Keywords: Multiparametric Liver Ultrasound (MLUS), NAFLD screening in primary healthcare, Morfometric-ultrasound, APRI Score, artificial intelligence, Point of Care Ultrasonography(POCUS), .
Background:
NAFLD is a global public health issue, which progressively covers a spectrum of liver pathology, including steatosis, steatohepatitis, fibrosis, and cirrhosis, and their incidence increases exponentially. This study aimed to evaluate the diagnostic accuracy of the multiparametric-liver-ultrasonographic-screening with uses of artificial-intelligence performed by family doctors, compared to the evaluation performed by a specialist, at the targeted patients with a high-risk of NAFLD/NASH.
Research questions:
How can we improve the early diagnosis of NAFLD progression to NASH/fibrosis and cirrhosis to high-risk-patients in primary healthcare?
Method:
We conducted a multiparametric-liver-ultrasound-screening(MLUS) on 4751patients, with a high-risk of NAFLD/NASH, which presented as inclusion criteria: mixed dyslipidemia, obesity(BMI≥30), type2-diabetes, metabolic-syndrome(NCEP-criteria), chronic-lithiasis-cholecystitis, liver cirrhosis, chronic-hepatitis-B/hepatitis-C. APRI-score was initially calculated to stratify the fibrosis risk.
We use "standard-protocol", which could improve reproducibility and facilitate dynamic comparison, in grayscale, color/power-Doppler-US, and Strain-Elastography in standard-liver-scans as:transverse,oblique,and longitudinal-views. We established the cut-off/median-values(morphometric-ultrasound) of normal-ratios, between the anterior-posterior-diameters of the normal-liver-segments(Couinaud)/lobes, with the kidney/spleen-long-axis-ratio(not influenced by fatty-tissue-loading).
The high-risk-patients identified with NAFLD were first examined by a experienced-family-doctor subsequently compared with ultrasound-review by the specialist. We have developed a Smart-Computerized-Diagnostic-Algorithm of NAFLD/ NASH-pathology for US-diagnosis by family-physicians. The agreement between family-physicians and specialists on each finding was evaluated using Cohen’s-kappa-coefficient.
Results:
We identified 4751-patients with NAFLD/NASH,or cirrhosis and subsequently confirmed by the specialist. The positive-results of this screening were:2592 steatosis, NASH/steatofibrosis 971persons, and 22cases with Cirrhosis. The accuracy of liver-US-screening by family-physicians was:95,87% with95%CI=95.27%to96.42%,Sensitivity:97,12%,Specificity:91,59%, which were subsequently confirmed by the specialist as the"Gold-Standard"-method through fibroscan. The prevalence of liver-pathology was:77,48% with 95%CI:76,26%at78.66%. Reports of the two groups of specialists for identifying NAFLD/NASH showed a very-good strength of agreement-k=0.875;95%CI=0.864–0.887,standard-error:0,005.
Conclusions:
The uses of Multiparametric-Liver-Ultrasound-Screening(MLUS), morphometric-US(MUS), and artificial-intelligence(AI), performed by trained-family-physicians are comparable to diagnostic performed by the gastroenterologist. The use of a diagnostic-algorithm based on ratios between the axes of organs, using artificial-intelligence can identify early fatty-liver.
Points for discussion:
Is it possible to perform liver multiparametric ultrasound in a multidisciplinary screening team by family doctors specially trained in this regard?
How can artificial intelligence help us together with ultrasound technology as a diagnostic method in the practice of family doctors?
Can we consider clinical-morfometric-ultrasound as a means of diagnosing NAFLD(Nonalcoholic fatty liver disease) or NASH(Nonalcoholic-steatohepatitis) pathology by family physicians?