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Biliary malignancies include those arising from the intrahepatic and extrahepatic bile ducts as well as the gallbladder and hepatopancreatic ampulla of Vater. The majority of intrahepatic and extrahepatic malignancies are cholangiocarcinomas (CCAs). They arise owing to a complex interplay between the patient-specific genetic background and multiple risk factors and may occur in the liver (intrahepatic CCA), hilum (perihilar CCA), or extrahepatic bile ducts (distal CCA). Biliary-type adenocarcinoma constitutes the most common histologic type of ampullary and gallbladder malignancies. Its prognosis is poor and surgical resection is considered curative, so early detection is key, with multimodality imaging playing a central role in making the diagnosis. There are several risk factors for biliary malignancy as well as predisposing conditions that increase the risk; this review highlights the pertinent imaging features of these entities with histopathologic correlation. The predisposing factors are broken down into three major categories

Introduction: Early noninvasive detection of incipient liver damage is crucial to prevent long-term adverse health outcomes. A variety of scores to assess liver status have been proposed, mostly for adult populations. Validation of noninvasive hepatic scores to identify children at risk of metabolic dysfunction-associated fatty liver disease (MAFLD) is a gap in research, particularly in youth with severe obesity considering pubertal stage and sex. Methods: In a well-characterized pediatric population aged 9–19 years (n = 115), 19 published liver scores were analyzed. The area under the receiver operating characteristic curve (AUROC) for determination of MAFLD as assessed by magnetic resonance imaging was calculated. Results: The pediatric indices PNFI, B-AST, and M-APRI and several scores developed in adults significantly differed in children with MAFLD compared to children without, while some established indices did not. Only nonalcoholic fatty liver disease liver fat score (NAFLD-LFS) and the model by Cao et al. [PLoS One. 2013;8(12):e82092] showed acceptable predictive accuracy (AUROC >0.8) independently of pubertal stage and sex. When stratifying for pubertal stage and sex, the GSG-Index was superior in pubertal girls, and NAFLD-LFS performed best in pubertal boys. Conclusion: NAFLD-LFS and the model by Cao et al. [PLoS One. 2013;8(12):e82092] were well suited to predict MAFLD in youth with severe obesity. In pubertal children, GSG-Index and NAFLD-LFS performed best in girls and boys, respectively.

Relative enhancement (RE) in gadoxetate disodium (Gd-EOB-DTPA)-enhanced MRI is a reliable, non-invasive method for the evaluation and differentiation between simple steatosis and non-alcoholic steatohepatitis in adults. This study evaluated the diagnostic accuracy of RE in Gd-EOB-DTPA-enhanced liver MRI and hepatic fat fraction (HFF) in unenhanced liver MRI and ultrasound (US) for non-alcoholic fatty liver disease (NAFLD) screening in pediatric obesity. Seventy-four liver US and MRIs from 68 pediatric patients (13.07 ± 2.95 years) with obesity (BMI > BMI-for-age + 2SD) were reviewed with regard to imaging biomarkers (liver size, volume, echogenicity, HFF, and RE in Gd-EOB-DTPA-enhanced MRIs, and spleen size), blood biomarkers, and BMI. The agreement between the steatosis grade, according to HFF in MRI and the echogenicity in US, was moderate. Alanine aminotransferase correlated better with the imaging biomarkers in MRI than with those in US. BMI correlated better with liver size and volume on MRI than in US. In patients with RE < 1, blood biomarkers correlated better with RE than those in the whole sample, with a significant association between gamma-glutamyltransferase and RE (p = 0.033). In conclusion, the relative enhancement and hepatic fat fraction can be considered as non-invasive tools for the screening and follow-up of NAFLD in pediatric obesity, superior to echogenicity on ultrasound.

