0:02

Hello and welcome to Noon Conference, hosted by modality

0:05

Noon Conference connects the global radiology community

0:08

through free live educational webinars that are accessible

0:11

for all and is an opportunity

0:13

to learn alongside top radiologists from around the world.

0:16

You can access the recording of today's conference

0:18

and previous noon conferences by creating a free account.

0:22

Today we are so honored to welcome back

0:24

to the noom conference stage Dr.

0:26

Alka Singal for a lecture entitled role

0:28

of ultrasound elastography

0:31

and ultrasound fat quantification in fatty Liver.

0:34

Dr. Singal is an associate director of radiology at Madonna,

0:37

me City Hospital Deli, NCR India,

0:41

and has over 28 years of experience in radiology.

0:44

She's authored several publications

0:46

and talks for leading national and international conferences

0:49

and is the author of Atlas of Parathyroid ultrasound.

0:53

At the end of the lecture, please join her in a q

0:54

and A session where she will address questions you may have

0:57

on today's topic.

0:59

Please remember to put your questions into that q

1:01

and A feature so we can get to as many as we can

1:04

before our time is up.

1:05

With that, we're ready to begin today's lecture. Dr.

1:08

Singal, please take it from here.

1:10

Great, thank you so much. Thank you for inviting me.

1:14

And so today's topic is Advanced liver imaging,

1:18

so UDFF and ultrasound elastic.

1:21

So both, both the two things are a little bit different.

1:25

They are different modalities

1:27

and they are pretty much,

1:29

the good part is they're both available in the advanced

1:32

ultrasound equipment

1:34

and they're both often available within the same transducer.

1:38

So if you upgrade your current ultrasound machine

1:40

or if you have it currently,

1:43

so UDFF is ultrasound derived fat fraction of the liver

1:47

and the liver graph is the stiffness of the liver.

1:52

So over a period of time as we grew up in our residency,

1:55

we've been looking at focal hepatic lesions

1:58

and what are the cystic or neoplastic or metastatic

2:03

or calcifications and biliary tract and the pathologies.

2:07

But per se, looking at the diffuse paradigm

2:10

of the liver has really taken a leaps and leaps

2:14

and leap in the diagnostic imaging modality now.

2:17

So currently we have the best cap equipment capabilities

2:21

to really give a very early diagnosis to the TRA ion

2:25

and also to see how much of

2:28

that heart has already deposited causing metabolic

2:32

and then fibrotic changes leading to stiffness of the liver.

2:36

Let's see, so, um, M-A-S-L-D

2:41

as we all know, is the term it's called as me

2:45

metabolic dysfunction associated stenotic liver disease.

2:48

So, which was earlier called as fatty, uh, liver disease

2:53

or N-E-F-L-D, like non-alcoholic liver disease, right?

2:59

So basically as our understanding it spans, we understand

3:03

that it, it's basically a metabolic

3:06

phenomenon which is causing increased fat

3:08

to be deposited in the liver

3:10

and beyond a certain point it will lead

3:13

to fibrotic inflammation and fibrotic changes in the cells.

3:17

So if we can catch it very early, we can catch,

3:20

quantify the amount of fat and really give an estimate

3:24

and maybe adopt changes.

3:26

So we reverse the process.

3:29

If it goes to stiffness process, then again we can grade it

3:33

and reverse the process

3:34

before it goes to the end stage phenomenon.

3:37

So as we all know, MAs, LD is one of the most common forms

3:42

of chronic liver disease

3:43

and definitely it is often seen more in pre obesity

3:48

and in type two diabetes

3:50

and global estimates, approximately 30% worldwide,

3:55

uh, population is affected by it.

3:58

So obviously without treatment this will lead

4:00

to severe liver diseases as I explained.

4:03

And so our intention of the elevated diagnostic mortality,

4:07

the advanced modalities, is to give an early diagnosis

4:10

and the early treatment which can,

4:14

uh, prevent it.

4:16

Okay? Now, so level reading has always been

4:20

for ultrasound physicians, a very subjective phenomena,

4:24

a very subjective phenomena is very good.

4:26

It's just easy. It's by the experience of the person.

4:29

Yes, there are defined landmarks that we observe

4:33

and so we, um, uh, we have to still go

4:38

by the guidelines.

4:39

However, it's a subjective integration

4:42

and assessment by the person

4:45

and it could also be varied by the subjective, uh,

4:49

the machine settings

4:50

and the understanding of the gain parameters

4:53

and other factors.

4:56

So however we will quantify it so

5:00

that we dissolve the discrepancies

5:03

and we give a number to it, which can be

5:06

comparable from machine to machine operator to operator

5:10

or institute to institute

5:12

and over a various timeline as well.

5:15

So as we all know,

5:16

higher grades inclu indicate increasing liver brightness

5:20

and poorer visualization,

5:21

and the bright liver is more of a fatty liver.

5:24

Right Now, what are the factors

5:26

that we consider in that diagnosis?

5:28

Is a liver to kidney contrast different in echogenicity

5:31

between the liver and the

5:36

difference in the echogenicity between the liver

5:38

and the kidney and the, whether we are able

5:40

to see the diaphragm or not, um, whether we are able

5:44

to see the diaphragm or not.

5:45

And, and

5:47

how is the portal vein definition going second.

5:51

Okay, you right. So let's see. So what is grade one?

5:56

As we all know, it's the diffuse increase in genicity,

6:00

but the periportal

6:01

and diaphragmatic e echogenicity is still appreciable.

6:03

We look at the images soon.

6:05

Grade two is diffusely increased hepatic epigenesis,

6:08

which is obscure in the periportal genicity.

6:10

However, we can still see the diaphragm behind, right?

6:14

It can, we can still appreciate what is the posterior,

6:17

the boundary of the liver, right?

6:19

Grade three is increased echogenicity, which is obscuring

6:23

for the periportal region as well

6:25

as the diaphragmatic echogenicity.

6:27

Simple. So grade one, grade two periportal is also obscured.

