Reliability of Ultrasound in Patients with Chronic Liver Disease in the Diagnosis of Cirrhosis - A Systematic Review

Mishal Javaid^*, Syed Muhammad Yousaf Farooq, Syeda Khadija Tul Sughra, Muhammad Zubair, Mehreen Fatima, Abeer Gohar and Lina Khaled Fares Jallad Department of Radiological Sciences and Medical Imaging Technology, The University of Lahore, Lahore, Pakistan
^*Correspondence: Mishal Javaid, Department of Radiological Sciences and Medical Imaging Technology, The University of Lahore, Lahore, Pakistan, Email:

Received: Mar 04, 2022, Manuscript No. JEBMH-22-54389; Editor assigned: Apr 06, 2022, Pre QC No. JEBMH-22-54389; Reviewed: Apr 20, 2022, QC No. JEBMH-22-54389; Revised: Jun 02, 2022, Manuscript No. JEBMH-22-54389; Published: Jun 14, 2022, DOI: 10.18410/jebmh/2022/09.10.31

Citation: Javaid M, Farooq SMY, Sughra SKT, et al. Reliability of Ultrasound in Patients with Chronic Liver Disease in the Diagnosis of Cirrhosis - A Systematic Review. J Evid Based Med Healthc 2022;9(10):31.

Keywords

Chronic liver disease, Liver cirrhosis, Reliability, Ultrasound

Introduction

Chronic Liver Disease (CLD) is one of the reasons of death in the devolving world. Recently, the incidence of CLD has been increased and the mainstream of CLD in the developed world contain; alcoholic liver, viral hepatitis B and C, non - alcoholic hepatic steatosis, and hemochromatosis.¹ According to the NVSR in 2017 from the CDCP in USA, about 45,00,000 adults had CLD and liver cirrhosis, which is 1.8 % of the adult populace and approximately 41,673 deaths from CLD and cirrhosis. It is very common clinical condition, and it causes an advanced worsening of liver functions in 06 months. It is a constant progression of infection, obliteration, and redevelopment of liver parenchyma, which leads to fibrosis and cirrhosis. The variety of causes is comprehensive for CLD, which contains toxins, alcohol abuse for a persistent time, infection, autoimmune diseases, genetic and metabolic disorders. The problem of Hepatitis C Virus (HCV) associated with CLD in Pakistan has increased over the years and the current data demonstrations approximately 60.0 % to 70.0 % patients with chronic liver disease tend to be positive for anti - hepatitis C virus. It had revealed that approximately 50.0 % patients with hepatocellular carcinoma in Pakistan have positive HCV.² Cirrhosis is a last phase of CLD. The diagnosis of cirrhotic patients is determined by the incidence and development of Hepatocellular Carcinoma (HCC).^3,4In Pakistan, there are no national accepted guidelines for screening high risk patients. The most mutual tendency is six months ultrasonography and serum alpha fetoprotein level.⁵ Approximately 10.0 % patients are diagnosed with hepatocellular carcinoma on screening base in Pakistan and that possibly clarifies the delayed exhibition and poor diagnosis in majority of hepatocellular carcinoma patients.⁶The relationship between higher level of alpha fetoprotein and hepatocellular carcinoma diagnosis are variable because hepatocellular carcinoma may be present in 7.5 - 100 % patients with higher level of alpha fetoprotein.⁷ In hepatology liver fibrosis is main clinical problem and it is a result of entirely CLD. Cirrhosis is the last phase of fibrosis and patients might have severe medical problems including PHT and HCC. An accurate established findings and presentation of liver fibrosis is achieved by histopathological investigation of biopsy. In mutual unsighted biopsy series, there are delayed by false negative identifies of cirrhosis due to sampling errors in an assessed average of 24.0 %. Furthermore, there is limitation of biopsy in clinical training because of the inappropriateness and risk problems. Since cirrhosis is frequently exposed by its problems and the possibility of variceal rupture is peak in the two years resulting the finding of cirrhosis, the primary finding of severe fibrosis and cirrhosis is necessary. It is a common disease, which is commonly undiagnosed, and the risks and limits of biopsy stop its use for screening of this situation. In the previous few years, another non - invasive procedure to assessment liver disease has been estimated, containing clinical signs, sonographic signs, or biochemical parameters in the blood. The sensitivity of ultrasonography for the finding of liver cirrhosis has been assessed to be 62.0 % for liver biopsy and 87.0 % for sonography with the characteristic sonographic signs of cirrhosis. Ultrasonography had a main role in the finding and organization of Chronic Liver Disease (CLD) by providing analytical and predictive evidence as well as identifying difficulties such as Hepatocellular Carcinoma (HCC) and Portal Hyper Tension (PHT). Although conservative sonography is appreciated in the valuation of liver parenchyma and recognition of liver lesions, a variety of other sonography procedures had remained established that raises its prospective worth. Non - invasive procedures of dimensions in CLD are quickly changing in presentation proficiencies and accessibility. These embrace laboratory tests and imaging studies.⁸

