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Polish Journal of Radiology
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vol. 88
Gastrointestinal and abdominal radiology
Original paper

Diffusion tensor magnetic resonance imaging in the grading of liver fibrosis associated with congenital ductal plate malformations

Mohammed Elhawary
Mostafa Elmansy
Khadiga Ali
Ebtesam Abdallah
Ahmed Razek
Tarik Barakat
Amr Sarhan

Faculty of Medicine, Mansoura University, Egypt
Mansoura University Children Hospital, Egypt
© Pol J Radiol 2023; 88: e135-e140
Online publish date: 2023/03/08
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Ductal plate malformations (DPM) or fibropolycystic liver disease are broad terms used to describe a complex group of congenital disorders that result from aberrant remodelling or persistence of the ductal plate [1,2]. This disease spectrum entails multiple subtypes, including congenital hepatic fibrosis (CHF), Caroli disease, polycystic liver disease, biliary hamartoma, and choledochal cysts, in addition to biliary atresia [3]. The manifestations of this pathology are variable, but most of them are related to portal hypertension. The patient may present with oesophageal varices, splenomegaly, or spontaneous luminal gastrointestinal bleeding [4]. Some patients may present with cholangitis [5,6]. Associated renal anomalies have also been reported, including polycystic kidney disease (PCKD), nephronophthisis, and medullary sponge kidney [2]. It is worth mentioning that this pathology progresses into liver fibrosis and subsequent true cirrhosis, and this is responsible for the previously mentioned portal hypertensive manifestations [4,7]. Moreover, these patients are at increased risk of developing hepatocellular carcinoma [2,4]. Therefore, frequent evaluation of patients with DPM is important for early detection and grading of the degree of liver fibrosis. The definite diagnosis of DPM is established by liver biopsy [2], which is also helpful in the assessment of the degree of fibrosis [8]. Nonetheless, it is an invasive procedure that carries some risk of complications like bleeding [9].
Magnetic resonance imaging (MRI) plays a crucial role in the diagnosis and management of this disease spectrum because it helps the physician accurately detect and differentiate its subtypes [3,10]. It also provides multiplanar imaging with high-contrast resolution without radiation exposure, as in computed tomography with good efficacy in the diagnosis and monitoring of liver diseases [11-13]. Diffusion MRI is a variant of conventional MRI, which depends on water molecule movement inside tissues without the application of chemical tracers or contrast intake [14]. The diffusion of these molecules between tissues depends on multiple factors, including tissue type, architecture, integrity, as well as the presence of barriers [14,15]. The liver fibrosis process is an integral part of the natural history of DPM. It was previously mentioned that fibrosis is associated with an increase in the impermeable structures in the cell membrane and is often accompanied by oedema and an increase in the intracellular to extracellular volume ratio, leading to restriction of water molecule free movement [16]. Therefore, fibrosis will lead to a restricted diffusion, which in turn will cause a decline in the measured ADC values [17-19]. The current literature is poor, with studies evaluating the role of DT-MRI in the grading of liver fibrosis associated with DPM. Hence, the current research was conducted to report DT-MRI findings in patients with DPM and to elucidate the role of its parameters (ADC and FA in particular) in predicting the degree of hepatic parenchymal fibrosis.

Material and methods

Patient population

This prospective case-control study was conducted at the Radiology Department in collaboration with Mansoura University Children’s Hospital, Egypt. This was done after obtaining approval from the local Scientific Committee in our medical school. The study was designed for children whose ages ranged between 2 and 18 years, diagnosed with DPM, and confirmed by liver biopsy. Patients were recruited during the period between January 2020 and December 2021. We excluded children aged below 2 years or whose serum creatinine was elevated (> 1.2 mg/dl).
Twenty-eight paediatric patients met our inclusion criteria, and they were enrolled in our study after obtaining consent from their guardians after a simple explanation of the benefits and possible drawbacks of each intervention. The data of these patients were collected and compared with the data of 20 age- and gender-matched healthy paediatric subjects who presented to the children’s hospital for seasonal vaccination.

