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影像学检查在慢加急性肝衰竭中的应用
DOI: 10.12449/JCH260129
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作者贡献声明：肖涵负责查阅文献，撰写论文；原雨航负责补充查阅文献；徐卫玲负责提供修改意见并最终定稿。
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摘要: 慢加急性肝衰竭（ACLF）是在慢性肝病基础上出现的多器官衰竭综合征，短期病死率极高，其诊断标准在全球范围内尚未统一。影像学检查在ACLF的评估与预后预测中发挥重要作用，可以构成从形态、功能到血流动力学的多维度评估体系。计算机断层扫描可用于测量肝脏体积及诊断肌少症，提供关键的形态学与营养状态参数。磁共振成像特别是钆贝葡胺增强扫描，能实现肝功能定量评估，对预测短期生存率具有重要意义。超声及其弹性成像技术则通过无创测量肝脏硬度和血流动力学参数，实现早期预警ACLF发病和病程动态监测。本文系统综述了3种不同影像学检查在ACLF诊断及病情监测中的关键作用，有助于整合多种影像学优势，并可联合临床指标构建诊疗模型，可作为未来实现ACLF早期干预、改善临床结局的关键方向。
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关键词:
- 慢加急性肝衰竭 /
- 体层摄影术， X线计算机 /
- 磁共振成像 /
- 超声检查
Abstract: Acute-on-chronic liver failure （ACLF） is a syndrome of multiple organ failure on the basis of underlying chronic liver disease and has an extremely high short-term mortality rate， while there is still a lack of unified diagnostic criteria around the world. Radiology plays an important role in the evaluation and prognostic prediction of ACLF， constituting a multi-dimensional assessment system covering morphology， function， and hemodynamics. Computed tomography can be used for the measurement of liver volume and the diagnosis of sarcopenia by providing key morphological and nutritional parameters. Magnetic resonance imaging （MRI）， especially gadobenate dimeglumine-enhanced MRI， enables quantitative assessment of liver function and has critical significance for predicting short-term survival rate. Ultrasonography and elastography techniques facilitate the early warning of ACLF onset and the dynamic monitoring of its progression through noninvasive measurement of liver stiffness and hemodynamic parameters. This article systematically reviews the pivotal role of these three imaging modalities in the diagnosis and monitoring of ACLF， and integrating the strengths of multiple imaging techniques with clinical indicators to construct diagnostic and prognostic models may become a key future direction for achieving early intervention and improving clinical outcomes in ACLF. -
表 1 影像学检查技术在ACLF中应用的优势与不足
Table 1. Advantages and limitations of radiological techniques in the application of ACLF
影像学
技术核心优势 主要局限 CT 快速、高分辨率，精准量化肝脏定量指标；能谱CT可定量细胞外
容积，助力预后预测；与临床指标结合，可以构建高精度预后模型辐射剂量相对较大，限制重复扫描；功能性评估能
力有限，依赖对比剂；软组织对比度低于MRIMRI 无辐射困扰，利用肝特异性对比剂可进行肝功能定量；可同时评
估肝性脑病相关脑部改变；可测量无脂肪肌肉量等肌少症诊断
的精细指标检查时间长，危重患者耐受性差；扫描成本高，设备
普及度低；对伪影敏感；部分患者（如幽闭恐惧症）
禁忌US 无辐射、实时、低成本，适于动态监测；利用弹性成像及多普勒超
声进行无创肝功能评估；深度学习模型可提升预后预测性能操作者依赖性强；结果易受患者体型、肠气干扰；深
部病变显示能力有限注：CT，计算机体层成像；MRI，磁共振成像；US，超声。
