for all enrolled patients with FLLs was 75884 USD. When the expenses for additional CT and MRI examinations performed in inconclusive cases were added, the total cost was 90540 US dollar(USD). If all patients had been examined by CT or MR as the first-line method, the costs would have been 78897 USD or 384235 USD, respectively. The difference between the cost of CT and CEUS was 3013 USD(4%) and that between MRI and CEUS was 308352 USD(406.3%). We correctly described 97.06% of benign or malignant lesions, with 96.99% sensitivity and 97.09% specificity. Positive predictive value was 94.16% and negative predictive value was 98.52%. In cases with 4 and more lesions, malignancy is significantly more frequent and inconclusive findings significantly less frequent(P < 0.001).CONCLUSION While the costs of CEUS and CT in evaluating FLLs are comparable, CEUS examination is far more costeffective in comparison to MRI.

Distinctive aspects of peptic ulcer disease,Dieulafoy'slesion,and Mallory-Weiss syndrome in patients withadvanced alcoholic liver disease or cirrhosis

AIM:To systematically review the data on distinctive aspects of peptic ulcer disease(PUD),Dieulafoy’s lesion(DL),and Mallory-Weiss syndrome(MWS)in patients with advanced alcoholic liver disease(a ALD),including alcoholic hepatitis or alcoholic cirrhosis.METHODS:Computerized literature search performed via Pub Med using the following medical subject heading terms and keywords:"alcoholic liver disease","alcoholic hepatitis","alcoholic cirrhosis","cirrhosis","liver disease","upper gastrointestinal bleeding","nonvariceal upper gastrointestinal bleeding","PUD",‘‘DL’’,‘‘Mallory-Weiss tear",and"MWS’’.RESULTS:While the majority of acute gastrointestinal(GI)bleeding with a ALD is related to portal hypertension,about 30%-40%of acute GI bleeding in patients with a ALD is unrelated to portal hypertension.Such bleeding constitutes an important complication of a ALD because of its frequency,severity,and associated mortality.Patients with cirrhosis have a markedly increased risk of PUD,which further increases with the progression of cirrhosis.Patients with cirrhosis or a ALD and peptic ulcer bleeding(PUB)have worse clinical outcomes than other patients with PUB,including uncontrolled bleeding,rebleeding,and mortality.Alcohol consumption,nonsteroidal anti-inflammatory drug use,and portal hypertension may have a pathogenic role in the development of PUD in patients with a ALD.Limited data suggest that Helicobacter pylori does not play a significant role in the pathogenesis of PUD in most cirrhotic patients.The frequency of bleeding from DL appears to be increased in patients with a ALD.DL may be associated with an especially high mortality in these patients.MWS is strongly associated with heavy alcohol consumption from binge drinking or chronic alcoholism,and is associated with a ALD.Patients with a ALD have more severe MWS bleeding and are more likely to rebleed when compared to non-cirrhotics.Preendoscopic management of acute GI bleeding in patients with a ALD unrelated to portal hypertension is similar to the management of a ALD patients with GI bleeding from portal hypertension,because clinical distinction before endoscopy is difficult.Most patients require intensive care unit admission and attention to avoid over-transfusion,to correct electrolyte abnormalities and coagulopathies,and to administer antibiotic prophylaxis.Alcoholics should receive thiamine and be closely monitored for symptoms of alcohol withdrawal.Prompt endoscopy,after initial resuscitation,is essential to diagnose and appropriately treat these patients.Generally,the same endoscopic hemostatic techniques are used in patients bleeding from PUD,DL,or MWS in patients with a ALD as in the general population.CONCLUSION:Nonvariceal upper GI bleeding in patients with a ALD has clinically important differences from that in the general population without a ALD,including:more frequent and more severe bleeding from PUD,DL,or MWS.