6:31

And grade three, even the diaphragmatic surface is obscure.

6:35

So grade zero is normal, right?

6:37

So it's similar to liver, right? So it's the same thing.

6:41

Good visualization of diaphragmatic vessels

6:43

and this, so let's look at the pictures.

6:46

So in the normal liver we can very well see. Mm-hmm.

6:51

So in the normal liver we can very well see the uh,

6:56

kidney and the uh, genic periportal traps, right?

7:01

However, um, the uh,

7:04

and we can see the hypergo walls, uh,

7:06

the high hypergo walls in the portal in branches

7:09

and in grade one

7:11

that I promise seen there is a periportal

7:13

genicity still present.

7:15

And this background diffusely increased echogenicity

7:18

of the liver as we can very well appreciate here.

7:23

And so similarly here we can see there's a increase

7:28

the contrast, the echogenicity that we can appreciate coming

7:33

to what happens in grade two.

7:35

Now, so the hyperbaric war in the portal,

7:38

brain punches are seen in the normal liver.

7:40

However, there is loss

7:42

of this periportal echogenicity in case of grade two, he,

7:47

uh, fatty liver, right?

7:49

So this periportal echogenicity is lost.

7:52

That means this is appearing like a, a hyper area

7:56

and of course the background genicity

7:58

of the liver is increased, right?

8:00

Coming to the next, the grade three.

8:04

Now here what's happening is

8:06

the diaphragm is very subtly visualized.

8:09

We cannot really appreciate the posterior margin,

8:11

the diaphragm right here.

8:13

So what happens in grade three?

8:15

There's a marked increase in echogenicity,

8:17

which is making the liver much

8:18

more brighter than the kidneys.

8:20

And there's poor seco texture of course,

8:22

of the background parenchyma.

8:24

And there's poor visualization of the hepatic vessels

8:27

and the diaphragmatic surface is not very,

8:30

that's grade three, okay?

8:34

Right? So again, another example.

8:36

So very echogenic liver and obscured portal vein branches

8:40

and of course limited visualization of the do of diaphragm.

8:44

Easy, simple. Okay?

8:47

Now with that, now let's understand

8:50

what is UDFF ultrasound, right?

8:52

Fat fraction. So A SF uh, ma, uh, metabolic associated

8:58

TIC liver disease is the most common cause of CLD globally.

9:02

So 20 to 30% of the people will progress to a meh diagnosis

9:07

and which is hepatitis

9:08

and which will lead to fibrosis,

9:11

cirrhosis, and liver failure.

9:13

So what's our intention here is to give an early diagnosis,

9:17

quantify it, and then it can be managed

9:19

and followed up as well.

9:22

Now this is the reference literature.

9:25

Now what is happening is we were doing it, uh,

9:30

subjective grade one, grade two, grade three.

9:33

Now we, uh, and which are difficult to understand.

9:37

So we come to the solution of ultrasound, right fraction,

9:41

which is fast, simple

9:44

and very, uh, it's very precise

9:47

and it's very good even for patient counseling

9:50

and convincing and follow up as well.

9:54

So it exam time is less than a minute as what Siemens says.

9:58

However, basically in five

10:00

to 10 minutes you would less than five minutes,

10:02

you can finish the scan.

10:03

So you can have a index

10:06

of value greater than 5% delivering a clinical

10:10

similar clinical utility as MR.

10:13

Fat estimation. So how do we grade it now?

10:18

So basically you can,

10:20

you do it using the DS curve transducer.

10:23

So this measures a fat fraction

10:25

or the fat content in the level, right?

10:28

And we record the median value

10:31

validate from five validated site, right?

10:34

So validated site is again, we try

10:36

and avoid the uh, sampling.

10:39

We basically want to see the in the fat pen grammar, right?

10:43

So when you're placing a cursor, we have

10:45

to keep it away from the capsule,

10:46

away from the blood vessels,

10:48

away from the portu brain branches.

10:50

So we want to just sample absolutely the per right?

10:54

So which is a bit, which will give us uh, the normal liver,

10:58

the fat component is less than 5%,

11:01

which is grade zero or healthy.

11:04

So between five to 20% is mild,

11:08

or actually this is a little more, um, intense grade.

11:11

Practically between five to 10% I would say is mild

11:16

and 10 to 15 is moderate

11:18

and more than 15 kind of let's let say compare grade three.

11:22

Okay? So these numbers are

11:25

need require requiring correction.

11:28

Now, so we go for, I go

11:31

with this classification, which is what is here.

11:34

So more than 5% for mild, which is rate one

11:37

and more than between five to 10% is grade two

11:40

or moderate, okay?

11:43

And then more than 15% is grade three, right?

11:48

So this is grade three.

11:50

So the optimal threshold for UDF is

11:52

to remind us more than six,

11:54

6% first grade one more than 15%, grade two

11:58

or more than 53% for grade three.

12:00

But if you go by subjective um, analysis, the

12:05

the appearances, the numbers will probably come even at

12:08

15 to 20%.

12:11

So this is a very good tool

12:14

and which gives a very instant, quick estimate.

12:20

So just in the measurement there's a control animation

12:23

parameter, which is uh, the technology which is behind it

12:28

that uses the fiber, uh, measures this.

12:32

So, uh, it's measures the attenuation

12:35

of the ultrasound waves as they pass through the liver

12:37

and the higher cap values indicating greater value of

12:42

fat accumulation, right?

12:44

And it is measured in decimals per meter. Okay?

12:49

Right? So let's look at some cases for the UDFF.

12:53

So here's an ultrasound

12:55

and we have the corresponding uh, images.

12:58

So here as we can see,

12:59

we can see very nice port vein verticals.

13:02

We can see nice to diaphragm.

13:03

Nice, nice, nice, all looking good.

13:06

And look at the uh, fraction here.

13:09

Fat fraction is coming to us 3%.

13:12

Can you see this number here? This is 3% here.

13:15

Okay, so here the number is four, right?