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[1] XIANG XG, SHANG DB, ZHANG JM. The definition and pathogenesis of acute-on-chronic liver failure[J]. J Clin Hepatol, 2023, 39( 10): 2281- 2287. DOI: 10.3969/j.issn.1001-5256.2023.10.003.项晓刚, 尚大宝, 张金铭. 慢加急性肝衰竭的疾病定义及发病机制[J]. 临床肝胆病杂志, 2023, 39( 10): 2281- 2287. DOI: 10.3969/j.issn.1001-5256.2023.10.003. [2] MOREAU R, JALAN R, GINES P, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis[J]. Gastroenterology, 2013, 144( 7): 1426- 1437, 1437.e1- 9. DOI: 10.1053/j.gastro.2013.02.042. [3] SARIN SK, CHOUDHURY A, SHARMA MK, et al. Acute-on-chronic liver failure: Consensus recommendations of the Asian Pacific association for the study of the liver(APASL): An update[J]. Hepatol Int, 2019, 13( 4): 353- 390. DOI: 10.1007/s12072-019-09946-3. [4] SARIN SK, CHOUDHURY A, SHARMA MK, et al. Acute-on-chronic liver failure: Consensus recommendations of the Asian Pacific association for the study of the liver(APASL): An update[J]. Hepatol Int, 2019, 13( 4): 353- 390. DOI: 10.1007/s12072-019-09946-3. [5] WU TZ, LI J, SHAO L, et al. Development of diagnostic criteria and a prognostic score for hepatitis B virus-related acute-on-chronic liver failure[J]. Gut, 2018, 67( 12): 2181- 2191. DOI: 10.1136/gutjnl-2017-314641. [6] USUKI N, MIYAMOTO T. Chronic hepatic disease: Usefulness of serial CT examinations[J]. J Comput Assist Tomogr, 2002, 26( 3): 418- 421. DOI: 10.1097/00004728-200205000-00017. [7] YAMAGISHI Y, SAITO H, EBINUMA H, et al. A new prognostic formula for adult acute liver failure using computer tomography-derived hepatic volumetric analysis[J]. J Gastroenterol, 2009, 44( 6): 615- 623. DOI: 10.1007/s00535-009-0045-7. [8] HU CH, JIANG N, ZHENG J, et al. Liver volume based prediction model for patients with hepatitis B virus-related acute-on-chronic liver failure[J]. J Hepatobiliary Pancreat Sci, 2022, 29( 12): 1253- 1263. DOI: 10.1002/jhbp.1112. [9] XU Y, LI FK, LIU B, et al. A short-term predictive model for disease progression in acute-on-chronic liver failure: Integrating spectral CT extracellular liver volume and clinical characteristics[J]. BMC Med Imaging, 2025, 25( 1): 69. DOI: 10.1186/s12880-025-01600-9. [10] XU Y, LI YF, LI SL, et al. Dual-energy CT quantification of extracellular liver volume predicts short-term disease progression in patients with hepatitis B liver cirrhosis-acute decompensation[J]. Insights Imaging, 2023, 14( 1): 51. DOI: 10.1186/s13244-023-01393-x. [11] ARROYO V, MOREAU R, JALAN R. Acute-on-chronic liver failure[J]. N Engl J Med, 2020, 382( 22): 2137- 2145. DOI: 10.1056/nejmra1914900. [12] LAI M, XU MM, WANG X, et al. Prognostic evaluation of liver transplantation for acute-on-chronic liver failure[J]. Organ Transplant, 2025, 16( 3): 482- 488. DOI: 10.12464/j.issn.1674-7445.2025002.赖曼, 徐曼曼, 王鑫, 等. 慢加急性肝衰竭肝移植预后评估[J]. 器官移植, 2025, 16( 3): 482- 488. DOI: 10.12464/j.issn.1674-7445.2025002. [13] WACKENTHALER A, MOLIÈRE S, ARTZNER T, et al. Pre-operative CT scan helps predict outcome after liver transplantation for acute-on-chronic grade 3 liver failure[J]. Eur Radiol, 2022, 32( 1): 12- 21. DOI: 10.1007/s00330-021-08131-1. [14] ZHOU C, LIU Y, LIANG XX, et al. A novel imaging index for predicting adverse progression in acute-on-chronic liver failure related to hepatitis B virus: The low erector spine index[J]. BMC Gastroenterol, 