Performance of morphologic criteria for the diagnosis of cirrhosis in patients with non-alcoholic steatohepatitis compared to other etiologies of chronic liver disease: effect of level of training and experience

Purpose: To compare the diagnostic performance of morphologic criteria for detection of cirrhosis in patients with alcoholic liver disease (ALD), hepatitis C (HCV), and non-alcoholic steatohepatitis (NASH). Methods: One hundred patients (53 male) with different etiologies of chronic liver disease (NASH, n = 41; HCV, n = 39; and ALD, n = 20) and with different degrees of fibrosis on histopathologic examination (74 with cirrhosis) were retrospectively evaluated. Four readers (R1: fellowship-trained abdominal radiologist, R2: community attending radiologist, R3: senior radiology resident/research fellow, R4: junior radiology resident) analyzed the contrast-enhanced CTs for presence of commonly accepted morphologic changes of cirrhosis and portal hypertension. Each reader assigned an overall score (using a 5-point scale) for possibility of cirrhosis based on liver morphology and features of portal hypertension. Diagnostic performance, sensitivity, and specificity for the diagnosis of cirrhosis were calculated and compared between different etiologies of chronic liver disease. Results: Performance of readers was affected by their level of training. Less experienced readers had overall lower sensitivity for diagnosis of cirrhosis in NASH group (R3: 81.5%, R4: 63.0% compared to 96.3% for both R1 and R2). Sensitivities for detection of NASH cirrhosis significantly decreased for less experienced readers in the absence of ascites (R3: 75.0%, R4: 62.0%) or other features of portal hypertension (R3: 50.0%; R4: 0%). The specificity was consistently high among different etiologies and for all readers (85.7–100%). Inter-reader agreement for morphologic features ranged widely from fair to almost perfect (k: 0.23–0.85). Conclusion: Cirrhotic changes in NASH are subtler and can be underestimated by less experienced readers.