The Efficiency of Diagnostic Ultrasound in the Diagnosis and Management of Liver Cirrhosis - Essay Example

?The Efficiency of Diagnostic Ultrasound in the Diagnosis and Management of Liver Cirrhosis Introduction Diagnosis is one of the most essential elements of efficient medical management. In order to establish the exact condition of patients, the patient has to be assessed and diagnosed first with the use of various assessment processes, including diagnostic tests. This is very much true for liver cirrhosis. In order to adequately diagnose it as a disease, various processes and tests have to be carried out. This paper shall establish a critical evaluation of studies carried out on the application of ultrasound in the diagnosis and management of liver cirrhosis. First, a general description of the liver, including related affectations for this organ will be presented. Secondly, a critical assessment of the role of diagnostic ultrasound in the diagnosis of benign and diffuse liver condition will also be considered. Thirdly, other imaging modalities will also be discussed. Limitations in the use of ultrasound and other modalities shall be evaluated. Fourthly, this paper shall also consider the new advantages which help in the diagnosis of hemangioma and cirrhosis (contrast agent and Doppler). Finally, a summary and conclusion will be drawn from the entire discussion. 2. Literature Review A. Diffuse liver conditions Diffuse liver conditions may also be apparent for some patients. These conditions often lead to failures in the main functions of the liver in detoxifying and synthesizing (Stocksley, 2001). As a result, jaundice often becomes apparent in these patients. Where there is a more significant failure in liver functions, then the patient may die (Stocksley, 2001). Cirrhosis is one of these diseases featuring diffuse liver conditions. It refers to the scarring of the liver, accompanied by poor liver functions. It is also the final stage in chronic liver disease. It is usually caused by hepatitis C infection, long-term alcohol abuse, autoimmune inflammation of the liver, and related diseases which are usually prolonged (Longstreth, 2011). The pathophysiology of this disease is indicated in Appendix F. Diffuse liver conditions were chosen for this study because most of the time, these are usually chronic conditions which are major threats to the health of patients (Appendix E). There is a need to establish early and accurate diagnostic measures for these diseases in order to ensure early interventions and management of diffuse liver conditions, most especially liver cirrhosis. B. Imaging modalities for liver cirrhosis In a 2005 study by Zheng and colleagues, the researchers sought to establish the best option in the diagnosing liver cirrhosis based on three diagnostic applications – ultrasonography (otherwise known as US) (Appendix B), Computer Tomography (CT) (Appendix C), and Magnetic Resonance Imaging (MRI) (Appendix D). The authors reviewed imaging findings on US, CT and MRI covering 42 patients with liver cirrhosis, and they used severity scoring methods as outcome measures. Cirrhotic livers usually manifest in ultrasounds with livers having small nodes with irregularity in various areas. The caudate lobe may also appear larger, as well as fissures widened (Udell, et.al., 2012). Zheng and colleagues (2005) were able to establish that blunt liver edges, abnormalities in the parenchyma and changes in the liver morphology were the best predictive signals for an ultrasonography diagnosis of liver cirrhosis. For MRIs, the irregular liver surface, abnormalities in the parenchyma, and portal hypertension were considered the best predictive signs. These indicators were also apparent in the use of CT. In terms of accuracy and sensitivity, MRI presented as most accurate, and ultrasonography was the least accurate; however, for specificity, ultrasonography was more specific, and MRI was the least specific. The authors established that MRI and CT presented with greater superiority than US in the diagnosis of liver cirrhosis; however, no significant difference was seen in terms of diagnostic accuracy. In general, this study was able to point out that the three imaging tests for liver cirrhosis have varying predictive signals, as well as imaging features and diagnostic superiority. All of them played a crucial role in the diagnosis of liver cirrhosis. This study was able to establish a comparative portrait of US, CT, and MRI in relation to the diagnosis of liver cirrhosis. The authors