2023, 23( 1): 367. DOI: 10.1186/s12876-023-02995-x. [15] PENG H, ZHANG Q, LUO L, et al. A prognostic model of acute-on-chronic liver failure based on sarcopenia[J]. Hepatol Int, 2022, 16( 4): 964- 972. DOI: 10.1007/s12072-022-10363-2. [16] BAI J, XU MM, PENG FL, et al. A nomogram based on psoas muscle index predicting long-term cirrhosis incidence in non-cirrhotic patients with HBV-related acute-on-chronic liver failure[J]. Sci Rep, 2023, 13( 1): 21265. DOI: 10.1038/s41598-023-47463-4. [17] KHAN S, BENJAMIN J, MAIWALL R, et al. Sarcopenia is the independent predictor of mortality in critically ill patients with cirrhosis[J]. J Clin Transl Res, 2022, 8( 3): 200- 208. [18] LI TZ, XU MM, KONG M, et al. Use of skeletal muscle index as a predictor of short-term mortality in patients with acute-on-chronic liver failure[J]. Sci Rep, 2021, 11( 1): 12593. DOI: 10.1038/s41598-021-92087-1. [19] XU MM, LI TZ, KONG M, et al. Psoas muscle index can be used to predict long-term mortality in young male patients with acute-on-chronic liver failure[J]. Front Nutr, 2022, 9: 811826. DOI: 10.3389/fnut.2022.811826. [20] WANG J, BAI JJ, WANG HM, et al. Relationship between skeletal muscle index at the third lumbar vertebra with infection risk and long-term prognosis in patients with acute-on-chronic liver failure[J]. Front Nutr, 2024, 10: 1327832. DOI: 10.3389/fnut.2023.1327832. [21] GENG N, KONG M, ZHANG JT, et al. Dynamic skeletal muscle loss and its predictive role on 90-day mortality in patients with acute-on-chronic liver failure[J]. Front Nutr, 2025, 12: 1446265. DOI: 10.3389/fnut.2025.1446265. [22] KIRCHIN MA, PIROVANO GP, SPINAZZI A. Gadobenate dimeglumine(Gd-BOPTA). an overview[J]. Invest Radiol, 1998, 33( 11): 798- 809. DOI: 10.1097/00004424-199811000-00003. [23] POETTER-LANG S, BASTATI N, MESSNER A, et al. Quantification of liver function using gadoxetic acid-enhanced MRI[J]. Abdom Radiol, 2020, 45( 11): 3532- 3544. DOI: 10.1007/s00261-020-02779-x. [24] LIU CX, SHEN ZJ, MA H, et al. Gd-BOPTA-enhanced hepatobiliary phase MR imaging can predict the prognosis of patients with acute-on-chronic liver failure[J]. Eur Radiol, 2022, 32( 5): 3006- 3015. DOI: 10.1007/s00330-021-08440-5. [25] BASTATI N, BEER L, MANDORFER M, et al. Does the functional liver imaging score derived from gadoxetic acid-enhanced MRI predict outcomes in chronic liver disease?[J]. Radiology, 2020, 294( 1): 98- 107. DOI: 10.1148/radiol.2019190734. [26] BASTATI N, BEER L, BA-SSALAMAH A, et al. Gadoxetic acid-enhanced MRI-derived functional liver imaging score(FLIS) and spleen diameter predict outcomes in ACLD[J]. J Hepatol, 2022, 77( 4): 1005- 1013. DOI: 10.1016/j.jhep.2022.04.032. [27] LAN LJ, LU XF, SHU J. T(2) values for diagnosing acute-on-chronic liver failure in hepatitis B patients[J]. Curr Med Imaging, 2021, 17( 1): 129- 135. DOI: 10.2174/1573405616666200625152357. [28] DU YN, GUAN CS, LV ZB, et al. T2-weighted imaging and dynamic contrast-enhanced