13:19

So this is 4%, this is again 4%.

13:21

So we will take random, at least five samples

13:24

and then we will the cal, the median

13:28

of course this is done with breath holding.

13:30

Patient is preferably with fasting at least stood four hours

13:34

to avoid the gases and we sample the right clo.

13:38

Now again, another case,

13:40

this is patient has a bit of sitis here.

13:42

So we are trying to uh, sample here.

13:46

Um, and we see that the fat value is 3% here,

13:51

3% here, 3% here,

13:54

2% here, 3% here.

13:57

So again, these are all less than 5%.

14:00

So it's grade zero

14:01

or the, so this is again just a recap.

14:06

So this is again grade one fatty liver.

14:08

Now we see a little bit of blurring of the uh, periportal.

14:12

Uh, we see a little bit muffled margins.

14:16

So there's loss of echogenicity,

14:17

however, we can still see the diaphragm very well.

14:20

So this, now we've done the corresponding

14:25

images for the UDFF and this is the same patient

14:29

and the same patient scan.

14:31

So it's the same data, same patient.

14:33

These both these patients are same, right?

14:36

Both these belong to the same patient. So the values is 8%.

14:41

Here again, at this site also is, it's 8%, right?

14:45

So 8% for this, right?

14:47

So between five to eight we have grade one pat label.

14:51

Again, this is an same patient.

14:53

So we have the value, which is 12 here.

14:56

So which is like the upper limit of grade coming

15:01

to the next we have grade two,

15:04

so which is got a increased echogenicity here

15:07

and the values are, this one's 29,

15:10

which is significantly quite high though.

15:13

And another one which is um, uh, again,

15:17

which is probably looks like a little bit

15:19

of stiffness as well.

15:20

Probably again,

15:22

this is also pretty much high 29 and three three.

15:26

So this is grade two, grade two, grade two loss

15:31

and kind of doom is well seen, which is up

15:34

to UDFF values going up to 30%, coming

15:38

to the another one, grade two to three you can call it.

15:41

So again, the values are 29, 30% or 26%.

15:47

So very easy, simple test to do

15:49

and gets a great inflammation.

15:51

Now we have also got, um, an uh, a sample

15:56

that's will take multiple images at the same time.

16:00

So it has got 1, 2, 3, 4, 5, 1, 2, 3, 4, 5, 5, 15.

16:06

So basis of the number of dots that you have that will show

16:09

that how much is it, um, aligned

16:13

or how much is the margin of error, right?

16:16

Simple. So if you have more number of dots like five

16:20

or selected, that means you are in good, good alignment

16:24

and good breath holding and you're doing it more accurately.

16:28

So with that technology, we can uh,

16:33

do it and the cutoffs are 5%, 10%

16:36

or 15% for moderate, mild, moderate and severe.

16:40

And it's a very reliable modality. We look at more cases.

16:45

So if we have caught the patient at this level

16:49

of fatty liver disease done the UDFF patient's managed well,

16:53

great, if patient hasn't,

16:55

and it's left untreated, are unmanaged for a long period

16:58

of time, obviously, as we all know, progresses

17:01

to chronic liver disease, right?

17:03

So in chronic liver disease, what happens, as we all know,

17:07

there is a progressive deterioration of liver function.

17:10

So basically, uh, all the metabolic function,

17:13

there's continuous uh, inflammation,

17:15

then there's destruction

17:16

and regeneration of pan chima leading to fibrosis

17:20

and cirrhosis, right?

17:21

And cirrhosis is the final stage of the, which is going to

17:26

lead to widespread nodules, maybe neo, neo angiogenesis

17:31

and others.

17:33

Right? Now of course there is a lot of etiology, pathology

17:38

and all these things that goes on to explain.

17:42

And the incidence of CLD is very high.

17:44

It leads to a large number of transplant work

17:47

that we do at my institute where I work.

17:50

So what can we do?

17:53

Be aware of the geologies early diagnosis and prevention.

17:57

Alcohol, as we know is one

17:58

of the very common, uh, this thing.

18:00

And the other one is the metabolic diabetes

18:04

and infections, chronic hepatitis

18:07

and of course other uh, uh,

18:11

l less common spectrum of genetic causes

18:15

of enzyme deficiencies and others.

18:17

And autoimmune primary ary sclerosis, sclerosis,

18:22

cholangitis or autoimmune, he and ING can have drugs

18:26

but carry and those idiopathic.

18:28

So there's a long list of causes, right?

18:31

Definitely many are preventable, right?

18:33

However, all need to be managed all need to be quantified

18:38

as term of pathology

18:40

or we need to get a value of the ELA gap

18:42

or the stiffness of the lipkin, right, to be able to manage.

18:47

So we all understand that if we leave it there,

18:50

it'll progress to hepatitis, fibrosis,

18:52

cirrhosis and liver failure.

18:54

Hepatitis is inflammation. So inflammation happens.

18:58

A lot of fat is deposited or stiffness in inflamed

19:01

and then healing, inflame healing, inflamed healing

19:05

fibrosis, right?

19:06

Once there is fibrosis,

19:08

then fibrosis is not a functional tissue, right?

19:11

So obviously the functional pan component

19:14

of the cells goes down.

19:16

So liver function goes down

19:18

and lots of um, process

19:23

of all the collaterals and everything ensures, right?

19:27

So what is fibrosis?

19:28

It's basically stiffening of the liver as the thin bends

19:32

of the scar tissue gradually add up, right?

19:35

Okay, so this is what happens.

19:36

The scar tissue reduces the blood flow through the liver,

19:39

which reduces its its oxygen and nutrients.

19:43

And this is how the liver's vitality, right?

19:46

It's life begins to gradually decline.

19:50

Remarkably, some amount

19:51

of fibrosis is definitely reversible.

19:54

Uh, however, if it, it is ens.

19:59

So cirrhosis as we know will not be able to recover.