utilized a significant population for their study and thereby allowed for a general application of these results to a greater population. The methods used are appropriate and facilitated the evaluation of the research variables and issue. The authors also presented the results of their study clearly, with appropriate research outcomes testing the different variables of the study. In a similar study, Colli, et.al., (2006), the authors set out to systematically assess and present a systematic review of the accuracy of US, spiral CT, MRI, and alpha-fetoprotein in diagnosing liver cancer and cirrhosis. Their review covered various relevant databases, focusing on the use of these tests in the diagnosis of liver cancer and liver cirrhosis. The authors were able to include about 14 studies on US, sensitivity was at 60%, specificity at 97%; for the 10 CT studies, sensitivity was at 68% and specificity was at 93%; for the 9 MRI studies, the sensitivity was 81% and specificity was 85%; and for AFP, the sensitivity and sensitivity was very much varied. Based on their review, the authors established that ultrasonography is a highly specific diagnostic test in detecting liver cancer and liver cirrhosis; however, it is also not sensitive enough in detecting HCC in most patients with cirrhosis. As a result, ultrasonography cannot effectively support an effective surveillance program for liver cirrhosis. The application of CT is comparable and MRIs are the more sensitive options in liver cirrhosis. This study also helped provide support for previous results in earlier studies, especially in relation to the specificity of US and the greater accuracy which is often apparent in MRI, as compared to CT and US in the diagnosis of liver cirrhosis. The results of this study also provide basis for future studies, especially those which relate to AFP and imaging studies in the diagnosis of liver cirrhosis. This study by Colli, et.al., (2006) however is a secondary research because it is a compilation and critical evaluation of other researches. As a result, this study has a lower reliability, especially when compared with randomized controlled trials. Nevertheless, this study is able to provide results which are relevant to the issue being discussed and the authors were able to apply reliable methods in their research process, thereby ensuring the validity of their study. C. Ultrasonography in liver cirrhosis Diagnostic ultrasonography for liver cirrhosis is part of the evaluation process for the disease. It is an imaging test which helps identify various image techniques. Through MRIs (Magnetic Resonance Imaging), alcoholic cirrhosis is clearly apparent with the enlargement of the caudate lobe and with the presence of a right posterior hepatic notch (Taylor, 2011). Through ultrasonography, the liver contour is often established and possible fatty infiltration may be seen and may indicate hepatitis or cirrhosis (Taylor, 2011). Various studies have been carried out on the role and impact of diagnostic ultrasonography among liver cirrhosis patients. The accuracy, sensitivity and specificity of ultrasonography in diagnosing liver cirrhosis have always been a major issue among practitioners. Under these considerations, Ong and Tan (2003) carried out their study in order to establish the accuracy of ultrasonography in diagnosing compensated liver cirrhosis in the clinical practice, outside the realm of clinical trials. The authors carried out their study from 1998 to 2001, covering patients undergoing liver biopsy and ultrasonography. There were 151 liver biopsies included with 88 patients also undergoing ultrasonography. Only 17 of the patients had cirrhosis diagnosed through the ultrasonography, only six however were verified via liver biopsies. Ten out of sixteen cases of cirrhosis were missed by ultrasonography. Based on the data gathered, the sensitivity of ultrasonography for liver cirrhosis is low, only at 37.5% with 84.7% specificity. All in all, the authors concluded that ultrasonography is not sensitive enough in establishing a clear diagnosis for liver cirrhosis in regular clinical practice. This study is adequately supported by the literature and the results presented. The population is however still very much limited, nevertheless, the researchers were able to come up with a specific group of respondents for their study. In effect, the results of this study are highly reliable and can be generalizable to a larger group of respondents sharing similar qualities. In a related study, authors O’Donohue and