Clinical assessment

All patients were subjected to full history taking, including the age at the time of diagnosis, disease presentation, and family history of similar conditions. After clinical examination and routine laboratory assessment (mainly coagulation profile), an ultrasound-guided liver biopsy was done for all patients, and the existing hepatic fibrosis was graded according to the 6-stage Modified Histological Activity Index (Ishak system) (Suppl Figure 1) [20].

Magnetic resonance imaging

All patients and controls were subjected to pelviabdominal MRI using a 1.5-tesla machine (Philips, Inginea). The T2 MRI-weighted images were obtained in axial and coronal axes with respiratory gating, using the following parameters: 80 ms echo time, 1250 ms repetition time, 400 × 400 matrix size, 6-mm slice thickness, 400 × 350 × 196 mm field of view. The DTI was performed using a single-shot fast spin-echo echo-planar sequence with respiratory gating, using the following parameters: 85 ms echo time, 6000 ms repetition time, 128 × 128 matrix size, 2.5-mm slice thickness, 224 × 224 × 196 mm field of view, and 3 averages.
The apparent diffusion coefficient (ADC) of the liver was estimated using the b values of 50, 400, and 800 s/mm2. The ADC values were calculated at each of the 4 right liver segments, and the mean of them was calculated to get the final ADC. We omitted the left lobe to avoid motion artifacts (caused by cardiac movements). The collected ADC values were compared between patients and controls, and then correlated with the degree of liver fibrosis in the patient group. Merged images between colour-mapped axial cuts of DTI and axial T2 WI were obtained, and example images are presented in Figure 1 and Figure 2.

Statistical analysis

Our data were transferred to SPSS software for analysis. The receiver operator characteristic (ROC) curve was used to determine the best cut-off point for both FA and ADC measurements. Spearman’s correlation was used to test the correlations between the grades of liver fibrosis and our DTI parameters. All our results were deemed significant with a p-value of 0.05 or less.


Patient characteristics

CHF was the most commonly encountered pathology among our patients (75%). CHF was combined with PCKD in 3 patients (10.7%), while it was combined with solitary kidney in one patient (3.6%). Additionally, 3 patients (10.7%) had PCKD along with Caroli disease (Figure 1). The sociodemographics of our included sample with regards to age, sex, and family history of different pathologies are shown in Table 1.

Comparison between patients and controls regarding fractional anisotropy and apparent diffusion coefficient

All patients with DPM, whatever its type, expressed significantly lower hepatic ADC compared to controls (p < 0.001). The mean ADC values of the patients diagnosed with CHF, PCKD with Caroli disease, PCKD with CHF, and solitary kidney with CHF were 1.29 × 10-3, 1.32 × 10-3, 1.89 × 10-3, and 1.02 × 10-3 mm2/s, respectively, while the same value was 1.915 × 10-3 mm2/s for controls. Liver FA had mean values of 0.242, 0.297, 0.263, and 0.293 in the same patient groups, respectively, with no significant difference between our encountered pathologies and controls (p = 0.873) (Table 2).
Correlation between apparent diffusion coefficient and hepatic fibrosis grade When the included DPM patients were classified based on the fibrosis grade, it was evident that patients with higher fibrosis grades had significantly lower hepatic ADC, indicating a negative correlation between ADC and the grade of hepatic fibrosis; rs = –0.901, p < 0.001 (Table 3, Figure 3). On the other hand, no statistically significant differences or correlations were noted between the FA and hepatic fibrosis grades; p-value = 0.4 and 0.7, respectively. The ADC value of 1.65 mm2/s × 10-3 had sensitivity and specificity of 82.1% and 90%, respectively, in differentiating DPM patients from the healthy controls, with an accuracy of 85.4% (Figure 4).