20:03

So liver failure begins when the liver can no longer

20:06

function adequately for the body's knee

20:07

and it, you can in originally have a decompensated cirrhosis

20:12

and of course as the liver functions begin to break down

20:15

that it effect throughout the body

20:17

and it is a gradual process

20:20

and eventually it is fatal without any liver transplant.

20:24

And one does need a liver to live, right?

20:26

So then they end up in transplant.

20:29

But we want to prevent that.

20:31

We can see and diagnose early clinically.

20:34

However, there is a big overlap of symptoms with fatty liver

20:39

and GIT upset.

20:41

So these symptoms can be weak for abdominal pain,

20:46

nausea, loss of appetite, fatigue or MA soap.

20:50

We need a, uh, we have other diagnosis

20:53

of advanced stage which are jaundice

20:55

and uh, basically these are complications due

20:59

to complications of hepatic failure, right?

21:02

So which are jaundice tackle, urine tackle,

21:05

light colored stool

21:07

because of ary,

21:08

while not pain there digest difficulties

21:11

especially with fats.

21:12

Weight loss and muscle loss, musty smelling, right?

21:15

Mild brain impairment, middle brain, mild brain impairment,

21:19

atic encephalopathy, pruritus which is skin

21:21

with no visible rash, right?

21:25

So if we can diagnose by spoony, Terry, knee clubbing,

21:30

spider tumors, easy bleeding and all those features

21:34

and we can have swollen ankles, feeds and other carriages

21:38

and of course it'll lead to liver transplant.

21:41

We can have collaterals, pre hepatic pulmonary syndrome,

21:45

HEPA syndrome, hypers,

21:47

and various complications due to that.

21:51

So what are we going to do?

21:53

Now we understand that if left untreated the spectrum

21:58

of the clinical picture, all that the patient's going

22:01

to three is a huge one, right?

22:03

We want to prevent that, we want to catch it early.

22:07

So another good tool that we have is to do a

22:12

ELA of course.

22:14

How are we going to do it?

22:15

We need the patient in fast in state

22:18

and we for this, we will actually be using a position of

22:24

ERs and we will obviously do various other modality scan

22:28

as well to have a thorough view of the parenchyma

22:32

before we move on to the elastography problem.

22:37

So let's understand what is ultrasound elastic? Do we do it?

22:41

How do we do it? And what's the applications?

22:44

So it's a technique to assess the elasticity

22:46

of the stiffness of the tissues aiming

22:48

to give an insight similar

22:49

to palpation on clinical examination.

22:52

The technique is based on the changes in elasticity

22:54

of the soft tissues in response to the physiological

22:57

and pathological processes such as fibrosis, inflammation,

23:01

and neuro neovascularization.

23:04

So what happens is it provides complimentary information

23:07

to the BMO imaging and that can be measured

23:11

and documented both qualitatively and quantitatively.

23:16

So it's got a wide spectrum

23:17

of clinical applications in liver brace, thyroid, kidney,

23:20

prostate, lymph nodes, and

23:22

musculoskeletal ultrasound, right?

23:25

So as you all know, it's of two types.

23:27

One is qualitative, the compression elastic to gravity

23:30

where you have the different colors

23:31

and the codes and things like that.

23:34

And you have quantitative

23:35

where you get information in numbers, right?

23:39

Rv. So the, what is the principle,

23:42

the heterogeneous elements of the tissue,

23:44

they respond differently to the differences due

23:47

to differences in the elasticity

23:49

and are displayed in different colors on the skin.

23:52

So the qualitative changes, the structural pan

23:55

says using a color scale,

23:57

there's often you'll see a vertical bar which has colors

24:00

and it'll be written on one side.

24:02

If you read very finely, then we soft treat somewhere

24:05

and a hard written somewhere.

24:06

You know why it's important?

24:07

Because you can actually reverse the setting.

24:09

So you need to know how you are reading

24:11

and interpreting that information as well.

24:14

Okay? So the scale reflects the character stiffness

24:18

of the organ of the lesion that's being detected.

24:20

A stiffer tissue is displaced usually

24:22

as a color coded fit on the screen back convent,

24:25

however you can change it

24:27

and a more elastic tone is displayed in sheets of blue

24:30

and free easy.

24:33

So now, uh, as you all know,

24:37

elasticity images is easy, it's very comfortable

24:40

and you can easily assess and diagnose with confidence.

24:44

Right? Now we use a virtual

24:50

touch technique and it can give a pinpoint site if you want

24:54

to see the stiffer area that you want to sample,

24:57

that's an added advantage that you can get, right?

25:01

And we will, we use um,

25:05

ROI box of one millimeter, which we will just see.

25:11

So what happens is basically what's the

25:14

principle and what, how does it work?

25:15

There's a long wave push.

25:19

So the higher sheer wave speeds

25:21

and smaller displacement are associated

25:23

with stiffer tissues, right?

25:25

And slower sheer wave speeds

25:27

and larger displacement occur with more compliant tissues.

25:30

So the most stiffer the tissue higher the velocity they find

25:35

R images have special uh, special resolution comparable to

25:39

that P mode, often

25:40

with greater contrast providing matched

25:42

adjunctive information.

25:45

Okay? So the more so the more higher the velocity of the,

25:50

that is documented and recorded, right?

25:53

Okay, next is,

25:57

so like I said, this is the same pictor position.

26:00

We did the UDFF and we did the fatty liver, right?

26:04

And then now we are doing the ELA

26:08

to detect the fibro process

26:10

before it goes into frank cirrhosis, right?

26:16

Fatty liver disease we did right?

26:18

Major causes, we already covered.

26:21

Process of chronic liver disease we've covered

26:24

has got an overlap.

26:26

Now what is the gold standard test for diagnosis?

26:30

Of course it is the biopsy right now for biopsy,

26:34

always lesion and invasive procedure

26:36

and you cannot go on doing biopsy.

26:38

Maybe you can do it once,

26:39

but then uh, to see for the response

26:42

to treatment he wouldn't go on doing

26:44

redoing the biopsy, right?

