Title: Transient elastography for accurate staging of liver fibrosis and predicting complications in children with autoimmune hepatitis  

Source: Journal of Pediatric Gastroenterology and Nutrition 2026, Mar 16. [E–publication] 

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Date of publication: March 2026 

Publication type: Cohort study

Abstract: Objectives: Autoimmune hepatitis (AIH) presents as hepatitis, chronic or acute liver failure. Liver fibrosis may progress to liver cirrhosis. Pharmacological treatment aims to preserve liver function and induce remission. Transient elastography (FibroScan®, TE) has already been applied in many chronic liver diseases for non-invasive liver stiffness/fibrosis assessment. We aimed to evaluate the usefulness of liver stiffness measurement (LSM) in relation to liver fibrosis on biopsy, selected clinical features and laboratory markers of liver function in the largest paediatric AIH cohort studied.

Methods: We included 86 children with AIH (41 females) with a mean age of 14 years with AIH. Thirty-seven patients were naïve, and 49 had been previously pharmacologically treated. All patients underwent diagnostic or monitoring liver biopsy and LSM on TE. In selected cases, upper gastrointestinal (UGI) endoscopy was performed to search for oesophageal varices (EV). The relationship between LSM and fibrosis stage was analysed statistically. The optimal cut-off values of LSM were calculated to predict individual fibrosis stages and the presence of EV using the area under the receiver operating characteristic curve (AUROC).

Results: In our study, LSM was highly accurate in assessing fibrosis staging. LSM strongly correlated with liver fibrosis r = 0.81, p < 0.0001. TE discriminated patients with severe fibrosis (F ≥ 3) from others with excellent sensitivity and specificity-AUROC of LSM was 0.95 with an optimal cut-off point of 8.3 kPa. Similar results were produced when analysing naïve and treated patients. In addition, LSM showed prognostic value in predicting EV with AUROC of 0.77.

Conclusions: TE can be accurately and reliably used in children with AIH to diagnose and monitor liver fibrosis and its complications as portal hypertension. TE may help to identify patients with severe fibrosis who may require UGI surveillance, therapy modifications and possibly liver transplantation.

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Title: Vibration-controlled transient elastography in pediatric metabolic dysfunction-associated steatotic liver disease

Source: Journal of Pediatric Gastroenterology and Nutrition 2025, Dec 12. [E–publication]

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Date of publication: December 2025

Publication type: Prospective multicentre cohort study

Abstract: Objectives: Metabolic dysfunction-associated steatotic liver disease (MASLD) is a prevalent disease in children. Vibration-controlled transient elastography (VCTE) offers a noninvasive alternative to liver biopsy, using controlled attenuation parameter (CAP) to estimate steatosis and liver stiffness measurement (LSM) for fibrosis. However, pediatric data with histological validation are limited. This prospective, multicenter study evaluated the accuracy of CAP and LSM in pediatric MASLD.

Methods: Children with histologically confirmed MASLD from the Nonalcoholic Steatohepatitis Clinical Research Network (NASH CRN) Database 3 underwent VCTE within 6 months of liver biopsy. CAP was evaluated for correlation with steatosis grades, and LSM for correlation with fibrosis stages. The diagnostic performance of LSM in distinguishing fibrosis stages was analyzed using histological findings as the reference standard.

Results: Among 92 children with MASLD (mean age 13 ± 3 years), CAP values were similar across steatosis grades (median 325, 310, and 323 dB/m for grades 1-3, respectively) and showed no significant correlation with histologic steatosis (p = 0.422). Median LSM values increased with fibrosis stage (6.0-8.8 kPa), but significant differences were detected only between stage 0 and stage 3 fibrosis (p = 0.037). For advanced fibrosis (stages 3-4), area under the receiver operating characteristic curve was 0.67, with sensitivity 67%, specificity 76%, positive predictive value 40%, and negative predictive value 90%.

Conclusion: In this prospective, multicenter cohort, VCTE showed modest accuracy for grading steatosis or staging fibrosis in pediatric MASLD. Improved noninvasive methods are urgently needed for evaluation and monitoring in this population.