colleagues (2004) carried out their research by evaluating the clinical application and intra-observer and inter-observer variability of the Doppler ultrasonography assessment of the hepatic and portal vessels including the measurement of spleen size in the assessment of liver cirrhosis. The authors revealed that 71% of patients with cirrhosis also had enlarged spleens. They concluded that splenomegaly and abnormal HVP (hepatic vein profile) are important indicators in chronic liver disease and cirrhosis and can help provide accurate and reliable, as well as reproducible results in diagnosing the disease. This study was able to carry out a significant topic which is very much relevant to the current diagnosis of liver cirrhosis and related affectations. The background information was clear and was able to provide sufficient support for the research topic. The methodology applied, including the data gathering processes were sufficiently and clearly explained. The inclusion and exclusion criteria were also specified and such criteria appropriately fulfilled the needs of the researchers. The research process was adequately specified, thereby allowing repeatability of the process. The results were clearly presented and were then explained in detail. The outcome measures were based on the standard measures for the diagnostic processes. The discussion section also provided a clear interconnection between the variables and the results, including the previous known information about the subject matter. The conclusion was well-supported and was consistent with the results and the discussion portion. Limitations on the study were also related to the limited number of respondents which also limited the applicability of the results to a larger population. However, these results are very much consistent with the previous studies on the subject matter and are well supported by the clear processes of research applied by the researchers. D. Ultrasonography and its comparative accuracy Sahani, et.al., (2004) point out that ultrasonography are inexpensive diagnostic options, and are often easily accessible to patients and clinical practitioners. It is an accurate and reliable test in screening the liver for obstructions or the gall bladder for any affectation; it is also useful in evaluating vascular patency. It is also a test which is very much sensitive in distinguishing cysts from solid liver lesions (Sahani, et.al., 2004). However, when compared with other tests such as computerized tomography (CT) or magnetic resonance imaging (MRI), its sensitivity is relatively lower, especially in detecting focal liver lesions (Glover, et.al., 2002). Experienced operators are usually able to detect metastases in liver cancer however, these results were not apparent in other countries, especially the US (Teefey, et.al., 2005). Under these conditions, the sensitivity of ultrasonography has been low. Moreover, Paulson, et.al., (2001) also only support a 40% to 70% sensitivity of ultrasonography in the detection of liver cirrhosis, as well as the detection of liver carcinoma. The operators declare that ultrasonography are often unable to detect lesions on the liver which are less than a centimeter in size; and under these conditions, these ultrasonography are not reliable or sensitive tests in the detection of liver carcinoma. For diffuse liver disease, the sensitivity of ultrasonography is also low, and for pseudolesions, or focal fatty sparings, specificity is low, especially when considered in relation to other pathologic liver lesions (Sahani, et.al., 2004). Recent improvements in the use of ultrasonography, including laparoscopic ultrasonography has presented more favorable options in ultrasonography diagnosis. The use of laparoscopic ultrasonography has established a highly sensitive option in detecting liver lesions, especially those which are not apparent during routine preoperative imaging; it has also proven its value in preoperative imaging, and in assessing the impact of the lesions on the liver blood vessels, as well as the detection of liver cirrhosis (Schmidt, et.al., 2000). All in all, these studies provide valuable tools in the accurate and early detection of liver diseases, most especially those which have the potential to turn chronic or those which have high mortality rates. Due to the comparative sensitivity and specificity of other diagnostic imaging tests, this paper shall also evaluate the application of MRI and CT scans in the establishment of liver cirrhosis. E. Accuracy of ultrasonography