26:45

So biopsy involve course sampling,

26:50

again at least five portal tracts

26:52

and sampling of more than 11 portal tracts is optimal.

26:56

And then each course, uh,

26:59

sample should be at least two centimeter long lip.

27:04

Now limitations, obviously it's an invasive,

27:07

you can have errors and hemo there.

27:11

Basically it's an invasive procedure.

27:14

So we come to the other uh,

27:18

technique which is our ultrasound probe,

27:20

which is going to do the RV.

27:23

Now it's one of the modalities to get the

27:27

liver stiffness.

27:29

So, and it'll give us a quantitative measurement.

27:34

Now, according to many studies, the higher the degree

27:36

of lesion stiffness revealed by asto response

27:39

to high probability of its malignant origin

27:43

or to the higher risk of its malignant potential.

27:46

Now this is the main area that we need to focus upon.

27:50

So if the values are higher, so we are looking at

27:54

increased risk of malignant potential, of course

27:59

that's the reference.

28:01

So how do we do it? Okay?

28:07

So what happens is we just uh, did the principles,

28:10

we will have the velocity, we've sent out a wave and the ROI

28:14

and the displacement happens and that velocity is added

28:18

and we get the velocity in centimeters per second.

28:22

And now the machine's directly calculated

28:25

and give it in a ki kilo basket as well.

28:28

However, there may be nomograms in chart,

28:30

you can manually calculate and convert it into that as well.

28:34

And we usually avoid the area very close to the capsule,

28:38

close to uh, closer to the blood vessels.

28:41

So we try and sample a plain area

28:44

of the per IDE serve, okay?

28:47

So the fibrotic livers are stiffer

28:49

and they move to greater decrease compared

28:51

to high velocity on lip, right?

28:55

So in that shell, what is the elastography provides,

28:59

it provides an information for the stiffness of the tissue.

29:02

It aids in a size assessment of the lesion.

29:05

Sometimes when you do color coding, right?

29:07

So the lesion margin sometimes the it could text your

29:12

appearance may still be similar,

29:14

but when you do the stiffness mapping, you see

29:16

that the lesion is far more than what is was visible to you.

29:21

Malign. These tend to be stiffer than benign

29:23

and often they may have a larger extension that is not

29:27

so visible due to altered architecture patterns.

29:31

And of course it can help identify ISO coic lesions

29:34

because they are not visible and be more imaging.

29:37

But when you apply the stiffness criteria that

29:40

with the stiffness filter, they may be detect it, right?

29:45

And of course they can help guide intervention, uh,

29:49

intervention biopsy procedures

29:51

by identifying stiffness areas without a lesion, right?

29:57

Right. So the little graph

29:59

and fibrosis assessment are conducted according

30:01

to the MIBI scale.

30:03

Now what is the MIBI scale

30:06

that we already know is information and not,

30:09

but we'll just come to it.

30:10

So basically for the sheer way,

30:13

we'll ask you see imaging, how do we do it?

30:17

What is the principle?

30:19

How do we interpret, how do we correlate with FibroScan?

30:23

Andwe? Now what the advantages

30:25

of FibroScan water limitations, uh, or concluding remarks.

30:30

Let's understand the MET V no,

30:34

these are the other scoring systems

30:36

with liver fibro process.

30:38

We are follow met score.

30:40

So this is system used to assess the extent of inflammation

30:44

and fibrosis by histopathological

30:47

evaluation in a layer of biopsy.

30:50

And the grade indicates what this activity

30:54

or the degree of inflammation while the stage represents

30:58

the amount of fibrosis or scarring

31:01

and the grade is the activity.

31:03

So activity, we get the blood tests right?

31:06

And fibrosis is a stiffness that we measure.

31:09

So fibrosis is again on a five point scale

31:12

and activity is on a scale of a zero

31:16

to three, alright?

31:19

Four point scale, okay?

31:21

So fibrosis is F zero to F four, okay?

31:26

Right? And activity is a zero two

31:31

A three activity.

31:34

Alright? So

31:36

accordingly you will have this picture.

31:41

Now all these measurements

31:44

are performed using a software which is integrated into a

31:47

conventional ultrasound machine.

31:49

So which is looking like this,

32:06

okay?

32:06

Alright, so what is a method?

32:11

We will use the sample bots, which is position beamer, image

32:14

of the liver and ELAs.

32:16

Uh, ELA measurements are obtained

32:18

by pressing the button, okay?

32:22

Right? So here we will send in the pulse down

32:26

and by using short it's duration, it's al acoustic pulses.

32:31

This it side tissue of the tissues

32:33

and that generates a micron displacement in the tissue

32:36

and this displacement results in the sheer way

32:39

propagation, right?

32:41

And then the velocity which is of this is tracked

32:44

by ultrasonic correlation based method and is recorded

32:48

and displayed, right?

32:50

So ROI is a blue rectangle which is placed

32:53

at the desired location.

32:54

This is the ROI as we can see here.

32:58

And a standard transducers used

32:59

to apply a ultrasound push pulse

33:03

and that runs alongside the ROI or the area of interest

33:08

because that's the area where it'll capture the velocity

33:12

and it is higher, the most differ the tissue is.

33:15

So the re result tissue

33:17

and compression causes a propagation of the sheer waves,

33:19

the yellow lines, right?

33:22

And the those velocities we will record. Okay?

33:28

Right? These detection pulses can be used

33:32

to calculate the speed of the shearer waves

33:34

and analyzing the return equals right?

33:37

And the speed of the sheway correlates

33:39

with the tissue stiffness.

33:43

Okay? Right? So we've covered this part.

33:49

Now most of the equipments uh,

33:51

currently give the value in both meters per second

33:55

and in kilo basket,

33:57

however you can convert it as well

34:00

if it's not displayed using the um,

34:04

and the, the data, the information

34:07

provided by the equipment and ture.

34:10

And of course as we all know, the stiffer the tissue,

34:13

the higher is the speed, right?

