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Chronic Liver Disease

Variant: 1   Chronic liver disease. Diagnosis and staging of liver fibrosis. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US shear wave elastography abdomen Usually Appropriate O
MR elastography abdomen Usually Appropriate O
US abdomen May Be Appropriate O
US abdomen with IV contrast May Be Appropriate O
US duplex Doppler abdomen May Be Appropriate O
MRI abdomen without and with hepatobiliary contrast May Be Appropriate O
MRI abdomen without and with IV contrast May Be Appropriate O
MRI abdomen without IV contrast May Be Appropriate O
CT abdomen with IV contrast multiphase May Be Appropriate ☢☢☢☢
CT abdomen without IV contrast Usually Not Appropriate ☢☢☢
CT abdomen without and with IV contrast Usually Not Appropriate ☢☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Variant: 2   Chronic liver disease. No prior diagnosis of hepatocellular carcinoma (HCC). Screening and surveillance for HCC.
Procedure Appropriateness Category Relative Radiation Level
US abdomen Usually Appropriate O
MRI abdomen without and with hepatobiliary contrast Usually Appropriate O
MRI abdomen without and with IV contrast Usually Appropriate O
US duplex Doppler abdomen May Be Appropriate (Disagreement) O
MRI abdomen without IV contrast May Be Appropriate O
CT abdomen with IV contrast multiphase May Be Appropriate (Disagreement) ☢☢☢☢
US abdomen with IV contrast Usually Not Appropriate O
US shear wave elastography abdomen Usually Not Appropriate O
MR elastography abdomen Usually Not Appropriate O
CT abdomen without IV contrast Usually Not Appropriate ☢☢☢
CT abdomen without and with IV contrast Usually Not Appropriate ☢☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Variant: 3   Chronic liver disease. Previous diagnosis of HCC. Post-treatment monitoring for HCC.
Procedure Appropriateness Category Relative Radiation Level
MRI abdomen without and with hepatobiliary contrast Usually Appropriate O
MRI abdomen without and with IV contrast Usually Appropriate O
CT abdomen with IV contrast multiphase Usually Appropriate ☢☢☢☢
CT abdomen without and with IV contrast Usually Appropriate ☢☢☢☢
US abdomen May Be Appropriate O
US abdomen with IV contrast May Be Appropriate O
MRI abdomen without IV contrast May Be Appropriate O
US duplex Doppler abdomen Usually Not Appropriate O
US shear wave elastography abdomen Usually Not Appropriate O
MR elastography abdomen Usually Not Appropriate O
CT abdomen without IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Mustafa R. Bashir, MDa; Jeanne M. Horowitz, MDb; Ihab R. Kamel, MD, PhDc; Hina Arif-Tiwari, MDd; Sumeet K. Asrani, MD, MSce; Victoria Chernyak, MD, MSf; Alan Goldstein, MDg; Joseph R. Grajo, MDh; Nicole M. Hindman, MDi; Aya Kamaya, MDj; Michelle M. McNamara, MDk; Kristin K. Porter, MD, PhDl; Lilja B. Solnes, MD, MBAm; Pavan K. Srivastava, MDn; Atif Zaheer, MDo; Laura R. Carucci, MDp.
Summary of Literature Review
Introduction/Background
Discussion of Procedures by Variant
Variant 1: Chronic liver disease. Diagnosis and staging of liver fibrosis. Initial imaging.
Variant 1: Chronic liver disease. Diagnosis and staging of liver fibrosis. Initial imaging.
A. CT Abdomen
Variant 1: Chronic liver disease. Diagnosis and staging of liver fibrosis. Initial imaging.
B. FDG-PET/CT Skull Base to Mid-Thigh
Variant 1: Chronic liver disease. Diagnosis and staging of liver fibrosis. Initial imaging.
C. MR Elastography Abdomen 
Variant 1: Chronic liver disease. Diagnosis and staging of liver fibrosis. Initial imaging.
D. MRI Abdomen
Variant 1: Chronic liver disease. Diagnosis and staging of liver fibrosis. Initial imaging.
E. US Abdomen
Variant 1: Chronic liver disease. Diagnosis and staging of liver fibrosis. Initial imaging.
F. US Abdomen with IV Contrast
Variant 1: Chronic liver disease. Diagnosis and staging of liver fibrosis. Initial imaging.
G. US Shear Wave Elastography Abdomen
Variant 1: Chronic liver disease. Diagnosis and staging of liver fibrosis. Initial imaging.
H. US Duplex Doppler Abdomen
Variant 2: Chronic liver disease. No prior diagnosis of hepatocellular carcinoma (HCC). Screening and surveillance for HCC.
Variant 2: Chronic liver disease. No prior diagnosis of hepatocellular carcinoma (HCC). Screening and surveillance for HCC.
A. CT Abdomen
Variant 2: Chronic liver disease. No prior diagnosis of hepatocellular carcinoma (HCC). Screening and surveillance for HCC.
B. FDG-PET/CT Skull Base to Mid-Thigh
Variant 2: Chronic liver disease. No prior diagnosis of hepatocellular carcinoma (HCC). Screening and surveillance for HCC.
C. MR Elastography Abdomen
Variant 2: Chronic liver disease. No prior diagnosis of hepatocellular carcinoma (HCC). Screening and surveillance for HCC.
D. MRI Abdomen
Variant 2: Chronic liver disease. No prior diagnosis of hepatocellular carcinoma (HCC). Screening and surveillance for HCC.
E. US Abdomen
Variant 2: Chronic liver disease. No prior diagnosis of hepatocellular carcinoma (HCC). Screening and surveillance for HCC.
F. US Abdomen with IV Contrast
Variant 2: Chronic liver disease. No prior diagnosis of hepatocellular carcinoma (HCC). Screening and surveillance for HCC.
G. US Shear Wave Elastography Abdomen
Variant 2: Chronic liver disease. No prior diagnosis of hepatocellular carcinoma (HCC). Screening and surveillance for HCC.
H. US Duplex Doppler Abdomen
Variant 3: Chronic liver disease. Previous diagnosis of HCC. Post-treatment monitoring for HCC.
Variant 3: Chronic liver disease. Previous diagnosis of HCC. Post-treatment monitoring for HCC.
A. CT Abdomen
Variant 3: Chronic liver disease. Previous diagnosis of HCC. Post-treatment monitoring for HCC.
B. FDG-PET/CT Skull Base to Mid-Thigh
Variant 3: Chronic liver disease. Previous diagnosis of HCC. Post-treatment monitoring for HCC.
C. MR Elastography Abdomen 
Variant 3: Chronic liver disease. Previous diagnosis of HCC. Post-treatment monitoring for HCC.
D. MRI Abdomen
Variant 3: Chronic liver disease. Previous diagnosis of HCC. Post-treatment monitoring for HCC.
E. US Abdomen
Variant 3: Chronic liver disease. Previous diagnosis of HCC. Post-treatment monitoring for HCC.
F. US Abdomen with IV Contrast
Variant 3: Chronic liver disease. Previous diagnosis of HCC. Post-treatment monitoring for HCC.
G. US Shear Wave Elastography Abdomen
Variant 3: Chronic liver disease. Previous diagnosis of HCC. Post-treatment monitoring for HCC.
H. US Duplex Doppler Abdomen
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
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The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.