Elsevier

Clinical Radiology

Volume 72, Issue 1, January 2017, Pages 93.e7-93.e13
Clinical Radiology

Technical Report
Surveillance liver MRI for monitoring patients with known or suspected chronic liver disease

https://doi.org/10.1016/j.crad.2016.08.009Get rights and content

Highlights

  • A MR protocol for chronic liver disease detection and surveillance is presented.

  • Markers of chronic liver disease including fat infiltration, iron overload and fibrosis are quantified.

  • The protocol includes DIXON in-phase out-of-phase images, r2* maps and MR elastography.

  • Non-invasiveness and feasibility are the main strength of this protocol.

Introduction

Chronic liver disease (CLD) affects 3 million people in the United States.1 The leading causes of CLD are hepatitis C (HCV) and B (HBV) viruses, alcohol abuse and, in western countries, non-alcoholic fatty liver disease (NAFLD). Less common risk factors include immune-mediated liver disease, such as autoimmune hepatitis, sclerosing cholangitis, and primary biliary cirrhosis; genetic-related liver disease, such as hereditary haemochromatosis; and toxins (e.g., iron overload). The morphological and functional changes seen with CLD, ranging from steatosis to fibrosis and, ultimately, cirrhosis, are due to a failed wound-healing process in response to these inciting factors. CLD is a dynamic, reversible process up to a point, beyond which fibrosis becomes irreversible.2

Patients with risk factors for CLD require monitoring for early detection and staging, for assessment of disease progression rate, and for early diagnosis of hepatocellular carcinoma (HCC).3 The presence of CLD must be evaluated prior to liver transplantation in both the donor and recipient, as its presence influences the outcome for both individuals. Further, select patients may be monitored for inciting factors of CLD, such as monitoring hepatic fat infiltration in patients undergoing bariatric procedures and surveillance for iron overload in patients undergoing repeated blood transfusions. Response to therapy for CLD should also be monitored, given the high costs and the side effects of treatment.4

Liver biopsy represents the reference standard for evaluation of CLD; however, it has several limitations. It is an invasive procedure with serious complications occurring in about 1.1% of cases.5 Bleeding is the most frequent complication and increases in patients with a low platelet count, a common feature of CLD. Liver biopsy requires patient cooperation (e.g., breath hold) and may be limited in the paediatric population. Further, samples obtained by biopsy may not fully capture the overall stage of disease, as the liver is heterogeneously affected by CLD and different stages in the continuum from normal to cirrhotic may be present simultaneously.6

Given the limitations of biopsy, imaging plays an important role in the surveillance of patients with risk factors for CLD.4 The challenge for imaging is detecting the earliest changes of CLD, such as early fat infiltration, iron overload, and progressive stiffness increase. New ultrasonography (US) techniques, such as sonoelastography and contrast-enhanced US, have been introduced to quantify fibrosis, with promising results.7 Although these US techniques are low in cost, they are limited by acoustic window, operator-dependence, and particularly important in this patient population, body habitus. Moreover, US does not provide fat and iron quantification. Radiation dose and high cost limit the use of new computed tomography (CT) tools, such as dual-energy CT.8 With the introduction of new magnetic resonance imaging (MRI) sequences that can provide fat and iron quantification, as well as assessment of fibrosis, MRI, without radiation dose or significant operator dependence, is poised as the ideal means for accurate, reproducible monitoring of patients with CLD.9, 10

Section snippets

Technique

Recent advances in MRI sequences have made MRI well suited for assessment and quantification of the early markers most frequently associated with CLD: hepatic fat infiltration, iron overload, and stiffness (or fibrosis). At Johns Hopkins Medical Institution, a new unenhanced surveillance liver MRI protocol has been implemented, which is performed separate from the more traditional, comprehensive, contrast-enhanced liver protocols. The goal of the surveillance protocol is fast, low-cost, and

Discussion

Although liver biopsy may be the reference standard for the diagnosis of CLD, as a non-invasive technique, MRI has an important role to play in surveillance. Additionally, MRI is particularly well suited for capturing the heterogeneity of CLD. Early detection of CLD represents the primary challenge for imaging, and in the last few years several MRI sequences have been developed to quickly and accurately assess fat infiltration, iron overload, and fibrosis, which occur in the early stages of

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