利用聲輻射力脈波影像系統(ARFI)超音波纖維測量儀以評估慢性肝病患者之肝纖維化程度及食道靜脈瘤發生之分析

Using acoustic radiation force imaging (ARFI) sonoelastography to evaluate stage of liver fibrosis and occurrence of esophageal varices in patients with chronic liver diseases

汪奇志(Chi-Chih, Wang)

指導教授 ： 林俊哲 ； 魏正宗

中山醫學大學/醫學院/醫學研究所/碩士(2014年)

https://doi.org/10.6834/CSMU.2014.00061

摘要

研究目的:一般超音波檢查雖可正確診斷較晚期的肝硬化，對於初期肝硬化的診斷率則稍嫌不足。初期肝硬化的診斷目前則有賴肝臟切片的病理檢查，然而肝臟切片檢查具高度的侵襲性，追蹤上也有一定的限制，因此非侵襲性肝纖維化檢查在近五年來發展快速。同時，胃、食道靜脈瘤是影響肝硬化病人死亡的重要因素，雖然AASLD的治療指引建議所有肝硬化患者皆應接受上消化道內視鏡篩檢，但是礙於對於侵入性檢查的接受度較低，真正接受篩檢的病人比率並不高，我們需要其他的風險評估因子來篩選出高風險的胃、食道靜脈瘤患者。本研究的目的為探究慢性肝炎及肝硬化病人肝、脾硬度與食道靜脈瘤之間的關係。
研究方法及資料：在中部某醫學中心收集慢性肝炎病人(含B、C型病毒性肝炎及酒精性肝炎)共118名，取得病患同意下進行超音波纖維測量儀(ARFI)檢查，首先將病人區分為臨床診斷肝硬化的病人85名與慢性肝炎病人33名，進行單變量和多變量分析以找出可區分肝硬化的非侵入性測量方式。另外，將肝硬化且一年內有接受上消化道內視鏡檢查的族群區分成有食道靜脈瘤和沒有的，進行單變量，多變量和The area under the receiver-operating characteristic curve (AUROC)的分析用以預測食道靜脈瘤的有無。
研究結果：在肝硬化的分析當中，我們發現ARFI測量之liver stiffness(LS)為多變數分析當中唯一達統計學上之顯著差異(P= 0.009)的變項，由此可知ARFI測量之LS可以有效區分有無肝硬化之發生。在食道靜脈瘤的預測方面，發現僅約一半(49.4%)肝硬化病人於一年內接受過上消化道內視鏡檢查，當中26人有食道靜脈瘤，另16人無食道靜脈瘤，多因子變數分析當中僅ARFI測量之spleen stiffness(SS) (P=0.048)和脾臟直徑大小(P=0.033)達統計學上之顯著差異；另外於AUROC curve中可以發現取SS為2.82(m/s)時，敏感度為0.96，特異性為0.50。
結論與建議：本研究發現ARFI所測量之LS可以有效區分臨床上慢性肝炎與肝硬化的差別；另外ARFI所測量之SS ≥ 2.82(m/s)有高敏感度的特性，應該可以作為肝硬化病人罹患食道靜脈瘤的篩選指標，幫助我們區分出最需要進行上消化道內視鏡篩檢的病人族群。

關鍵字

非侵襲性肝纖維化檢測 ； 脾臟硬度檢測 ； 食道靜脈瘤

並列摘要

Introduction: Current sonography diagnosis of cirrhosis is not good enough. Some early diagnosis of liver fibrosis currently rely on liver biopsy. However, liver biopsy are highly invasive and series follow up is therefore limited. Non-invasive liver fibrosis measurement become important and Acoustic Radiation Force Impulse (ARFI) is one of these methods. Meanwhile, gastric and esophageal varices are independent mortality factors of these patients. Although the AASLD guideline recommended that all patients with cirrhosis should receive esophagogastroduodenoscopy (EGD) screening, few patients actually screened because of uncomfortable and invasiveness. We need to screen out the real high-risk varices group who need EGD screening.
Purpose: To evaluate the relationship of liver and spleen stiffness measured by ARFI sonography and esophageal varices formation
Method: From December 2013 to March 2014, 118 patients (81 men, 37 women) were included for ARFI sonography examination. Eighty five patients were clinically diagnosed liver cirrhosis and other 33 were chronic hepatitis patients. Variables found to be associated with the presence of cirrhosis on univariate analysis (P<0.05) were entered into multivariate logistic regression analysis. Then we further divided cirrhosis patients, who ever received EGD within one year into EV or non-EV group. Univariate, multivariate analysis and AUROC curve were analyzed using SPSS 19.0 version for Windows.
Result: In cirrhosis diagnosis, we found only liver stiffness meet statistical difference in multivariate logistic regression analysis. The AUROC values for predicting cirrhosis were 0.91 (95% CI, 0.86-0.97) for liver stiffness measured by ARFI sonography. Levels of spleen stiffness were higher amount patient with EVs ( 3.43 ± 0.44 m/s, n= 26) than controls (3.03 ± 0.68 m/s, n= 16). An SS cutoff value of 2.82 m/s identified patient with EVs with a 96.2% sensitivity, 50% specificity in our study.
Conclusion: In our study, liver stiffness measured by ARFI sonography could identified clinically cirrhosis patient precisely (cutoff value: 1.64 m/s, sensitivity: 81.2%, specificity: 93.9%). Spleen stiffness can play a role for cirrhosis patients who need accepted EGD screening because of its high sensitivity (cutoff value: 2.82 m/s, sensitivity: 96.2%, specificity: 50%) for predicting EV formation

並列關鍵字

Acoustic radiation force impulse (ARFI) ； liver fibrosis ； spleen stiffness ； esophageal varices

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