Differential diagnosis of different types of solid focal liver lesions using two-dimensional shear wave elastography

BACKGROUND The clinical management and prognosis differ between benign and malignant solid focal liver lesions(FLLs),as well as among different pathological types of malignant FLLs.Accurate diagnosis of the possible types of solid FLLs is important.Our previous study confirmed the value of shear wave elastography(SWE)using maximal elasticity(Emax)as the parameter in the differential diagnosis between benign and malignant FLLs.However,the value of SWE in the differential diagnosis among different pathological types of malignant FLLs has not been proved.AIM To explore the value of two-dimensional SWE(2D-SWE)using Emax in the differential diagnosis of FLLs,especially among different pathological types of malignant FLLs.METHODS All the patients enrolled in this study were diagnosed as benign,malignant or undetermined FLLs by conventional ultrasound.Emax of FLLs and the periphery of FLLs was measured using 2D-SWE and compared between benign and malignant FLLs or among different pathological types of malignant FLLs.RESULTS The study included 32 benign FLLs in 31 patients and 100 malignant FLLs in 96 patients,including 16 cholangiocellular carcinomas(CCCs),72 hepatocellular carcinomas(HCCs)and 12 liver metastases.Thirty-five FLLs were diagnosed as undetermined by conventional ultrasound.There were significant differences between Emax of malignant(2.21±0.57 m/s)and benign(1.59±0.37 m/s)FLLs(P=0.000),and between Emax of the periphery of malignant(1.52±0.39 m/s)and benign(1.36±0.44 m/s)FLLs(P=0.040).Emax of liver metastases(2.73±0.99 m/s)was significantly higher than that of CCCs(2.14±0.34 m/s)and HCCs(2.14±0.46 m/s)(P=0.002).The sensitivity,specificity and accuracy were 71.00%,84.38%and 74.24%respectively,using Emax>1.905 m/s(AUC 0.843)to diagnose as malignant and 23 of 35(65.74%)FLLs with undetermined diagnosis by conventional ultrasound were diagnosed correctly.CONCLUSION Malignant FLLs were stiffer than benign ones and liver metastases were stiffer than primary liver carcinomas.2D-SWE with Emax was a useful complement to conventional ultrasound for the differential diagnosis of FLLs.

Multiphase convolutional dense network for the classification of focal liver lesions on dynamic contrast-enhanced computed tomography

BACKGROUND The accurate classification of focal liver lesions(FLLs)is essential to properly guide treatment options and predict prognosis.Dynamic contrast-enhanced computed tomography(DCE-CT)is still the cornerstone in the exact classification of FLLs due to its noninvasive nature,high scanning speed,and high-density resolution.Since their recent development,convolutional neural network-based deep learning techniques has been recognized to have high potential for image recognition tasks.AIM To develop and evaluate an automated multiphase convolutional dense network(MP-CDN)to classify FLLs on multiphase CT.METHODS A total of 517 FLLs scanned on a 320-detector CT scanner using a four-phase DCECT imaging protocol(including precontrast phase,arterial phase,portal venous phase,and delayed phase)from 2012 to 2017 were retrospectively enrolled.FLLs were classified into four categories:Category A,hepatocellular carcinoma(HCC);category B,liver metastases;category C,benign non-inflammatory FLLs including hemangiomas,focal nodular hyperplasias and adenomas;and category D,hepatic abscesses.Each category was split into a training set and test set in an approximate 8:2 ratio.An MP-CDN classifier with a sequential input of the fourphase CT images was developed to automatically classify FLLs.The classification performance of the model was evaluated on the test set;the accuracy and specificity were calculated from the confusion matrix,and the area under the receiver operating characteristic curve(AUC)was calculated from the SoftMax probability outputted from the last layer of the MP-CDN.RESULTS A total of 410 FLLs were used for training and 107 FLLs were used for testing.The mean classification accuracy of the test set was 81.3%(87/107).The accuracy/specificity of distinguishing each category from the others were 0.916/0.964,0.925/0.905,0.860/0.918,and 0.925/0.963 for HCC,metastases,benign non-inflammatory FLLs,and abscesses on the test set,respectively.The AUC(95%confidence interval)for differentiating each category from the others was 0.92(0.837-0.992),0.99(0.967-1.00),0.88(0.795-0.955)and 0.96(0.914-0.996)for HCC,metastases,benign non-inflammatory FLLs,and abscesses on the test set,respectively.CONCLUSION MP-CDN accurately classified FLLs detected on four-phase CT as HCC,metastases,benign non-inflammatory FLLs and hepatic abscesses and may assist radiologists in identifying the different types of FLLs.