Objectives The 9th International Forum for Liver Magnetic Resonance Imaging (MRI) was held in Singapore in September 2019, bringing together radiologists and allied specialists to discuss the latest developments in and formulate consensus statements for liver MRI, including the applications of gadoxetic acid–enhanced imaging. Methods As at previous Liver Forums, the meeting was held over 2 days. Presentations by the faculty on days 1 and 2 and breakout group discussions on day 1 were followed by delegate voting on consensus statements presented on day 2. Presentations and discussions centered on two main meeting themes relating to the use of gadoxetic acid–enhanced MRI in primary liver cancer and metastatic liver disease. Results and conclusions Gadoxetic acid–enhanced MRI offers the ability to monitor response to systemic therapy and to assist in pre-surgical/pre-interventional planning in liver metastases. In hepatocellular carcinoma, gadoxetic acid–enhanced MRI provides precise staging information for accurate treatment decision-making and follow-up post therapy. Gadoxetic acid–enhanced MRI also has potential, currently investigational, indications for the functional assessment of the liver and the biliary system. Additional voting sessions at the Liver Forum debated the role of multidisciplinary care in the management of patients with liver disease, evidence to support the use of abbreviated imaging protocols, and the importance of standardizing nomenclature in international guidelines in order to increase the sharing of scientific data and improve the communication between centers. Key Points • Gadoxetic acid–enhanced MRI is the preferred imaging method for pre-surgical or pre-interventional planning for liver metastases after systemic therapy. • Gadoxetic acid–enhanced MRI provides accurate staging of HCC before and after treatment with locoregional/biologic therapies. • Abbreviated protocols for gadoxetic acid–enhanced MRI offer potential time and cost savings, but more evidence is necessary. The use of gadoxetic acid–enhanced MRI for the assessment of liver and biliary function is under active investigation.

OBJECTIVE Heterotaxy or isomerism of the atrial appendages is a congenital disorder with variable presentation, associated with both cardiac and non-cardiac anomalies, which may have a serious impact on fetal outcome. The aim of this exploratory study was to assess the value of fetal magnetic resonance imaging (MRI), as a complementary tool to ultrasound, for describing the morphological spectrum encountered in heterotaxy. METHODS This retrospective study included 27 fetuses that underwent fetal MRI following prenatal suspicion of heterotaxy on ultrasound from 1998 to 2019 in a tertiary referral center. Heterotaxy was classified as left atrial isomerism (LAI) or right atrial isomerism (RAI) based on fetal echocardiography (FE) examination. In addition to routine prenatal ultrasound, fetal MRI was offered routinely to enhance the diagnosis of non-cardiac anomalies, which might have been missed on ultrasound. Prenatal findings on ultrasound, FE and MRI were reviewed systematically and compared with those of postnatal imaging and autopsy reports. RESULTS Twenty-seven fetuses with heterotaxy and cardiovascular pathology, of which 19 (70%) had LAI and eight (30%) had RAI, were included. Seven (7/19 (37%)) fetuses with LAI had normal intracardiac anatomy, whereas all fetuses with RAI had a cardiac malformation. All 27 fetuses had non-cardiac anomalies on fetal MRI, including situs and splenic anomalies. In 12/19 (63%) fetuses with LAI, a specific abnormal configuration of the liver was observed on MRI. In three fetuses, fetal MRI revealed signs of total anomalous pulmonary venous connection obstruction. An abnormal bronchial tree pattern was suspected on prenatal MRI in 6/19 (32%) fetuses with LAI and 3/8 (38%) fetuses with RAI. CONCLUSIONS Visualization on MRI of non-cardiac anomalies in fetuses with suspected heterotaxy is feasible and can assist the complex diagnosis of this condition, despite its limitations. This modality potentially enables differentiation of less severe cases from more complex ones, which may have a poorer prognosis. Fetal MRI can assist in prenatal counseling and planning postnatal management. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Objectives Porto-sinusoidal vascular disorder (PSVD) is a recently defined vascular liver disease. Since diagnosis remains challenging, we aimed to evaluate radiological features that are distinct between PSVD and cirrhosis. Methods Clinical, laboratory, and radiological parameters (CT/MRI) of patients with histologically-confirmed PSVD vs. cirrhosis vs. non-cirrhotic parenchymal liver disease were retrospectively evaluated. Results Sixty-three PSVD, 155 cirrhosis, and 41 non-cirrhotic patients were included. As compared to cirrhosis, PSVD patients were younger and had lower HVPG, liver stiffness, and MELD. Routine clinical and imaging findings indicative of portal hypertension were similarly common. Intrahepatic portal tract abnormalities (49% vs. 15%; p < 0.001), FNH-like lesions (30% vs. 1%; p < 0.001), and abnormal liver morphology defined as peripheral parenchymal atrophy and compensatory hypertrophy of central segments (32% vs. 7%; p < 0.001) were significantly more common in PSVD patients. Hypertrophy of segment I (70% vs. 84%; p = 0.019), atrophy of segment IV (24% vs. 47%; p = 0.001), and nodular liver surface (22% vs. 89%; p < 0.001) were more common in patients with cirrhosis. In patients with gadoxetic acid–enhanced MRI, we identified the distinct imaging feature of “periportal hyperintensity” in the hepatobiliary phase (HBP) in 42% of patients with PSVD (14/33) vs. 1% in cirrhosis (1/95) vs. 0% in non-cirrhotic controls (0/41); p < 0.001). Conclusions Diagnosis of PSVD must be considered in younger patients presenting with clinical features of portal hypertension, portal tract abnormalities, and FNH-like lesions on CT/MRI. ‘Periportal hyperintensity’ in the HBP of gadoxetic acid–enhanced MRI was identified as a specific radiological feature of PSVD. Key Points • Cross-sectional imaging can provide essential information to identify patients with porto-sinusoidal vascular disorder (PSVD). • Intrahepatic portal tract abnormalities, FNH-like lesions, and abnormal liver morphology are common in PSVD patients. • Periportal hyperintensity on the hepatobiliary phase of gadoxetic acid–enhanced MRI seems to be specific for patients with PSVD.