in liver cirrhosis diagnosis In a study by Aube, et.al. (2004), the authors set out to evaluate whether ultrasonography, specifically new Doppler signs impacted on diagnostic accuracy on available markers for the assessment of cirrhosis. The authors covered 106 patients who were subjected to the following options: clinical biochemical, and Doppler ultrasonography (Aube, et.al., 2004). The authors were able to establish that cirrhosis can be accurately evaluated in about 90% of patients through Doppler ultrasonography techniques. The authors claimed that this form of diagnosis can also be used in the first line diagnosis of cirrhosis. The authors were able to establish a relevant issue which is very much related to this current study. They presented a strong background for their topic, justifying their issue through significant studies related to the subject matter. The inclusion and exclusion criteria for their respondents were also sufficiently explained and appropriately applied to the paper. The results were presented clearly in tables, using the variables relevant to the study promptly explained in relation to the outcome measures which were presented in the methodology. The methodology applied for the paper was very much appropriate, and helped ensure that all the aspects of the study would be adequately evaluated. Limitations of the study relate to the limited population which did not allow for a more generalized application of the study results. Nevertheless, the authors were able to undertake a comprehensive and reliable study which is very much relevant to the current topic of this paper. Nishiura, et.al., (2005) discuss that liver biopsy is the most accurate diagnostic option in establishing severe liver fibrosis. In their study, they sought to evaluate the diagnostic sensitivity and accuracy of ultrasonography via low frequency and high frequency probes; evaluating its repeatability, cost, and reliability in establishing chronic liver disease. The authors covered 103 patients with chronic liver disease, with 75% having liver cirrhosis. The patients underwent initial liver biopsies and ultrasonography using two frequency levels. The authors were able to establish that the ultrasonography scores were very much related to the fibrosis, the higher the scores in the ultrasonography, the higher the level of fibrosis. Moreover, Figure 5 of the Appendix indicates the improved imaging seen with the application of high frequency probes in ultrasonography, with fine parenchymal texture seen in high frequency probes, mildly coarse parenchymal texture with high frequency probes, coarse parenchymal texture with low frequency probe, and a highly coarse parenchymal texture with low frequency probes. In effect, the ultrasonography provided a specific evaluation on the level of fibrosis for patients, especially those with chronic liver diseases. The authors pointed out that the patients with “an accumulated score of 6.5 or more were all found to have fibrosis stage 4 which the accuracy of our scoring system for correctly predicting cirrhosis was found to be 100% sensitive” (Nishiura, et.al., 2005). The authors also pointed out that the ultrasonography of the stage of liver fibrosis using the scoring system via low and high frequency probes was considered reliable in establishing the stage of chronic liver disease, including liver cirrhosis. This study did not specifically focus on patients with liver cirrhosis, nevertheless, majority of the respondents had liver cirrhosis, and ultrasonography using low and high frequency probes was helpful in evaluating the stage of the patient’s liver damage or affectation. Although the study covered a limited population, the results are significant and can be related to specific results for evaluating stages of liver fibrosis. Establishing the stage of liver fibrosis guides practitioners on their patient assessment, and the severity of the patient’s disease, especially for patients with chronic affectations. In an earlier study, Aube and colleagues (1999) were able to point out an improved outlook on the use of ultrasonography in the diagnosis of liver cirrhosis. The study by Aube, et.al., (1999) was directed more towards the sensitivity and accuracy of abdominal ultrasonography in the diagnosis of cirrhosis or fibrosis. The authors covered a greater number of patients – 243 patients – having chronic liver disease, with 89% having liver cirrhosis. In contrast to the Ong and Tan study, Aube and colleagues were able to establish that the diagnostic accuracy