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Title: Endoscopic retrograde cholangiopancreatography as a diagnostic key tool for biliary atresia: feasibility, safety and accuracy in neonates with cholestatic liver disease

Source: European Journal of Pediatrics 2025, 185 (1): 16

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Date of publication: December 2025 

Publication type: Single-centre study 

Abstract: Biliary atresia (BA) is a rare condition in newborns characterised by inflammation and obliteration of bile ducts, leading to cirrhosis. Early diagnosis and treatment through Kasai portoenterostomy are crucial for native liver survival. While diagnostic methods include clinical assessment, laboratory tests and imaging, no non-invasive test can definitively rule out BA. Therefore, laparotomy with cholangiography remains the gold standard for diagnosis. This study assesses the feasibility, safety and accuracy of endoscopic retrograde cholangiopancreatography (ERCP) for diagnosing BA in newborns. The single-center study was conducted at the University Hospital Tübingen. The study included infants with neonatal cholestasis and suspected BA scheduled for ERCP from 2011 to 2023. We identified 60 jaundiced infants with suspected BA scheduled for diagnostic ERCP with a median age of 50 days. Endoscopy was technically feasible in 58/60 children. In 23 of 58 cases, the bile ducts could not be visualized, suggesting BA. Normal bile duct anatomy was visualized in 35/58 patients, and BA was ruled out. The sensitivity was 100%, the specificity was 92.1%, the negative predictive value was 1.0, and the positive predictive value was 0.87. We did not observe any significant complications post-ERCP (in particular, no bleeding, perforation or pancreatitis). However, in one case (1/60; 2%), protracted weaning after general anesthesia occurred.Conclusions: ERCP is a safe, effective and reliable tool for excluding BA in jaundiced infants. ERCP’s integration into the diagnostic algorithm can reduce the burden of surgical diagnostic procedures and enable early diagnosis and portoenterostomy, thereby improving transplant-free survival. What is known – What is new: • Biliary atresia (BA) is the leading cause of obstructive jaundice in neonates, requiring early surgical intervention for optimal outcomes. • Current diagnostic approaches are multimodal but lack a definitive, non-invasive method to exclude BA. • This study demonstrates that ERCP is not only technically feasible in infants as small as 2.6 kg but also highly reliable in excluding BA with 100% sensitivity, 92.1% specificity and a negative predictive value of 1.0. • ERCP is a key diagnostic tool for early exclusion of BA, offering greater diagnostic precision than ultrasound, liver biopsy, or laboratory parameters.

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Title: Magnetic resonance cholangiopancreatography for cholangiopathy after pediatric liver transplantation: a retrospective analysis and correlation with clinical outcome

Source: Pediatric Transplantation 2025, 29 (8): e70216  

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Date of publication: November 2025 

Publication type: Retrospective analysis 

Abstract: Background: Magnetic resonance cholangiopancreatography (MRCP) is used to analyze anastomotic strictures (AS) and non-anastomotic strictures (NAS) after pediatric liver transplantation (LT). We aimed to determine the incidence and severity of AS and NAS after pediatric LT by means of MRCP, and to correlate these to clinical outcome severity.

Methods: All children who underwent an LT in our center at age < 12 years between 2010 and 2022 were identified, and those who underwent MRCP were included. Next, two abdominal radiologists retrospectively graded AS (none/< 50%/≥ 50% stenosis) and NAS (none/mild/moderate/severe) on these MRCPs. After consensus, the grades of AS and NAS were correlated with incremental grades of severity of clinical outcomes, with a focus on non-invasive and invasive procedures. This was done for short- (≤ 3 months) and long-term follow-up.

Results: Out of 216 LTs at age < 12 years old, 25.5% (55/216) underwent MRCP after LT (median age 2.6 years; IQR 0.7-5.8 years). In the entire LT population, 24.1% (52/216) had some degree of AS or NAS on MRCP, of which 19.4% (42/216) had at least one significant abnormality (≥ 50% AS or moderate/severe NAS). In 6.0% (13/216) the combination of both moderate/severe NAS and ≥ 50% AS occurred. No correlation between AS/NAS severity and clinical outcome severity was observed.

Conclusions: Incidences of high-grade AS and moderate/severe NAS after pediatric LT were considerable. However, AS/NAS severity on MRCP did not correlate with the severity of clinical outcomes.

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Title: Prospective multicenter longitudinal measurement of liver stiffness in school-age children with cholestatic liver disease

Source: Gastro Hep Advances 2025, 4 (10): 100788 

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Date of publication: September 2025

Publication type: Multicenter prospective longitudinal study

Abstract: Background and aims: A multicenter prospective longitudinal study of vibration-controlled transient elastography (VCTE) in school-age children with biliary atresia (BA), alpha-1 antitrypsin deficiency (a1-AT) and Alagille syndrome (ALGS) was undertaken to test the hypothesis that there would be measurable disease progression over 2 years.

Methods: Vibration-controlled transient elastography was performed annually for 2 years in children with BA, a1-AT and ALGS.