Zusammenfassung Klinisches/methodisches Problem Bei der chronischen Pankreatitis (CP) handelt es sich um eine langanhaltende Entzündung der Bauchspeicheldrüse, welche die normale Struktur und Funktion des Organs schädigt. Das breite Spektrum an entzündlichen Pankreaserkrankungen umfasst einzelne Entitäten, wie die fokale Pankreatitis (FP) oder den Pseudotumor („mass-forming pancreatitis“), welche radiomorphologisch ein Adenokarzinom der Bauchspeicheldrüse (PDAC) nachahmen können. In weiterer Folge kann eine Fehldiagnose zu einem vermeidbaren und unnötigen operativen Eingriff oder zu einer Therapieverzögerung führen. Radiologische Standardverfahren Der Ultraschall (US) ist das primäre bildgebende Verfahren zur Abklärung von Pankreaserkrankungen, gefolgt von kontrastmittelverstärkter Computertomographie (KM-CT), die als meistverwendete Methode bei der diagnostischen Abklärung von Bauchspeicheldrüsenerkrankungen gilt. Die Magnetresonanztomographie (MRT) und/oder die MR-Cholangiopankreatographie (MRCP) können als Problemlöser eingesetzt werden, um zwischen soliden und zystischen Läsionen zu unterscheiden sowie auch Anomalien der Pankreasgänge auszuschließen, welche bei rezidivierender akuter Pankreatitis (AP) vorhanden sein können, oder um frühe Anzeichen einer CP zu visualisieren. Die MRCP hat dabei die diagnostische endoskopische retrograde Cholangiopankreatographie (ERCP) in der Abklärung von therapeutischen Interventionen im Wesentlichen ersetzt. Empfehlung für die Praxis Folgender Übersichtsartikel fasst die relevanten Merkmale in der Computertomographie (CT) und MRT zusammen, um eine akkurate, frühzeitige Diagnose einer CP zu stellen und eine Differenzierung zwischen FP und Pankreaskarzinom zu ermöglichen, um somit – auch in schwierigen Fällen – ein adäquates Therapiemanagement zu gewährleisten.

Background Obesity-associated chronic low-grade inflammation leads to dysregulation of central lipid and glucose metabolism pathways leading to metabolic disorders. MicroRNAs (miRNAs) are known to control regulators of metabolic homeostasis. We aimed to assess the relationship of circulating miRNAs with inflammatory modulators and metabolic disorders in pediatric obesity. Methods From a pediatric cohort with severe obesity (n = 109), clinically thoroughly characterized including diverse routine blood parameters, oral glucose tolerance test, and liver MRI, a panel of 16 circulating miRNAs was quantified using qRT-PCR. Additionally, markers of inflammation TNFα, IL1 receptor antagonist, procalcitonin, CRP, and IL-6 were measured. Results Markers of obesity-associated inflammation, TNFα, IL-1Ra, and procalcitonin, all significantly correlated with concentrations of miRNAs 122 and 192. Concentrations of these miRNAs negatively correlated with serum adiponectin and were among those strongly linked to parameters of dyslipidemia and liver function. Moreover, miRNA122 concentrations correlated with HOMA-IR. Several miRNA levels including miRNAs 34a, 93, 122, and 192 were statistically significantly differing between individuals with prediabetes, impaired glucose tolerance, metabolic syndrome, or nonalcoholic fatty liver disease compared to the respective controls. Additionally, miRNA 192 was significantly elevated in metabolically unhealthy obesity. Conclusions A miRNA pattern associated with obesity-associated inflammation and comorbidities may be used to distinguish metabolically healthy from unhealthy pediatric patients with obesity. Moreover, these changes in epigenetic regulation could potentially be involved in the etiology of obesity-linked metabolic disease in children and adolescents.