of ultrasonography in diagnosing cirrhosis was at 84%. In a similar range, based on specific variables like compensated liver disease, alcoholic compensated chronic liver disease, and viral compensated chronic liver disease, the diagnostic accuracy of ultrasonography was in the 83% to 88% range. The authors declared that ultrasonography was very much sensitive and accurate in diagnosing patients with liver cirrhosis. However, the authors did indicate that due to the anatomical limitations of this technique, the accuracy of ultrasonography is decreased. In effect, the specificity of ultrasonography is low in terms of diagnosing liver cirrhosis and fibrosis. This was also mentioned previously by Ong and Tan and the results in this study are well supported and consistent in this aspect. As for other elements, mostly in relation to the accuracy of ultrasonography, these studies differ from each other. The Aube, et.al., (1999) study was able to cover a higher population and were able to cover various elements or variables in their research, thereby lending reliability to their results. 3. Limitations of ultrasonography and other modalities In the imaging process using ultrasonography in detecting liver cirrhosis, this process as discussed by Taylor, et.al., (1998) usually has low penetration among obese patients and patients with numerous air-filled bowel loops. It is also an imaging process which has low specificity in characterizing liver lesions (Taylor, et.al., 1998). This method is also operator dependent and its accuracy as well as its specificity can be influenced by the expertise (or lack thereof) of the operator. For patients with cirrhosis attributed to various risk factors, in relation to CT scanning, ultrasound seems to be less accurate (Fasani, et.al., 1999). The sensitivity of ultrasonography is also lower for those with heterogeneous livers, often causing the understaging of the cirrhosis. The understaging can cause bigger issues for the patient because it can deny patients certain treatment options which including transplantation or ablative therapy. The use of CT scans for patients with liver cirrhosis also has certain limitations and disadvantages. For one, it exposes the patient to radiation. For another, there is risk for allergy and nephropathy in the contrast agent if intravenous contrast is utilized (Thoeni, 1995). Taylor and Karani (2011) also discuss that although the scanning of the liver at various phases of contrast enhancement through CT scans is now routinely used for liver cirrhosis, it still as major limitations in identifying small lesions, those less than 2 cm, especially in patients with advanced cirrhosis. As for MRIs, this test has a low sensitivity. The homogeneity of the magnetic field is also crucial in establishing very clear images and any ferrous objects in the field can sometimes interfere with the homogeneity of the field. MRI is also very expensive to maintain and acquire for most hospitals, and for patients, it can be a costly diagnostic option. Patients with metal implants are also not allowed to undertake this test because of the magnetic process involved which can be dangerous for the patient. Taylor and Karani (2011) discuss that MRI also has a diagnostic accuracy very much similar to CT scans, especially with lesions over 1 cm in diameter. MRI has major limitations in terms of specific for the detection of small tumors. These limitations can however be overcome by major developments in tissue-specific contrast agents. Taouli, et.al., (2009) also discusses that image quality often needs improvement, especially at higher fields and liver fat as well as iron deposits can sometimes change diffusion assessments. Cardiac motion can also reduce the evaluation of the left liver lobe and respiration can also affect values in the right lobe. Discussion Early diagnosis of any disease is one of the key elements in its early management and treatment. For liver cirrhosis, using imaging studies can help establish accurate diagnosis. These imaging tests however can have various indications and accuracy. Choosing which can apply best for patients must be an issue which needs to be settled by research in order to ensure evidence-based practice. Based on the studies on the different types of imaging techniques for liver cirrhosis, it is apparent to note that depending on the focus of each of the studies, appropriate results can be seen. Most of the studies utilized appropriate quantitative research methods, however, limitations in these studies were