34:16

And we do correlate it with the blood test

34:18

and the score, okay?

34:21

Right? As we all know. Now how do we do it?

34:24

We examine the patient in a spine

34:26

or in the lateral disposition

34:28

and ma arm in later abduction, right?

34:31

And the transfusers located in the intercostal space in the

34:35

viapath lobe.

34:36

So just a summary.

34:39

So optimally patient is fasting,

34:42

patient position is decubitus with the right arm elevated

34:46

above the head for the optimal intercostals

34:49

and do not apply too much pressure on the skin

34:53

resting respiratory position.

34:55

And I always stays beneath the glisten capsule, at least

34:59

keep it 1.5 to two centimeters below so that you

35:04

avoid the reverberation artifacts.

35:06

And of course there's increased, slightly increased

35:09

or higher values closer to the capsule laser,

35:13

a capsular stiffness

35:15

and of course we'll apply, apply the ROI

35:19

avoiding the larger vessels

35:21

and the median value of five to 10 measurements

35:24

is considered and

35:25

and the unit could be either meters per ocular pascal

35:29

and of course we keep the lower standard deviation

35:34

and lower interquartile range, right?

35:36

So we diminish the error in sampling.

35:40

Now there's a question that's formally asked is why do we

35:43

use the right lo we use the right LO

35:46

because um, there's a lot

35:50

of movement in the high left side and the heart.

35:52

So it's very readings very So the fact

35:55

of excess is tissue motion as a secondary

35:58

to cardio pulsation can disrupt the velocity regions on

36:01

the left side.

36:03

So we reason why we do the right lobe but not the left lobe.

36:08

A statistically significant difference is found

36:10

between the shared velocity values in the deep right lobe

36:14

and the deep left lobe, which is 1.2 versus

36:17

one point zeros per second.

36:20

So there is some difference between the velocity

36:24

of the right and the left lobe, right?

36:27

Right. Lobe higher than the left lobe.

36:30

So RIV protect tissue,

36:33

the good part is it's more reproducible when applied

36:36

to the deeper portion of the right lung of the liver, right?

36:40

That's why we do the

36:44

technique we were redone.

36:46

We place the RI then the sample just to summary,

36:50

we have to stay,

36:52

do not place the ROI over the liver capsule, the vessels

36:57

with structure, any of the ligament areas,

37:00

only the liver parenchyma has to be targeted.

37:04

So only the liver parenchyma has to be targeted.

37:07

That has to be, remember

37:11

whenever we press the update key one tissue quantification

37:14

measure is required and we do ask the patient

37:17

to breath hold here.

37:19

Okay? Right.

37:21

So standard measurements at the depth of 2.5

37:23

to five centimes meet and values then calculated, okay?

37:28

And it is the depth not to be more than 5.5.

37:32

Here is a very high tip. That's an error NV sampling.

37:39

Okay? And here, so

37:41

whenever you do not get a reading, it will give you a,

37:44

so it'll not record anything.

37:46

It depends on manufacturer. Manufacturer.

37:48

You just have to need to and to check on your ance can.

37:53

In this case the depth is all okay?

37:55

The regions also looks okay, all right.

37:58

However, it does look a little bit very close

38:01

to the capsule though.

38:02

Okay? Now so then the machine calculates a chart like this

38:07

and gives us to us, we look at these numbers, the median

38:10

and the standard deviation we remember we had

38:13

to keep it less than less.

38:16

Then low 1 20, 30 degrees is better.

38:21

So these are the ways we interpret the results.

38:25

So lesson 1.1 is Patti,

38:27

and this is normal in the fibro process, livers are

38:32

1.32, 1.5, 1.5

38:36

to 1.6 and 1.62 2.0.

38:40

So these are areas of concern that do need to be uh, checked

38:45

and this is how you report and you grade it

38:48

and to be correlated 50 liter and the blood test.

38:53

So it is got more accuracy when

38:57

the values in meters per second can be converted

38:59

to K Ps per the conversion chart

39:01

provided by the manufacturer as per the software used.

39:04

Because that will vary from the

39:07

manufacturer to manufacturer.

39:09

Of course it is only like a sampling it,

39:13

it's not an absolute value, it's just the machines trying

39:16

to capture the stiffness and give it a number.

39:20

Okay? Comparison with the FibroScan,

39:22

which are geal are doing.

39:24

So basically the FibroScan, they are simply,

39:28

they've got this, the patients lying down,

39:30

they just put a transducer uh, on the side,

39:34

it's like a blind procedure.

39:37

So you are not with the ultrasound, it's really targeted

39:40

pinpointing what local area,

39:42

focal area that you're sampling.

39:44

So that is what is being done, but here it is not the case.

39:48

Okay? Right.

39:52

So what are the specific advantages over

39:54

the FibroScan people?

39:56

So this can be done in patients with sitis.

39:59

So a baseline stiffness values obtained in patients

40:02

with signs and symptoms of disease.

40:04

And then what happens? We can monitor it.

40:10

So even in AEs we can do it, we can do it in obese patients

40:14

with severe ptosis

40:15

and post-op patients, patients

40:17

with small intercostal spaces.

40:22

Mm-hmm. And the good part is in the same study

40:26

that you're doing whole abdo scan, you can just do a

40:30

ELAs UDFF all in one go.

40:35

So you can do it in children also.

40:38

You can have a different smaller size probe.

40:40

So it actually makes a good contact along

40:43

through the intercostal spaces.

40:45

And choices depend upon the age of the poverty size,

40:47

higher frequency probe in children less than five years

40:51

and using high frequency probing in children.

40:53

Last for a better analysis of the depth,

40:57

this children is taken between three to five centimeters.

41:01

Again, this is a case as you can see in the A mode,

41:04

the left probe is pretty at enlarged, right?

41:08

And then see here the long ting of the left lower liver

41:13

and the liver also appears scores and stiffness

41:16

and see the velocity value, the velocity value is coming

41:19

to 3.32 centimeters per meters per second,

41:24

which is pretty much high.