Chronic pancreatitis (CP) is a long-lasting inflammation of the pancreas that changes the normal structure and function of the organ. There are a wide range of inflammatory pancreatic diseases, of which some entities, such as focal pancreatitis (FP) or "mass-forming pancreatitis," can mimic pancreatic ductal adenocarcinoma (PDAC). As a consequence, a misdiagnosis can lead to avoidable and unnecessary surgery or delay of therapy.The initial imaging method used in pancreatic diseases is ultrasound due to its availability and low cost, followed by contrast-enhanced computed tomography (CE-CT), which is considered a workhorse in the diagnostic work-up of diseases of the pancreas. Magnetic resonance imaging (MRI) and/or MR cholangiopancreatography (MRCP) can be used as a problem-solving tool to distinguish between solid and cystic lesions, and to rule out abnormalities in the pancreatic ducts, such as those associated with recurrent acute pancreatitis (AP) or to show early signs of CP. MRCP has essentially replaced diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in the initial assessment before any therapeutic intervention.The following review article summarizes the relevant features of CT and MRI that can help to make the diagnosis of CP and to aid in the differentiation between focal pancreatitis and PDAC, even in difficult cases.KLINISCHES/METHODISCHES PROBLEM: Bei der chronischen Pankreatitis (CP) handelt es sich um eine langanhaltende Entzündung der Bauchspeicheldrüse, welche die normale Struktur und Funktion des Organs schädigt. Das breite Spektrum an entzündlichen Pankreaserkrankungen umfasst einzelne Entitäten, wie die fokale Pankreatitis (FP) oder den Pseudotumor („mass-forming pancreatitis“), welche radiomorphologisch ein Adenokarzinom der Bauchspeicheldrüse (PDAC) nachahmen können. In weiterer Folge kann eine Fehldiagnose zu einem vermeidbaren und unnötigen operativen Eingriff oder zu einer Therapieverzögerung führen.Der Ultraschall (US) ist das primäre bildgebende Verfahren zur Abklärung von Pankreaserkrankungen, gefolgt von kontrastmittelverstärkter Computertomographie (KM-CT), die als meistverwendete Methode bei der diagnostischen Abklärung von Bauchspeicheldrüsenerkrankungen gilt. Die Magnetresonanztomographie (MRT) und/oder die MR-Cholangiopankreatographie (MRCP) können als Problemlöser eingesetzt werden, um zwischen soliden und zystischen Läsionen zu unterscheiden sowie auch Anomalien der Pankreasgänge auszuschließen, welche bei rezidivierender akuter Pankreatitis (AP) vorhanden sein können, oder um frühe Anzeichen einer CP zu visualisieren. Die MRCP hat dabei die diagnostische endoskopische retrograde Cholangiopankreatographie (ERCP) in der Abklärung von therapeutischen Interventionen im Wesentlichen ersetzt. EMPFEHLUNG FüR DIE PRAXIS: Folgender Übersichtsartikel fasst die relevanten Merkmale in der Computertomographie (CT) und MRT zusammen, um eine akkurate, frühzeitige Diagnose einer CP zu stellen und eine Differenzierung zwischen FP und Pankreaskarzinom zu ermöglichen, um somit – auch in schwierigen Fällen – ein adäquates Therapiemanagement zu gewährleisten.