mostly related to failure to indicate compliance with informed consent requirements. The population covered in these studies was more or less sufficient, with numbers computed based on overall population of liver cirrhosis sufferers. However, some of the studies had limited generalizability due to limited population covered, some of the studies were able to cover less than 50 respondents and covered only patients admitted to specific hospitals. Nevertheless, the essential elements for credible and valid research were complied with in terms of sample population computation, appropriate statistical tools, randomized sampling and grouping techniques, as well as detailed and logical correlations between variables. The studies also establish important results which can assist in the practice, including valid recommendations for the use of ultrasonography, CT, and MRI in imaging studies for liver cirrhosis. On further assessment of data established, it can be noted that ultrasounds are favorable options during the initial stages of the disease where initial symptoms of disease are seen. Ultrasounds is the test which is cheaper and more accessible, hence, using it to possibly rule out or detect any growth which may require further testing is a favorable option. Ultrasounds have low sensitivity as far as heterogeneous liver cirrhosis is concerned, but CT scans can be the better options for heterogeneous liver cirrhosis. Ultrasounds also assist more accurately in the establishment of the level of fibrosis seen in liver cirrhosis. Under these conditions, they serve as a favorable option in the early and accurate diagnosis of liver cirrhosis. Studies on comparative efficacy are however needed in order to establish the actual and updated accuracy of ultrasonography, CT scans, and MRIs in the diagnosis of liver cirrhosis. 4. New advantages which help in diagnosis of cirrhosis In recent years, new developments in liver imaging have been introduced into health care practice. For a while conventional ultrasonography has been playing a major role in liver imaging practices, however, as shown above, this diagnostic option has various limitations. With recent technological breakthroughs, including contrast-enhanced ultrasonography (CEUS), elastography, and volume and fusion imaging techniques, improvements in liver imaging have been seen. According to Correas and Pol (2012), CEUS has provided real-time detection of contrast enhancement, also ensuring identification of the hypervascular pattern, as well as a diagnostic criterion in hepatocellular cancer. The kinetics of this test is differentiated for benign lesions and it is a significant test in defining focal liver (Correas and Pol, 2012). Ultrasound contrast agent tolerance is better in routine clinical applications with hardly any contraindications for liver or renal disease. Another test, the ultrasound elastography is a non-invasive technique which helps in the detection and quantification of liver fibrosis, especially in ensuring its application in defining focal liver disease (Correas and Pol, 2012). In this test, the stiffness of the soft tissues in the images is utilized in order to detect or define the cirrhosis. Fibrosis or lesions in the liver are often detected by elastography in instances of liver cirrhosis (Ganne-Carrie, et.al., 2006) The study by Szklaruk (2009) discusses how recent enhancements in contrast agents with the use of gadoxetic acid have allowed for better diagnosis, detection, as well as localization of lesions. Figure 4 in the Appendix demonstrates side by side, the difference in the imaging using the gadoxetic acid-enhanced contrast agents. Gadoxetic acid-enhanced MRI has proven to be better than other contrast agents, especially in relation to accuracy and sensitivity; moreover, it has also presented with lower rates in false-positives (Szklaruk, 2009). It has also proven to be useful in specifying and defining lesions, and distinguishing them from metastatic lesions. With improved lesion detection, improved surgical therapies, including radiotherapy can be established for patients. 