Results: Valid liver stiffness measurement (LSM) was determined at baseline/second follow-up in 254/180 (71%), 104/58 (56%) and 100/61 (61%) participants (mean elapsed time 2.27 years) with BA, a1-AT and ALGS, respectively. Modeling did not reveal a relationship between LSM and time since baseline: BA 1.2% (-1.6, 4.2%), a1-AT 0.1% (-3.8, 4.2%), and ALGS 3.6% (-2.9, 10.5%) LSM (% change/year; mean [95% confidence interval]). Similarly, mean LSM did not change significantly from baseline to visit 2 (BA 13.6 + 11.0 vs 15.1 + 12.8; a1-AT 7.8 + 5.1 vs 8.5 + 7.6; ALGS 10.6 + 9.4 vs 12.2 + 12.1 kPa, mean + standard deviation). Albumin and total bilirubin levels did not change in these participants. Platelet counts dropped at rates that were similar to a national representative sample, the National Health and Nutrition Examination Survey (ie, 5000 to 7000/μL per year).

Conclusion: Surprisingly, longitudinal measurement of LSM and laboratory parameters of liver disease severity over 2 years in school-age children with compensated BA, a1-AT, and ALGS did not reveal significant change, consistent with slow progression of cholestatic liver disease in this age group. These findings have implications for both clinical care and interventional trials in this patient population.

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Title: Best practices for pediatric liver MRI: guidelines from members of the Society for Pediatric Radiology Magnetic Resonance and Abdominal Imaging Committees 

Source: Pediatric Radiology 2025, Sep 10. [E–publication]

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Date of publication: September 2025  

Publication type: Review article

Abstract: Magnetic resonance imaging (MRI) has become an essential tool in the evaluation of pediatric liver disease. However, the unique physiological, anatomical, and behavioral characteristics of pediatric patients present distinct challenges that necessitate tailored imaging strategies. These guidelines, developed by members of the Society for Pediatric Radiology (SPR) Magnetic Resonance and Abdominal Imaging Committees, provide comprehensive recommendations for performing high-quality liver MRI in children. Drawing on multidisciplinary expertise from pediatric radiologists, MRI physicists, and technologists across diverse institutions, the document addresses key technical considerations, including field strength selection, motion mitigation, contrast agent use, and age-specific protocol optimization. These guidelines aim to standardize and elevate the quality of pediatric liver MRI, offering practical, evidence-informed recommendations to support safe, efficient, and diagnostically robust imaging across a wide range of clinical scenarios.

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Title: Pediatric liver transplant: anatomic, imaging, and surgical considerations – a report of the Pediatric LI-RADS Working Group, from the AJR Special Series on Critical Anatomy

Source: American Journal of Roentgenology 2025, Aug 27. [E–publication]

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Date of publication: August 2025

Publication type: Review article 

Abstract: Liver transplant is the definitive treatment for children with end-stage liver disease, select metabolic disorders, and unresectable hepatic malignancies. Radiologists play a central role in the multidisciplinary transplant team, contributing to preoperative assessment, surgical planning, and postoperative surveillance. This article, a report from the Pediatric LI-RADS working group in collaboration with pediatric liver transplant surgeons, highlights the unique aspects of pediatric liver transplantation, focusing on critical anatomic, imaging, and surgical considerations specific to children. Use of the PRE-Treatment EXTent of tumor (PRETEXT) system for tumor staging is described, along with anatomic factors relevant to resectability and transplant eligibility. Particular attention is given to technical aspects of transplantation, including the frequent use of living donor and segmental grafts in pediatric recipients. Imaging protocols for both donor and recipient evaluation are reviewed, with emphasis on volumetric analysis, vascular and biliary anatomy, and identification of anatomic variants that may influence surgical decision-making. Postoperative imaging findings, including common vascular and biliary complications, are also discussed. By understanding the unique anatomic and surgical considerations in pediatric liver transplantation, radiologists can enhance diagnostic accuracy, facilitate interdisciplinary communication, and support optimal outcomes for pediatric transplant recipients.

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Title: Assessment of liver fibrosis through shear wave elastography in pediatric liver transplant recipients

Source: Pediatric Transplantation 2025, 29 (3): e70056  

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Date of publication: March 2025

Publication type: Article  

Abstract: Background: Liver transplantation (LT) is the standard therapy for end-stage liver disease. Liver allografts are at risk for fibrosis, for which biopsy is the gold standard for evaluation but carries risks. There is a need for noninvasive modalities to track the trajectory of fibrosis.