Cholestasis is associated with disease severity and worse outcome in COVID-19. Cases of secondary sclerosing cholangitis (SSC) after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been described.Hospitalized patients with COVID-19 between 03/2020 and 07/2021 were included. Patients were stratified as having (i) no chronic liver disease (CLD), (ii) non-advanced CLD (non-ACLD), or (iii) advanced CLD (ACLD). Patients with CLD and non-COVID-19 pneumonia were matched to patients with CLD and COVID-19 as a control cohort. Liver chemistries before (Pre) and at first, second, and third blood withdrawal after SARS-CoV-2 infection (T1-T3) and at last available time point (last) were recorded. A total of 496 patients were included. In total, 13.1% (n = 65) had CLD (non-ACLD: 70.8%; ACLD: 29.2%); the predominant etiology was NAFLD/NASH (60.0%). COVID-19-related liver injury was more common among patients with CLD (24.6% vs. 10.6%; p = 0.001). After SARS-CoV-2 infection, patients with CLD exhibited progressive cholestasis with persistently increasing levels of alkaline phosphatase (Pre: 91.0 vs. T1: 121.0 vs. last: 175.0 U/L; p 0.001) and gamma-glutamyl transferase (Pre: 95.0 vs. T1: 135.0 vs. last: 202.0 U/L; p = 0.001). A total of 23.1% of patients with CLD (n = 15/65) developed cholestatic liver failure (cholestasis plus bilirubin ≥6 mg/dl) during COVID-19, and 15.4% of patients (n = 10/65) developed SSC. SSC was significantly more frequent among patients with CLD and COVID-19 than in patients with CLD and non-COVID-19 pneumonia (p = 0.040). COVID-19-associated SSC occurred predominantly in patients with NAFLD/NASH and metabolic risk factors. A total of 26.3% (n = 5/19) of patients with ACLD experienced hepatic decompensation after SARS-CoV-2 infection.About 20% of patients with CLD develop progressive cholestasis after SARS-CoV-2 infection. Patients with NAFLD/NASH and metabolic risk factors are at particular risk for developing cholestatic liver failure and/or SSC after COVID-19.

The introduction of hepatobiliary contrast agents, most notably gadoxetic acid (GA), has expanded the role of MRI, allowing not only a morphologic but also a functional evaluation of the hepatobiliary system. The mechanism of uptake and excretion of gadoxetic acid via transporters, such as organic anion transporting polypeptides (OATP1,3), multidrug resistance-associated protein 2 (MRP2) and MRP3, has been elucidated in the literature. Furthermore, GA uptake can be estimated on either static images or on dynamic imaging, for example, the hepatic extraction fraction (HEF) and liver perfusion. GA-enhanced MRI has achieved an important role in evaluating morphology and function in chronic liver diseases (CLD), allowing to distinguish between the two subgroups of nonalcoholic fatty liver diseases (NAFLD), simple steatosis and nonalcoholic steatohepatitis (NASH), and help to stage fibrosis and cirrhosis, predict liver transplant graft survival, and preoperatively evaluate the risk of liver failure if major resection is planned. Finally, because of its noninvasive nature, GA-enhanced MRI can be used for long-term follow-up and post-treatment monitoring. This review article aims to describe the current role of GA-enhanced MRI in quantifying liver function in a variety of hepatobiliary disorders.

Background & Aims To explore whether sarcopenia, diagnosed by an abbreviated magnetic resonance imaging (MRI) protocol is a risk factor for hepatic decompensation and mortality in patients with chronic liver disease (CLD). Methods In this retrospective single‐centre study we included 265 patients (164 men, mean age 54 ± 16 years) with CLD who had undergone MRI of the liver between 2010 and 2015. Transverse psoas muscle thickness (TPMT) was measured on unenhanced and contrast‐enhanced T1‐weighted and T2‐weighted axial images. Sarcopenia was defined by height‐adjusted and gender‐specific cut‐offs in women as TPMT