imaging in predicting the prognosis in patients with acute-on-chronic liver failure[J]. BMC Gastroenterol, 2023, 23( 1): 285. DOI: 10.1186/s12876-023-02920-2. [29] KANG TW, KIM M, KIM YK, et al. The qualitative and quantitative image analysis of MR imaging in patients with acute-on-chronic liver failure[J]. Clin Imaging, 2018, 47: 18- 24. DOI: 10.1016/j.clinimag.2017.08.004. [30] GUPTA T, DHIMAN RK, AHUJA CK, et al. Characterization of cerebral edema in acute-on-chronic liver failure[J]. J Clin Exp Hepatol, 2017, 7( 3): 190- 197. DOI: 10.1016/j.jceh.2017.04.001. [31] JADAUN SS, SHARMA S, MADHUSUDHAN KS, et al. Spectrum of neuroimaging abnormalities in brain in patients of acute-on-chronic liver failure[J]. J Clin Exp Hepatol, 2022, 12( 2): 343- 352. DOI: 10.1016/j.jceh.2021.08.007. [32] CHAVARRIA L, CORDOBA J. Magnetic resonance of the brain in chronic and acute liver failure[J]. Metab Brain Dis, 2014, 29( 4): 937- 944. DOI: 10.1007/s11011-013-9452-9. [33] PRAKTIKNJO M, BOOK M, LUETKENS J, et al. Fat-free muscle mass in magnetic resonance imaging predicts acute-on-chronic liver failure and survival in decompensated cirrhosis[J]. Hepatology, 2018, 67( 3): 1014- 1026. DOI: 10.1002/hep.29602. [34] JIN LZ, LI XF. MRI-defined sarcopenia predicts mortality in patients with chronic liver disease[J]. Liver Int, 2021, 41( 1): 223. DOI: 10.1111/liv.14691. [35] YUAN SS, HUANG XZ, WU XP, et al. A model based on two-dimensional shear wave elastography for acute-on-chronic liver failure development in patients with acutely decompensated hepatitis B cirrhosis[J]. Quant Imaging Med Surg, 2022, 12( 5): 2732- 2743. DOI: 10.21037/qims-21-871. [36] JIN JY, ZHENG YB, ZHENG J, et al. 2D shear wave elastography combined with MELD improved prognostic accuracy in patients with acute-on-chronic hepatitis B liver failure[J]. Eur Radiol, 2018, 28( 10): 4465- 4474. DOI: 10.1007/s00330-018-5336-z. [37] WU LL, JIN JY, ZHOU TC, et al. A prognostic nomogram with high accuracy based on 2D-SWE in patients with acute-on-chronic liver failure[J]. J Clin Transl Hepatol, 2022, 10( 5): 803- 813. DOI: 10.14218/JCTH.2021.00278. [38] VOGG J, MAIER-STOCKER C, MUNKER S, et al. Hepatic perfusion as a new predictor of prognosis and mortality in critical care patients with acute-on-chronic liver failure[J]. Front Med, 2022, 9: 1008450. DOI: 10.3389/fmed.2022.1008450. [39] SOLÍS-MUÑOZ PA, WILLARS C, WENDON J, et al. Interlobar artery resistive index predicts acute-on-chronic liver failure syndrome in cirrhotic patients with acute decompensation[J]. Ultraschall Med, 2018, 39( 1): 39- 47. DOI: 10.1055/s-0042-120258. [40] HUANG XZ, YUAN SS, ZHOU AY, et al. Predicting prognosis of patients with hepatitis B virus-related acute-on-chronic liver failure from longitudinal ultrasound images using a multi-task deep learning approach[J]. Ann Med, 2025, 57( 1): 2551819. DOI: 10.1080/07853890.2025.2551819. -
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