This study showed and confirmed a significant decline in ADC values in DPM patients compared to controls (p < 0.001). In particular, the ADC cut-off value in our study of 1.65 mm2/s × 10-3 had sensitivity and specificity of 82.1% and 90%, respectively, in differentiating DPM patients from the healthy controls. Moreover, our study noted a significant negative correlation between the grades of liver fibrosis and ADC.
In a previous similar study, which correlated the ADC values with the degree of liver fibrosis in adult patients with chronic hepatitis, Hu et al. noted that the ADC values were significantly decreased as the liver fibrosis state progressed [16]. Bonekamp et al. also confirmed the previous findings [21]. In our opinion, this finding could be applied in clinical practice to mitigate the need for repeated liver biopsies, especially for monitoring the progress of liver fibrosis in patients with DPM. Serial DTI-MRI with its ADC should be recorded and compared over different time points, and the biopsy should be reserved as the last assessment method. However, that concept needs to be further studied in larger-scale investigations.
In contrast to the previous findings, other researchers denied any significant relationship between ADC and fibrosis grades [22,23]. The difference between the published reports could be explained by heterogeneous imaging parameters as well as different disease criteria and fibrosis grading systems.
Our findings showed no significant relation between FA and the grade of liver fibrosis. FA reflects the direction of water diffusion across tissue microstructure, and this depends mainly on tissue orientation [24-26]. Surprisingly, the literature contains studies reporting positive [27] and negative correlations [28,29] between FA and the degree of liver fibrosis. The previous heterogenicity related to FA findings could be attributed to the complex histopathological changes associated with fibrosis, such as inflammation, fatty infiltration, as well as extracellular collagen breakdown. The diffusion of water molecules is presumably constrained during the period when extracellular matrix proteins increase, resulting in a drop in the FA values. However, when cell necrosis occurs at the advanced stage, the FA increases. Although our study handled a unique research point that was poorly mentioned in the literature, we included a small sample size, and all of them were gathered from a single educational centre. Also, some subtypes of DPM, rather than CHF, entailed very few patients. More studies, including more patients from different paediatric hepatology centres, should be conducted to cover the mentioned drawbacks.


According to our findings, DT-MRI showed its efficacy in the diagnosis of DPM and grading of associated liver fibrosis. Moreover, ADC could be applied to monitor the degree of liver fibrosis rather than the invasive liver biopsy. However, our findings showed no significant relation between FA and the grade of liver fibrosis. The application of this modality should be encouraged when evaluating such patients.


The authors report no conflict of interest.