5. Conclusion Liver cirrhosis is a chronic disease which has a significant danger and impact on the overall health of the affected patient. The management of this disease is very much dependent on timely and accurate assessment and diagnosis of this disease. For which reason, diagnostic options, like ultrasonography, CT scanning, and MR imaging are three of the options being made available for this disease. This paper sought to establish a critical evaluation of studies carried out on the application of ultrasound in the diagnosis and management of liver cirrhosis. The studies above indicate that ultrasonography seems to be the most popular option in diagnosing liver cirrhosis, however, based on the studies indicated, the accuracy of ultrasonography is high, however its sensitivity and specificity can be low. Similar issues are also apparent in the use of CT scanning and MRIs, with accuracy and specificity being low in the diagnosis of liver cirrhosis. In relation to ultrasonography, CT scans are more specific and sensitive, however, MRIs are more specific and sensitive when compared to CT scans. For MRIs, it is important to maintain the homogeneity of the magnetic field in order to ensure very clear images. Ferrous objects in the field can also limit the homogeneity of the field. MRIs are also very expensive to maintain and acquire for most hospitals, and for patients, it can be a costly diagnostic option. The accuracy for all three imaging modalities is not however significant as they seem to present with more or less comparable accuracy levels. However, MRI and CT scanning processes may not be able to detect smaller lesions. There are also fewer risks associated with the use of ultrasounds, especially for pregnant women and those with metal implants. Ultrasounds are cheaper and more widely available as compared to MRIs and CT scans. Recent developments in medical technology and diagnostics have also presented various options for the detection of liver cirrhosis, especially with the introduction of contrast-enhanced ultrasonography (CEUS), elastography, and volume and fusion imaging techniques. These new options help support ultrasonography, MRI, and CT scans in the early and accurate diagnosis of liver cirrhosis. References American Liver Foundation, 2007. Cirrhosis of the liver [online]. http://findmeacure.com/2007/10/22/cirrhosis-of-the-liver/ [Accessed 01 August 2012]. Aube, C., Oberti, F., Korali, N., Namour, M., et.al., 1999. Ultrasonographic diagnosis of hepatic fibrosis or cirrhosis. J Hepatol., 30(3), 472-8. Bastati-Huber, N., Prosch, H., Baroud, S., Magnaldi, S., et.al., 2011. New developments in MRI of the liver. Radiology, 51(8), 680-7. Chamberlain, R., Decorato, D., and Jarnagin, W., n.d. Benign liver lesions. Sultan Qaboos University [online]. Available at: http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/Hepatobiliary%20Cancer/DOCS/Ch1.pdf [Accessed 01 August 2012]. Colli, A., Fraquelli, M., Casazza, G., Massironi, S., et.al., 2006. Accuracy of ultrasonography, spiral CT, magnetic resonance, and alpha-fetoprotein in diagnosing hepatocellular carcinoma: a systematic review. Am J Gastroenterol., 101(3):513-23. Correas, J. and Pol, S., 2012. New developments in ultrasound imaging for chronic liver diseases: from anatomic imaging to structural and functional imaging. Presse Med., 41(2), 153-68. Fasani, P, Sangiovanni, A., and De Fazio, C., 1999. High prevalence of multinodular hepatocellular carcinoma in patients with cirrhosis attributable to multiple risk factors. Hepatology, 29(6), 1704-7. Ganne-Carrie, N, Ziol, M., and de Ledinghen, V., 2006. Accuracy of liver stiffness measurement for the diagnosis of cirrhosis in patients with chronic liver diseases. Hepatology 44 (6), 1511–7. Glover, C., Douse, P., and Kane, P., 2002. Accuracy of investigations for asymptomatic colorectal liver metastases. Dis Colon Rectum, 45, 476–484. Guthrie, J., 2004. Cirrhosis and focal liver lesions: MRI findings. Imaging, 16, 351-363 Heidelbaugh, J. and Sherbondy, M., 2006. Cirrhosis and Chronic Liver Failure: Part II. Complications and Treatment. Am Fam Physician, 74(5), 767-776. Liu, W., Lim, J., Park, C., Kim, M., et.al., 2003. Poor sensitivity of sonography in detection of hepatocellular carcinoma in advanced liver cirrhosis: accuracy of pretransplantation sonography in 118 patients. European Radiology, 13(7), 1693-1698 Longstreth, G., 2011. Liver cirrhosis; Cryptogenic chronic liver disease. National Institute of Health [online]. Available at: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001301/ [Accessed 02 August 2012]. Nishiura, R., Watanabe, H., Ito, M., Matsuoka, Y., Yano, K., et.al., 2005. Ultrasound evaluation of the fibrosis stage in chronic liver disease by the simultaneous use of low and high frequency probes. British Journal of Radiology, 78, 189-197 O’Donohue, J., Ng, C., Catnach, S.., Farrant, P., et.al., Diagnostic value of Doppler assessment of the hepatic and portal vessels and ultrasound of