Methods: We evaluated the diagnostic accuracy of shear wave elastography (SWE) liver stiffness (LS) measurements to quantify fibrosis in pediatric liver transplant recipients.

Results: Between 2007 and 2024, 93 patients had 106 liver biopsies performed within 13 months of elastography. LS values were significantly higher in patients with moderate (F2-3) fibrosis compared to those with no significant fibrosis (F0-1) (7.5 ± 0.48 kPa vs. 6.09 ± 0.18 kPa, p = 0.0015). LS values were significantly higher in patients with moderate fibrosis compared to those with no significant fibrosis in both whole (8.4 ± 0.95 kPa vs. 6.6 ± 0.54 kPa, p = 0.02) and segmental allografts (7.1 ± 0.52 kPa vs. 5.9 ± 0.17 kPa, p = 0.02). There was no significant difference in LS values according to allograft type or donor status. The AUROC for LS measurements was 0.71, indicating a good discriminative ability between no significant and moderate fibrosis. A cut-point of 6.09 kPa for SWE was identified, distinguishing between no significant and moderate fibrosis (sensitivity of 81%). A SWE cut-point of 10.40 kPa had a high specificity of 99% in determining moderate fibrosis.

Conclusion: We demonstrated a significant association between biopsy fibrosis and SWE LS values and conclude that SWE provides a noninvasive option for monitoring liver a fibrosis.

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Title: MR and ultrasound for liver fat assessment in children: techniques and supporting evidence

Source: Journal of Magnetic Resonance Imaging 2025, Mar 5. [E–publication]  

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Date of publication: March 2025  

Publication type: Review article

Abstract: Hepatic steatosis is a common imaging finding that can be a sign of chronic liver disease, most often associated with metabolic dysfunction-associated steatotic liver disease (MASLD). Imaging techniques for evaluating steatosis range from basic qualitative assessments to advanced and highly accurate quantitative metrics. Among these, MRI-based proton density fat fraction (PDFF) is widely regarded as a reliable and precise imaging biomarker for quantifying liver steatosis. Additionally, multiple ultrasound platforms now offer quantitative assessments of hepatic steatosis. These methods include attenuation coefficient, speed of sound, backscatter, or other multiparametric approaches such as ultrasound-derived fat fraction (UDFF) which combines attenuation and backscatter quantification. Newer and upcoming quantitative ultrasound methods include acoustic structure quantification (ASQ) and tissue scatter distribution imaging (TSI). Therefore, ultrasound-based liver fat measurements could potentially serve as an effective screening tool in certain clinical settings, such as suspected MASLD. In this review, we describe how, why, and when to use MRI- and ultrasound-based fat quantification techniques for assessing liver steatosis in children. We discuss practical strategies for adapting and optimizing these methods in pediatric settings, considering clinical indications, patient preparation, equipment needs, acquisition techniques, potential pitfalls, and confounding factors. Additionally, guidance is provided for interpretation and reporting, along with illustrative case examples.

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Title: Evaluating pediatric NAFLD with controlled attenuation parameter: a comprehensive narrative review

Source: Diagnostics 2025, 15 (3): 299   

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Date of publication: January 2025

Publication type: Review article

Abstract: Non-alcoholic fatty liver disease (NAFLD) in the pediatric population has emerged as a significant health concern due to its alarming rise in prevalence. In children, the characteristics of the disease differ from those seen in adults. NAFLD may progress to more severe liver disease in children compared to adults with similar profiles. Liver biopsy remains the gold standard for diagnosis; its invasive nature and high cost limit its use as a first-line tool. Alternatively, magnetic resonance imaging (MRI) techniques, such as magnetic resonance imaging-estimated liver proton density fat fraction (MRI-PDFF), have shown a good correlation with the degree of histological steatosis, although their use is limited by high costs and limited accessibility. Controlled attenuation parameter (CAP), integrated with vibration-controlled transient elastography (VCTE) (FibroScan^®), is a novel non-invasive, accessible, and effective method for diagnosing hepatic steatosis. In this article, we reviewed the existing literature on the diagnostic accuracy of CAP in pediatric NAFLD. The PubMed and EMBASE databases were searched. Seven relevant studies were identified, conducted in pediatric hospital populations with specific demographic characteristics. Two of these studies compared CAP with liver biopsy, one compared CAP with liver biopsy and MRI-PDFF, and the remaining four compared CAP with MRI. Overall, CAP proved to be accurate in detecting the presence or absence of fatty infiltration, positioning it as a promising tool to simplify the diagnosis of NAFLD in children. However, further studies in larger populations are needed to confirm these findings and facilitate its implementation in routine clinical practice.

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