Literature Review

Search Strategy

This systematic review and meta - analysis were carried out in agreement with the Preferred Reporting Items for Systematic Reviews and Meta - Analyses guidelines (PRISMA). We searched medicine and EMBASE research databases including: Google scholar, PubMed, NCBI, Scopus, and Crossref databases from 2000 up to 2021. The keywords included were; chronic liver disease, HCC and cirrhosis, hepatocellular carcinoma and ultrasound, liver cirrhosis, reliability of ultrasound in liver cirrhosis, cirrhotic liver, sonography of liver, sonography of CLD. To increase the affectability of the search the Google scholar was utilized with similar keywords, taking the newly available research studies in the sonography of hepatocellular carcinoma. Articles with original research work and peer - reviewed written in English were included in this review.

Selection Criteria

After independently screening the abstract and titles relevant articles. Studies investigating both adults and children together were included. The minimum data set required was sample size, anatomical region of the body, role of radial -space sampling technique, imaging indication, imaging time, presence of motion artifact, image quality and pathology Detection. Data were extracted from the full journal article and studies were assessed for applicability and quality. Summary statistics were calculated from the raw data given in the study if they were not reported. Numbers were read from graphs if not reported in the text of the articles.

Inclusion Criteria

• All the articles including authentic sources.
• Topics having relevant data
• HEC approved journals

Exclusion Criteria

• Duplicated articles
• Articles having clues of already taken data
• Articles not fulfilling the available variables

Data Collection and Analysis

We self - sufficiently selected studies removed data and presented the results of sensitivity and specificity of ultrasound in chronic liver disease patients, using forest - plot and arranged the results. We obtained the accuracy estimates using 95 % Confidence Intervals (CIs). We double�checked all data extractions and analyses.

Ethical Considerations

No ethical consideration is required for this type of study design.

Results

Our primary literature screening identified 242 articles. 122 articles were removed because of duplication. 120 studies were screened for titles and abstracts. 67 studies were excluded for not including the appropriate information. 53 studies (2235 patients) were included for the extraction of data related to reliability of ultrasound in the diagnosis of cirrhosis. The whole process of searching is depicted in (Figures 1 - 4). Table 1 shows the qualitative variables (number of patients, mean age, type of research, and place of research) of 53 screened studies. Table 2 shows the data set of 25 studies including the variables as accuracy, sensitivity, specificity, positive predictive value and negative predicative value in patients with chronic liver disease. Of 53 studies 27,751 patients were included, out of which 1615 are male patients and 1011 are female patients in 17 studies (08 studies did not mentioned male to female ratio). Tables 2 and 3 shows the main causes of chronic liver diseases. Out of 53 studies, 18 studies included the causes of CLD. Out of total of 2235 patients, 781 patients had hepatitis B virus, 497 patients had hepatitis C virus, and 957 patients had cirrhosis (Table 4).