the spleen in liver disease. European Journal of Gastroenterology & Hepatology, 16(2), 147-155. Ong, T., Tan, H., 2003. Ultrasonography is not reliable in diagnosing liver cirrhosis in clinical practice. Singapore Med J, 44(6), 293-295 Paulson, E., 2001. Evaluation of the liver for metastatic disease. Semin Liver Dis, 21, 225–236. Sahani, D. and Kalva, S., 2004. Imaging the liver. The Oncologist, 9(4), 385-397 Schmidt, J., Strotzer, M., and Fraunhofer, S., 2000. Intraoperative ultrasonography versus helical computed tomography and computed tomography with arterioportography in diagnosing colorectal liver metastases: lesion-by-lesion analysis. World J Surg, 24, 43–47. Sebastianes, P., Sales, D., Santos, J., Leao, A., et.al., 2010. Interobserver variability of ultrasound parameters in portal hypertension. Mem. Inst. Oswaldo Cruz, 105(4) Stocksley, M., 2001. Abdominal ultrasound. Cambridge: Cambridge University Press. Szklaruk, J., 2009. Recent developments in magnetic resonance imaging of the liver. US Gastroenterology & Hepatology Review, 5, 38-43 Taouli, B., Ehman, R., and Reeder, S., 2010. Advanced MRI methods for assessment of chronic liver disease. AJR Am J Roentgenol, 193(1), 14–27. Taylor, C., Karani, J., 2011. Cirrhosis imaging. Medscape [online]. Available at: http://emedicine.medscape.com/article/366426-overview#a21 [Accessed 01 August 2012]. Taylor, C., Garcia-Tsao, G., and Henson, B., 1998. Doppler ultrasound in the evaluation of cirrhotic patients: the prevalence of intrahepatic arteriovenous shunting, and implications for diagnosis of hepatocellular carcinoma. Ultrasound Med Biol., 23(8), 1155-63. Teefey, S., Hildeboldt, C., and Dehdashti, F., 2003. Detection of primary hepatic malignancy in liver transplant candidates: prospective comparison of CT, MR imaging, US, and PET. Radiology, 226, 533–542. The Scottish Government, 2008. Changing Scotland's relationship with alcohol: a discussion paper on our strategic approach [online]. Available at: http://www.scotland.gov.uk/Publications/2008/06/16084348/11 [Accessed 01 August 2012]. Thoeni, R., 1995. The role of imaging in patients with ascites. AJR, 165, 16-8. WebMD., 2009. Digestive disorders health center [online]. Available at: http://www.webmd.com/digestive-disorders/picture-of-the-liver [Accessed 01 August 2012]. Udell, J., Wang, C., Tinmouth, J., FitzGerald, J., et.al., 2012. Does this patient with liver disease have cirrhosis?. JAMA: the Journal of the American Medical Association, 307 (8): 832-42 Zheng, R., Huang, D., Zhang, B., Zhong-Zen, S., et.al., 2005. Comparison of ultrasonography, CT and MRI in the diagnosis of liver cirrhosis. World Chin J Digestol, 15, 13(8), 993-996 Appendix A The liver, overview The liver is a large organ found on the right side of the abdominal area (WebMD, 2009). It weighs about three pounds and is reddish brown in color. It has two major parts which is known to be its right and left lobes; the gallbladder lies under this organ, including portions of the pancreas and intestines (WebMD, 2009). The liver and the organs work with each other in order to digest and then process the food. It is the organ which helps in the filtration of the blood passing through the digestive system; it detoxifies the body of chemicals, and also allows for the metabolism of drugs. It secretes bile which is introduced into the intestines and helps in the digestion of fat. This organ also secretes proteins needed for blood clotting and other essential body functions. Various affectations impact on the liver, including hepatitis, cirrhosis, liver cancer, liver failure, ascites, gallstones, primary biliary cirrhosis, and hemachromatosis. Benign liver conditions are those which are often found by chance when unrelated conditions are being diagnosed among patients with known liver malignancies (Chamberlain, et.al., n.d). Symptoms which refer to these lesions will often eventually gain the attention of the patient, in some cases, the initial manifestation will be based on a disastrous event like rupture or hemorrhage (Chamberlain, et.al., n.d). Appendix B: Ultrasonography of cirrhotic liver Figure 1 (Sebastianes, et.al., 2010) Appendix C: CT scan of cirrhotic liver Figure 2 (American Liver Foundation, 2007) Appendix D: MRI of cirrhotic liver Figure 3 (Guthrie, 2004) Appendix E Figure 4 (Szklaruk, 2009) Appendix F (Nishiura, et.al., 2005) Appendix G: Liver cirrhosis mortality rate Table 1 (The Scottish Government, 2008) Appendix F. Pathophysiology of Liver cirrhosis Image 1 (Heidelbaugh, and Sherbondy, 2006) Read More