41:27

Okay? So these same patient, same images

41:30

but in the color page basically

41:33

using the different filters is all your personal preference

41:36

and it might just accentuate some areas

41:39

that maybe make it easier for you to detect

41:42

and appreciate a pathology.

41:44

Okay? So that's same patient again,

41:46

you have coarse liver left lovis pretty much

41:50

ate LO is also very prominent.

41:52

And then you have the left lobe which has got large

41:57

of the left lobe here, okay?

42:01

Right? You can marry a focal lesion if it's stiff.

42:03

And then how is the status background level?

42:06

This you can't do in FibroScan you can only do

42:08

an ultrasound, right?

42:10

So here there's a large lesion that's there in the liver.

42:15

The clinician wants to know how is the status,

42:17

the background level and then

42:20

accordingly they want

42:21

to make a call whether it we do just remove the lesion

42:24

or we remove the whole liver

42:26

or to plan something differently.

42:28

So when you do the astro of the left lobe,

42:31

there's specifically status of the left lobe

42:34

because right, they'll probably remove completely.

42:37

So here we can do selective assessment of particular lobe

42:41

or a segment also, right?

42:44

So here the values are of course it's three point,

42:48

one point, it's four, 1.5, 1.5,

42:51

not too high at least reasonably, alright, right?

42:54

So this is an added advantage.

42:56

You obviously have to take that value, store it

42:59

and then maybe do a reentry of the patient because

43:01

otherwise if you take all

43:03

of them together they will all get merged into the final

43:06

report that you're calculating.

43:09

So this is the affected area sampling,

43:11

which is obviously higher, 3.06, 2.87.

43:16

Okay? Alright.

43:18

So 2.48 is the stiffness

43:20

and of course we look at the standard division IQR

43:23

one is less than three, which is good

43:26

but could have been better.

43:27

We can check if there is any scope,

43:29

any erroneous reading which is out of the room a lot.

43:33

We kind of discovered delete that reading

43:35

and free do another one too.

43:37

Complete set of 10 right?

43:40

Now here's a case, there's a focal had at cyst lesion,

43:43

which is classy that you can see.

43:45

We want to assess whether this patient really needs a

43:48

transplant or is all right.

43:50

Right? So here we are going

43:52

to sample the background chy the background parent showing

43:55

1.9, 1.9.

43:57

So kind of reasonably, all right, not to back, okay?

44:02

So to summarize, elastography is inexpensive, safe,

44:06

reliable, and it's non safe.

44:09

There's no, there's no rule book

44:12

that this is the right way to do.

44:13

The ELA not whatever, what's best for you, you can do it

44:17

however you have to remember

44:19

after that is not reliant in patients

44:21

with atrial right lobe patients who cannot hold their breath

44:24

and there's this excess infectious center when the liver is

44:27

not only seen very well, what can you really do much, right?

44:32

We already talked about the sensitivity

44:34

and atory literature.

44:37

Obviously the technology has more sensitivity

44:41

and specificity at higher level

44:43

of liver pathologies, cirrhosis, right?

44:46

And the other one, right?

44:48

So what does journal of medical ultrasound say again?

44:51

The data they have calculated

44:53

and they've said that of course it is a good procedure,

44:57

it's a targeted procedure.

44:59

It work on those shortcomings at the uh, fibrous scan there,

45:04

the problem only position randomly

45:06

and use a plan they could advers.

45:08

So we can readily use it

45:10

with a ultrasound machine guidance, right?

45:14

Elective assessment and hepatic segment of condition

45:16

as possible and find it's a, compared with the score right

45:22

now it can be an all in one or you can put the ROI

45:26

and then it will give you the value.

45:28

Now this is going directly in the unit code KBA

45:32

here 70.

45:36

Now you can also do the elastic of the spleen.

45:41

You can see the velocities there, okay?

45:48

Right? And then we have a liver which is

45:52

cores, heterogeneous, maybe the ations as well.

45:57

And we do the uh uh, we do the elastic

46:02

and look, we have a good sample.

46:05

Now this, its itself

46:08

with good breath holding is a very complete diagnostic.

46:11

So each of the tracers is got all the four lights blowing.

46:16

So that means everything is done correctly.

46:19

The patient holding play.

46:21

And we were to three see well and analyze.

46:25

So this one value is quite representative

46:30

of the parenchyma and the way it just been assessed

46:33

and we could reli it.

46:34

However, you can take multiple readings.

46:36

So 3.7 is what it was 3.6.

46:40

And again 3.6 here again.

46:42

So whatever has actually been sampled has been

46:45

sampled accurately.

46:47

Whatever was not sampled, we do not, no.

46:50

Again, another one very well sampled.

46:53

So which is again showing consistency of 3.04.

46:59

Okay? So this is how it's giving us all the 10 sites, 10,

47:02

15, size four each one that we have assembled.

47:06

And accordingly we get a kidney.

47:08

Uh, K mean KPA value that you get document.

47:14

Thank you so much for your wonderful listening. Thank you.

47:17

And if there are any questions, I'm more than happy

47:20

to take them now.

47:23

Thank you so much for another great lecture.

47:26

Appreciate that. We will open the floor for some questions,

47:31

so if you've got them please put them

47:32

into the Q and A feature.

47:34

Yes, Dr. Sal, if you're able to open that up, I can start

47:37

Us off. I've done that. Yes,

47:38

you got it. Okay.

47:39

So the question number first is do you get 10 measurements

47:42

randomly in the right hepatic flow of choosing the area?

47:45

Yes I do. Or do you set one area

47:48

and get one measurement, then set another area

47:50

and get another measurement until you reach 10?

47:52

So basically I do all in the right low.

47:55

I would little bit move not in one particular area,

47:58

but I would just move around the area so

48:00

that way I've actually sample the poor liver

48:02

and if there's a particular path area that has any pathology

48:05

or assisted relation, I would avoid that area

48:08

because we are trying to get the sample

48:10

of the diffuse liver.

