Ultrasonographic evaluation of liver surface and transient elastography in clinically doubtful cirrhosis.

BACKGROUND & AIMS 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.