Background Gadoxetic acid-enhanced MRI enables estimation of liver function in patients with chronic liver disease (CLD). The functional liver imaging score (FLIS), derived from gadoxetic acid-enhanced MRI, has been shown to predict transplant-free survival in liver transplant patients. Purpose To investigate the accuracy of the FLIS for predicting hepatic decompensation and transplant-free survival in patients with CLD. Materials and Methods Patients with CLD who had undergone gadoxetic acid-enhanced liver MRI, including T1-weighted volume-interpolated breath-hold examination sequences with fat suppression, performed between 2011 and 2015 were included. FLIS was assigned on the basis of the sum of three hepatobiliary phase features, each scored on an ordinal 0-2 scale: hepatic enhancement, biliary excretion, and the signal intensity in the portal vein. Patients were stratified into the following three groups according to fibrosis stage and a presence or history of hepatic decompensation: nonadvanced CLD, compensated advanced CLD (CACLD), and decompensated advanced CLD (DACLD). The predictive value of FLIS for first and/or further hepatic decompensation and for transplant-free survival was investigated by using Kaplan-Meier analysis, log-rank tests, and Cox regression analysis. Results This study evaluated 265 patients (53 years ± 14 [standard deviation]; 164 men). Intraobserver (κ = 0.98; 95% confidence interval: 0.97, 0.99) and interobserver (κ = 0.93; 95% confidence interval: 0.90, 0.95) agreement for FLIS were excellent. In patients with CACLD, the FLIS was independently predictive of a first hepatic decompensation (adjusted hazard ratio, 3.7; 95% confidence interval: 1.1, 12.6; P = .04), but not for further hepatic decompensations in patients with DACLD (adjusted hazard ratio, 1.4; 95% confidence interval: 0.9, 1.9; P = .17). The FLIS was an independent risk factor for mortality in both patients with CACLD (adjusted hazard ratio, 7.4; 95% confidence interval: 2.7, 20.2; P < .001) and those with DACLD (adjusted hazard ratio, 3.8; 95% confidence interval: 1.7, 9.5; P = .004). Conclusion The functional liver imaging score derived from gadoxetic acid-enhanced MRI identified patients with advanced chronic liver disease who are at increased risk for a first hepatic decompensation and for mortality. © RSNA, 2019 Online supplemental material is available for this article.

Objectives To investigate the effect of saline-diluted gadoxetic acid, done for arterial-phase (AP) artifact reduction, on signal intensity (SI), and hence focal lesion conspicuity on MR imaging. Methods We retrospectively examined 112 patients who each had at least two serial gadoxetic acid–enhanced liver MRIs performed at 1 ml/s, first with non-diluted (ND), then with 1:1 saline-diluted (D) contrast. Two blinded readers independently analyzed the artifacts and graded dynamic images using a 5-point scale. The absolute SI of liver parenchyma, focal liver lesions (if present), aorta, and portal vein at the level of the celiac trunk and the SI of the paraspinal muscle were measured in all phases. The signal-to-norm (SINorm) of the vascular structures, hepatic parenchyma and focal lesions, and the contrast-to-norm (CNorm) of focal liver lesions were calculated. Results AP artifacts were significantly reduced with dilution. Mean absolute contrast-enhanced liver SI was significantly higher on the D exams compared to the ND exams. Likewise, SINorm of liver parenchyma was significantly higher in all contrast-enhanced phases except transitional phase on the D exams. SINorm values in the AP for the aorta and in the PVP for portal vein were significantly higher on the diluted exams. The CNorm was not significantly different between ND and D exams for lesions in any imaging phase. The interclass correlation coefficient was excellent (0.89). Conclusion Gadoxetic acid dilution injected at 1ml/s produces images with significantly fewer AP artifacts but no significant loss in SINorm or CNorm compared to standard non-diluted images. Key Points • Diluted gadoxetic acid at slow injection (1 ml/s) yielded images with higher SINormof the liver parenchyma and preservedCNormfor focal liver lesions. • Gadoxetic acid–enhanced MRI injected at 1 ml/s is associated with arterial-phase (AP) artifacts in 31% of exams, which maydegrade image quality and limits focal liver lesion detection. • Saline dilution of gadoxetic acid 1:1 combined with a slow injection rate of 1 ml/s significantly reduced AP artifacts from 31 to 9% and non-diagnostic AP artifacts from 16 to 1%.