Discussion

The purpose of our study was to assess the reliability of ultrasound in patients with chronic liver disease in the diagnosis of cirrhosis. The search was limited to the procedures that used sonographic image. Our study outcomes show that the sonographic features of chronic liver disease had high sensitivity in 24 out of 25 studies, only one study had low sensitivity 25.0 % 19 although the specificity was moderately high 100 %. We confirmed that observation with sonographic examination is highly accurate in CLD and hepatocellular carcinoma at any stage, with a mutual sensitivity of 80.0 % and pooled specificity of 84.5 % (Figure 2). Chronic liver diseases with viral disease patent variable grades of hepatic fibrosis ranging from no fibrosis to cirrhosis. Ultrasonographic investigation of the abdomen is require preferably every 6 to 12 months when cirrhosis had developed in patients with CLD to rule out the occurrence of HCC.^9-33 Usually B - mode and color Doppler sonography are safe, non - invasive, and low cost technique that is accessible in a wide variety of health care settings. To recognize the onset of cirrhosis in patients with CLD, sonography is routinely use in screening programmes. In accumulation, several studies confirm that B - mode and color Doppler sonography identifies of cirrhosis are related with high specificity.³⁴ these outcomes are reliable with our experience in this study. On the other hand, the finding of early HCC is of better significance for observation to be effective. While a systematic review had previously achieved on the effectiveness of ultrasonography in the finding of hepatocellular carcinoma, there are quite a few important variances from out review. First, we only included studies that used ultrasonography as an investigation method in a potential manner, although previous studies evaluated ultrasound as a one - time diagnostic tool. This is a significant difference assumed that ultrasonography is most frequently used as an investigation tool in clinical practice. Second, our analysis precisely assessed the sensitivity of ultrasound for cirrhotic patients. Singal et al. studied the surveillance of ultrasonography in the diagnosis of HCC in patients with cirrhosis.³⁵They also included those studies where sonography had observation procedure in a prospective manner. Chronic viral hepatitis is most common caused by the hepatitis B or C infection results in liver parenchyma injury and inflammation might be lead to fibrosis, cirrhosis or hepatocellular carcinoma. Cirrhosis often arises as an indolent disease and many patients are remaining asymptomatic until incidence of decompensation. The investigative accurateness of ultrasound in the finding of cirrhosis had exanimated in several studies. The specificity was high in 14 studies and sensitivity was in 11 studies, so the indicative accurateness varies from 65 - 100 % (Table 2). In specific, application of the purpose to identify principle is an important reason that reduced the diagnostic accuracy the non - invasive Evaluated of CLD had attempted by numerous research groups comprising either clinical signs, grayscale, or color Doppler sonographic signs. The use of color Doppler sonography in the finding and presentation of CLD built on the hypothesis that modification of liver hemodynamics due to chronic inflammatory changes may indirectly reflect the histological alterations. Hence, positive association studies had typically mentioned to velocity ratios of the hepatic artery to the portal vein. However, the role of color Doppler sonography remains controversial concerning the reproducibility and the numerical importance of the measurements in hepatic fibrosis and cirrhosis. Previous studies had evaluated numerous procedures for assessing the fibrosis stage of CLD by using different sonographic parameters. However, there are little studies regarding the accuracy in the diagnosing the signs of compensated liver cirrhosis by sonography. Hung suggested a complex sonographic scoring system via indices of the liver surface, parenchymal echotexture, vessel pattern, and spleen size etc. The role of sonography in the expecting cirrhosis had a subject of importance for decades, the most common sonographic features used for the recognition of liver is surface nodularity. Nishiura et al. found the sonographic assessment of the three Liver features that had reliable the predictors of the full spectrum of liver fibrosis. By developing a scoring system, they described that both advanced individual and total ultrasonography scores were intensely prognostic of a cumulative stage of fibrosis. Our search determines developed accuracies and exhibited increasing the sensitivity and accuracy of ultrasound in chronic liver diseases. The diagnostic presentations of previous studies in the diagnosing of severe fibrosis or cirrhosis were generally different, with sensitivities ranging from 25 - 100 %. Various investigators on the non - invasive observing of CLD report a variation of algorithms and scoring systems that could be valuable to progress the judgment of fibrosis, including combinations of biochemical, radiological, laparoscopic studies and some studies allow the documentation of patients with significant fibrosis.

Conclusion

In our study, with the several varieties of the causes, CLD is growing in incidence universal and cirrhosis is the most progressive phase of CLD. It is related with probable adverse event, such as the development of hepatocellular carcinoma which requires careful medical care. The ultrasonographic parameters are helpful for providing predictive evidence and also for influential the best beneficial choices throughout follow - up of patients with CLD, mainly in patients with HBV or HCV in order to predict the incidence of HCC.

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