1. Lewis J. Pathology of fibropolycystic liver diseases. Clin Liver Dis (Hoboken) 2021; 17: 238-243.
2. Veigel MC, Prescott-Focht J, Rodriguez MG, et al. Fibropolycystic liver disease in children. Pediatr Radiol 2009; 39: 317-327; quiz 420-421.
3. Mamone G, Carollo V, Cortis K, et al. Magnetic resonance imaging of fibropolycystic liver disease: the spectrum of ductal plate malformations. Abdom Radiol (NY) 2019; 44: 2156-2171.
4. Brancatelli G, Federle MP, Vilgrain V, et al. Fibropolycystic liver disease: CT and MR imaging findings. Radiographics 2005; 25: 659-670.
5. Safwan M, Ramachandran P, Vij M, et al. Impact of ductal plate malformation on survival with native liver in children with biliary atresia. Pediatr Surg Int 2015; 31: 837-843.
6. Palomba E, Maggioni M, Viero G, et al. Congenital hepatic fibrosis as a cause of recurrent cholangitis: a case report and review of the literature. Livers 2021; doi: 10.3390/livers1030012.
7. de Lédinghen V, Le Bail B, Trillaud H, et al. Case report: secondary biliary cirrhosis possibly related to congenital hepatic fibrosis. Evidence for decreased number of portal branch veins and hypertrophic peribiliary vascular plexus. J Gastroenterol Hepatol 1998; 13: 720-724.
8. Feng JY, Chen L, Ma YY, et al. Role of a liver pathology standardized scoring system in the diagnosis of congenital biliary atresia and its relationship with prognosis. Zhonghua Bing Li Xue Za Zhi 2019; 48: 755-761.
9. Midia M, Odedra D, Shuster A, et al. Predictors of bleeding complications following percutaneous image-guided liver biopsy: a scoping review. Diagn Interv Radiol 2019; 25: 71-80.
10. Krausé D, Cercueil JP, Dranssart M, et al. MRI for evaluating congenital bile duct abnormalities. J Comput Assist Tomogr 2002; 26: 541-552.
11. Shamir SB, Kurian J, Kogan-Liberman D, Taragin BH. Hepatic imaging in neonates and young infants: state of the art. Radiology 2017; 285: 763-777.
12. McDonald N, Eddowes PJ, Hodson J, et al. Multiparametric magnetic resonance imaging for quantitation of liver disease: a two-centre cross-sectional observational study. Sci Rep 2018; 8: 9189. doi: 10.1038/s41598-018-27560-5.
13. Ajmera VH, Liu A, Singh S, et al. Clinical utility of an increase in magnetic resonance elastography in predicting fibrosis progression in nonalcoholic fatty liver disease. Hepatology 2020; 71: 849-860.
14. Soares JM, Marques P, Alves V, Sousa N. A hitchhiker’s guide to diffusion tensor imaging. Front Neurosci 2013; 7: 31. doi: 10.3389/fnins.2013.00031.
15. Beaulieu C. The basis of anisotropic water diffusion in the nervous system – a technical review. NMR Biomed 2002; 15: 435-455.
16. Hu XR, Cui XN, Hu QT, Chen J. Value of MR diffusion imaging in hepatic fibrosis and its correlations with serum indices. World J Gastroenterol 2014; 20: 7964-7970.
17. Kwee TC, Takahara T, Koh DM, et al. Comparison and reproducibility of ADC measurements in breathhold, respiratory triggered, and free-breathing diffusion-weighted MR imaging of the liver. J Magn Reson Imaging 2008; 28: 1141-1148.
18. Liu B, Cai J, Zhu J, et al. Diffusion tensor imaging for evaluating biliary atresia in infants and neonates. PLoS One 2016; 11: e0168477. doi: 10.1371/journal.pone.0168477.
19. Kim J, Yoon H, Lee MJ, et al. Clinical utility of mono-exponential model diffusion weighted imaging using two b-values compared to the bi- or stretched exponential model for the diagnosis of biliary atresia in infant liver MRI. PLoS One 2019; 14: e0226627. doi: 10.1371/journal.pone.0226627.
20. Ishak K, Baptista A, Bianchi L, et al. Histological grading and staging of chronic hepatitis. J Hepatol 1995; 22: 696-699.
21. Bonekamp D, Bonekamp S, Ou HY, et al. Assessing liver fibrosis: comparison of arterial enhancement fraction and diffusion-weighted imaging. J Magn Reson Imaging 2014; 40: 1137-1146.
22. Harada TL, Saito K, Araki Y, et al. Prediction of high-stage liver fibrosis using ADC value on diffusion-weighted imaging and quantitative enhancement ratio at the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI at 1.5 T. Acta Radiol 2018; 59: 509-516.
23. Bülow R, Mensel B, Meffert P, et al. Diffusion-weighted magnetic resonance imaging for staging liver fibrosis is less reliable in the presence of fat and iron. Eur Radiol 2013; 23: 1281-1287.
24. Taouli B, Chouli M, Martin AJ, et al. Chronic hepatitis: role of diffusion-weighted imaging and diffusion tensor imaging for the diagnosis of liver fibrosis and inflammation. J Magn Reson Imaging 2008; 28: 89-95.
25. Tosun M, Inan N, Sarisoy HT, et al. Diagnostic performance of conventional diffusion weighted imaging and diffusion tensor imaging for the liver fibrosis and inflammation. Eur J Radiol 2013; 82: 203-207.
26. Cheung JS, Fan SJ, Gao DS, et al. Diffusion tensor imaging of liver fibrosis in an experimental model. J Magn Reson Imaging 2010; 32: 1141-1148.
27. Huang M, Lu X, Wang X, Shu J. Diffusion tensor imaging quantifying the severity of chronic hepatitis in rats. BMC Med Imaging 2020; 20: 74. doi: 10.1186/s12880-020-00466-3.
28. Lee Y, Kim H. Assessment of diffusion tensor MR imaging (DTI) in liver fibrosis with minimal confounding effect of hepatic steatosis. Magn Reson Med 2015; 73: 1602-1608.
29. Soylemez UPO, Mut DT, Alkim CA, et al. The efficiency of fractional anisotropy, apparent diffusion coefficient, and contrast enhancement index in liver fibrosis staging. Sisli Etfal Hastan Tip Bul 2022; 56: 113-118.
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