Magnetic resonance imaging with magnetic resonance cholangiopancreatography (MRI-MRCP) in primary sclerosing cholangitis (PSC) is currently based on qualitative assessment and has high interobserver variability. We investigated the utility and performance of quantitative metrics derived from a three-dimensional biliary analysis tool in adult patients with PSC. MRI-MRCP, blood-based biomarkers, and FibroScan were prospectively performed in 80 participants with large-duct PSC and 20 healthy participants. Quantitative analysis was performed using MRCP+ (Perspectum Ltd., United Kingdom), and qualitative reads were performed by radiologists. Inter-reader agreements were compared. Patients were classified into high risk or low risk for disease progression, using Mayo risk score (MRS), Amsterdam-Oxford model (AOM), upper limit of normal (ULN) alkaline phosphatase (ALP), disease distribution, and presence of dominant stricture. Performance of noninvasive tools was assessed using binomial logistic regressions and receiver operating characteristic curve analyses. Quantitative biliary metrics performed well to distinguish abnormal from normal bile ducts (P < 0.0001). Interobserver agreements for MRCP+ dilatation metrics (intraclass correlation coefficient, 0.90-0.96) were superior to modified Amsterdam intrahepatic stricture severity score (κ = 0.74) and Anali score (κ = 0.38). MRCP+ intrahepatic dilatation severity showed excellent performance to classify patients into high-risk and low-risk groups, using predictors of disease severity as the reference (MRS, P < 0.0001; AOM, P = 0.0017; 2.2 × ULN ALP, P = 0.0007; 1.5 × ULN ALP, P = 0.0225; extrahepatic disease, P = 0.0331; dominant stricture, P = 0.0019). MRCP+ intrahepatic dilatation severity was an independent predictor of MRS >0 (odds ratio, 31.3; P = 0.035) in the multivariate analysis. Conclusion: Intrahepatic biliary dilatation severity calculated using MRCP+ is elevated in patients with high-risk PSC and may be used as an adjunct for risk stratification in PSC. This exploratory study has provided the groundwork for examining the utility of novel quantitative biliary metrics in multicenter studies.

Background ECCO essential requirements for quality cancer care (ERQCC) are checklists and explanations of organisation and actions that are necessary to give high-quality care to patients who have a specific type of cancer. They are written by European experts representing all disciplines involved in cancer care. ERQCC papers give oncology teams, patients, policymakers and managers an overview of the elements needed in any healthcare system to provide high quality of care throughout the patient journey. References are made to clinical guidelines and other resources where appropriate, and the focus is on care in Europe. Oesophageal and gastric: essential requirements for quality care • Oesophageal and gastric (OG) cancers are a challenging tumour group with a poor prognosis and wide variation in outcomes among European countries. Increasing numbers of older people are contracting the diseases, and treatments and care pathways are becoming more complex in both curative and palliative settings. • High-quality care can only be a carried out in specialised OG cancer units or centres which have both a core multidisciplinary team and an extended team of allied professionals, and which are subject to quality and audit procedures. Such units or centres are far from universal in all European countries. • It is essential that, to meet European aspirations for comprehensive cancer control, healthcare organisations implement the essential requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship. Conclusion Taken together, the information presented in this paper provides a comprehensive description of the essential requirements for establishing a high-quality OG cancer service. The ERQCC expert group is aware that it is not possible to propose a ‘one size fits all’ system for all countries, but urges that access to multidisciplinary units or centres must be guaranteed for all those with OG cancer.

Functional liver imaging score (FLIS) - derived from gadoxetic acid-enhanced MRI - correlates with liver function and independently predicts liver-related mortality in patients with chronic liver disease (CLD), while splenic craniocaudal diameter (SCCD) is a marker of portal hypertension. The aim of this study was to investigate the accuracy of a combination of FLIS and SCCD for predicting hepatic decompensation, acute-on-chronic liver failure (ACLF), and mortality in patients with advanced CLD (ACLD).We included 397 patients with CLD who underwent gadoxetic acid-enhanced liver MRI. The FLIS was calculated by summing the points (0-2) of 3 hepatobiliary-phase features: hepatic enhancement, biliary excretion, and portal vein signal intensity. Patients were stratified into 3 groups according to liver fibrosis severity and presence/history of hepatic decompensation: non-ACLD, compensated ACLD (cACLD), and decompensated ACLD (dACLD).SCCD showed excellent intra- and inter-reader agreement. Importantly, SCCD was an independent risk factor for hepatic decompensation in patients with cACLD (per cm; adjusted hazard ratio [aHR] 1.13; 95% CI 1.04-1.23; p = 0.004). Patients with cACLD and a FLIS of 0-3 points and/or a SCCD of13 cm were at increased risk of hepatic decompensation (aHR 3.07; 95% CI 1.43-6.59; p = 0.004). In patients with dACLD, a FLIS of 0-3 was independently associated with an increased risk of ACLF (aHR 2.81; 95% CI 1.16-6.84; p = 0.02), even after adjusting for other prognostic factors. Finally, a FLIS and SCCD-based algorithm was independently predictive of transplant-free mortality and stratified the probability of transplant-free survival (TFS) in ACLD (p0.001): FLIS 4-6 and SCCD ≤13 cm (5-year TFS of 84%) vs. FLIS 4-6 and SCCD13 cm (5-year TFS of 70%) vs. FLIS 0-3 (5-year TFS of 24%).The FLIS and SCCD are simple imaging markers that provide complementary information for risk stratification in patients with compensated and decompensated ACLD.Magnetic resonance imaging (MRI) can be used to assess the state of the liver. Previously the functional liver imaging score, which is based on MRI criteria, was developed as a measure of liver function and to predict the risk of liver-related complications or death. By combining this score with a measurement of spleen diameter, also using MRI, we generated an algorithm that could predict the risk of adverse liver-related outcomes in patients with advanced chronic liver disease.