48:13

Okay, so IQ I QR is an interquartile range.

48:17

It's another parameter of standard deviation and statistics.

48:21

So which indicates that the values are lined

48:25

or out or erroneous.

48:27

So we try and keep that value low.

48:31

Spleen elastography uses OID malignancy and experience.

48:35

Any literature that you would suggest?

48:37

I'm sure there are many papers and

48:38

spleen elastography coming up.

48:40

We are doing routinely, uh, liver and spleen both

48:45

and they both have a role in prognostic, uh,

48:49

and diagnostic uh, management of these patients.

48:52

So they say more urg and more heis

48:56

and more, uh, there are, there is,

49:00

it's it's it's an evolving thing.

49:02

There's a thesis paper also going on

49:05

and definitely it is very helpful.

49:08

Any experience in thyroid strain?

49:10

Elastic probably with thyroid correlation.

49:12

But of my favorite questions, I do a lot

49:15

of work in thyroid scoring.

49:16

I've been invited faculty for an endocrine conference

49:19

but for the thyroid conference in

49:22

um, uh, Dyson.

49:25

So the thing is the thyroid, I do not go with asto

49:29

because thyroid has calcifications often

49:32

they're not used with hap.

49:34

So whenever it is calcification,

49:36

so the stiffness will obviously go up.

49:39

So it's really not that a criteria.

49:42

Elastography is good for lymph nodes, definitely to

49:46

evaluate whether the lymph nodes are

49:48

metastatic or non METAS status.

49:49

That's an area where you could technically apply them in the

49:52

neck, but applying them

49:53

for thyroid nodules hasn't been very rewarding.

49:57

It can be rather, um, misleading

50:00

and uh, take you away from the diagnosis.

50:03

So I would rather just apply the res feature

50:07

and by their size

50:08

and criteria suggest for a biopsy

50:11

that would be better in patient management.

50:14

Thank you. Next, is there any advantage

50:17

with AFI over another ultrasound machine

50:21

which incorporated FibroScan into the ultrasound machine?

50:25

I think lips, um, I'm mean gastro departments,

50:28

gastro department, ultrasound ultrasound department.

50:32

So we have our machine which will do our liver abdominal

50:35

scan and um, uh, liver abdominal scan,

50:41

which will do the liver abdominal scan

50:42

and the ELA graphic together.

50:45

So I need a machine which will do my work of

50:50

evaluating the focal heep lesions very well,

50:52

do the hepatic doppler also very well and do all my work.

50:56

So I mean I'm, I'm blessed

50:59

to use a very high end Siemens machine

51:01

so which gives me great shoot resolution

51:04

and that's where most of the work is being done.

51:07

Thank you. Um, uh,

51:10

Philip E 50 is the good.

51:13

We'll have to check with somebody

51:14

who's using that equipment.

51:16

Uh, we are on Siemens predominantly. Thank you.

51:21

Okay, so which uh,

51:24

ultrasound machine have this graphic software?

51:27

I mean I've already answered.

51:29

Most of the, most

51:30

of the machines today have anela graphic feature.

51:33

Okay. So most of them have

51:37

any points in UDF in heterogeneous fatty infiltration

51:40

of your, of course you can do it in that as well.

51:43

You are going to take random sampling so and will aggregate.

51:47

So even if there's a heterogeneous fat infiltration, um,

51:52

you take more values than you have reached them out.

51:55

Thank you. Uh, is there a name to the S zero S one rating

51:58

of liver attenuation fat quantification?

52:01

Basically zero is normal.

52:04

One, two and three are mild, moderate weight and severe.

52:07

Okay, so done.

52:11

And um, next is, uh,

52:15

can it be used in breast imaging?

52:16

And it's to read, you know, what imaging, yeah,

52:19

of course elastic is used in breast imaging

52:22

and lymph node imaging.

52:23

Yes, it is being used.

52:25

Um, to what extent is a question, uh,

52:29

but yes it has being used is MR in liver,

52:33

unless there more is more details

52:36

and you see, I mean MRI is good,

52:39

but ultra ultrasound is so easy, convenient,

52:41

and it's just one stop solution

52:43

and you have the transducer, it's just done in two minutes

52:46

and way better see

52:50

how many hours fasting

52:51

for deliver the last two roughly four hours.

52:53

Two to four is good, include water, water,

52:57

water patient can have.

52:58

So basically no food, water is okay.

53:02

Okay, so next

53:07

is, this is done.

53:09

We are doing ary a blast.

53:11

We believe this is different from rrp.

53:13

I have some experience with Siemens RRP as well.

53:17

Yes, I mean Siemens RP is good. We are doing ela.

53:20

Both are good. We, I've also done both of them, both good

53:26

role in endometrial carcinoma.

53:28

I haven't applied it, I haven't applied it.

53:31

And so basically it's just the gray scale features, the size

53:35

and the criteria and then suggestions to pathology.

53:40

Thank you. Thank you so much for all your questions.

53:44

Very wonderful interacting with all of you.

53:47

And thank you for your questions,

53:49

which made it very interesting and very exciting for me.

53:52

I've thoroughly enjoyed it. Thank you.

53:55

We enjoyed this so much Dr.

53:57

Singal, thank you so much for coming back

53:58

and sharing your expertise with us.

53:59

We love having you on

54:01

and thanks for everyone else for participating

54:03

and asking such great questions.

54:06

You can access a recording

54:07

of today's conference in all our previous noom conferences

54:09

by creating a free account.

54:11

We'll also email out a link to the replay later today.

54:14

Be sure to join us next week on Thursday,

54:16

July 10th at 12:00 PM Eastern, where Dr.

54:19

Steven Pomerance will deliver a lecture entitled practical

54:22

Aspects of post-op Spine imaging and reporting.

54:26

You can register for that@mrionline.com

54:28

and follow us on social media

54:30

for updates on future NOOM conferences.

54:32

Thanks again for learning with us and have a great day.