European Radiology

, Volume 29, Issue 12, pp 6499–6507 | Cite as

Assessment of hepatic steatosis by using attenuation imaging: a quantitative, easy-to-perform ultrasound technique

  • Jae Seok Bae
  • Dong Ho LeeEmail author
  • Jae Young Lee
  • Haeryoung Kim
  • Su Jong Yu
  • Jeong-Hoon Lee
  • Eun Ju Cho
  • Yun Bin Lee
  • Joon Koo Han
  • Byung Ihn Choi



To evaluate the diagnostic performance of attenuation imaging (ATI) in the detection of hepatic steatosis compared with a histopathology gold standard.


We prospectively enrolled 108 consecutive patients (35 males; median age, 54.0 years) who underwent percutaneous liver biopsy for evaluation of diffuse liver disease between January 2018 and November 2018 in a tertiary academic center. Grayscale ultrasound examination with ATI was performed just before biopsy, and an attenuation coefficient (AC) was obtained from each patient. The degree of hepatic steatosis, fibrosis stage, and necroinflammatory activity were assessed on histopathologic examination. The significant factor associated with the AC was found by a linear regression analysis, and the diagnostic performance of the AC for the classification into each hepatic steatosis stage was evaluated by receiver operating characteristic (ROC) analysis.


The distribution of hepatic steatosis grade on histopathology was 53/11/22/16/6 for none/mild (< 10%)/mild (≥ 10%)/moderate/severe steatosis, respectively. The area under the ROC curve, sensitivity, specificity, and optimal cutoff AC value for detection of hepatic steatosis ranged from 0.843–0.926, 74.5–100.0%, 77.4–82.8%, and 0.635–0.745, respectively. Multivariate analysis revealed that the degree of steatosis was the only significant determinant factor for the AC.


The AC from ATI provided good diagnostic performance in detecting the varying degrees of hepatic steatosis. The degree of steatosis was the only significant factor affecting the AC, whereas fibrosis and inflammation were not.

Key Points

• Attenuation imaging (ATI) is based on two-dimensional grayscale ultrasound images that can incorporate into routine ultrasound examinations with less than 2 min of acquisition time.

• ATI provided good diagnostic performance in detecting the varying degrees of hepatic steatosis with an area under the ROC curves ranging from 0.843 to 0.926, and there was no technical failure in this study indicating high applicability of this technique.

• The degree of hepatic steatosis was the only significant factor affecting the result of ATI examination.


Fatty liver Ultrasonography Biopsy Sensitivity and specificity Linear models 



Attenuation coefficient


Attenuation imaging


Area under the receiver operating characteristic curve


Body mass index


Controlled attenuation parameter


Magnetic resonance


Nonalcoholic fatty liver disease


Nonalcoholic steatohepatitis


Region of interest


Skin-capsular distance


Standard deviation


Transient elastography





The attenuation imaging method was provided by Canon Medical Systems, and this study was technically supported by Canon Medical Systems.


The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Byung Ihn Choi.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.


• Prospective

• Diagnostic or prognostic study

• Performed at one institution

Supplementary material

330_2019_6272_MOESM1_ESM.docx (19 kb)
ESM 1 (DOCX 18 kb)


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Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  1. 1.Department of RadiologySeoul National University HospitalSeoulRepublic of Korea
  2. 2.Department of RadiologySeoul National University College of MedicineSeoulRepublic of Korea
  3. 3.Institute of Radiation MedicineSeoul National University Medical Research CenterSeoulRepublic of Korea
  4. 4.Department of PathologySeoul National University HospitalSeoulRepublic of Korea
  5. 5.Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
  6. 6.Department of RadiologyChung-Ang University HospitalSeoulRepublic of Korea

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