Increasingly acute and chronic pancreatitis (AP and CP) are considered a continuum of a single entity. Nonetheless, if, after flare-up, the pancreas shows no residual inflammation, it is classified as AP. CP is characterised by a long cycle of worsening and waning glandular inflammation without the pancreas ever returning to its baseline structure or function. According to the International Consensus Guidelines on Early Chronic Pancreatitis, pancreatic inflammation must last at least 6 months before it can be labelled CP. The distinction is important because, unlike AP, CP can destroy endocrine and exocrine pancreatic function, emphasising the importance of early diagnosis. As typical AP can be diagnosed by clinical symptoms plus laboratory tests, imaging is usually reserved for those with recurrent, complicated or CP. Imaging typically starts with ultrasound and more frequently with contrast-enhanced computed tomography (CECT). MRI and/or MR cholangiopancreatography can be used as a problem-solving tool to confirm indirect signs of pancreatic mass, differentiate between solid and cystic lesions, and to exclude pancreatic duct anomalies, as may occur with recurrent AP, or to visualise early signs of CP. MR cholangiopancreatography has replaced diagnostic endoscopic retrograde cholangiopancreatography (ERCP). However, ERCP, and/or endoscopic ultrasound (EUS) remain necessary for transpapillary biliary or pancreatic duct stenting and transgastric cystic fluid drainage or pancreatic tissue sampling, respectively. Finally, positron emission tomography-MRI or positron emission tomography-CT are usually reserved for complicated cases and/or to search for extra pancreatic systemic manifestations. In this article, we discuss a broad spectrum of inflammatory pancreatic disorders and the utility of various modalities in diagnosing acute and chronic pancreatitis.

Purpose Gd-EOB-DTPA-enhanced liver MRI is frequently compromised by transient severe motion artifacts (TSM) in the arterial phase, which limits image interpretation for the detection and differentiation of focal liver lesions and for the recognition of the arterial vasculature before and after liver transplantation. The purpose of this study was to investigate which patient factors affect TSM in children who undergo Gd-EOB-DTPA-enhanced liver MRI and whether younger children are affected as much as adolescents. Methods One hundred and forty-eight patients (65 female, 83 male, 0.1–18.9 years old), who underwent 226 Gd-EOB-DTPA-enhanced MRIs were included retrospectively in this single-center study. The occurrence of TSM was assessed by three readers using a four-point Likert scale. The relation to age, gender, body mass index, indication for MRI, requirement for sedation, and MR repetition was investigated using uni- and multivariate logistic regression analysis. Results In Gd-EOB-DTPA-enhanced MRIs, TSM occurred in 24 examinations (10.6%). Patients with TSM were significantly older than patients without TSM (median 14.3 years; range 10.1–18.1 vs. 12.4 years; range 0.1–18.9, p Conclusion TSM in Gd-EOB-DTPA-enhanced liver MRI do not appear in children under the age of 10 years.

Background and Aims Portal hypertension (PH) and sarcopenia are common in patients with advanced chronic liver disease (ACLD). However, the interaction between PH and sarcopenia and their specific and independent impact on prognosis and mortality has yet to be systematically investigated in patients with ACLD. Methods Consecutive patients with ACLD and hepatic venous pressure gradient (HVPG) ≥10 mm Hg with available CT/MRI imaging were included. Sarcopenia was defined by transversal psoas muscle thickness (TPMT) at