These methods could give us information only in the stage of the fibrosis (F2-F4). The method of sharewave is better for this because the result we could calculate in pA. Dear collegue for the better diagnostic of all diffuse liver diseases you need good specialist in echography who could make decision about regular control for the patient. As to my mind Fibroscan (historicaly) was the first step in elastography development. Please note that high frequency ultrasound (B-mode) give so much detail information concerning liver tissue structure for hepatologist!

It may be of use to at least discard advanced fibrosis in case liver stiffness is lower than 9.5 kPa. Note that high liver stiffness (>9.5 kPa) does not necessarily mean advanced fibrosis, as inflammation plus steatosis in the case of NASH may increase FibroScan values. I suggest considering biopsy in patients with liver stiffness>9.5 kPa. New FibroScan version mounts CAP technology that may aid determining the intensity of steatosis in NAFLD/NASH patients.

If you have the chance to use CAP technology software together with the liver elastography by Fibroscan it can add some useful information regarding the steatosis grade. We have been using these both methods in all patients with NAFLD, and the kappa with the liver biopsy is high, so it seems like a reliable method to stage steatosis as well as liver disease.The main limitation so far is that CAP is available only for the M probe which limits the evaluation of some obese patients.

Dear Cristiane:

I would like for your answer. It is interesting that you use Fibroscan for all NAFLD patients without any inclusion criteria. I mean if are faced with a slightly overweight patient with a grade 1 steatosis at ultrasound and semi-normal liver enzymes, would you recommend Fibroscan? If yes, how much gain will you in that?

I would like to know if you have seen or heard about the newer XL probe to evaluate the obese patients?

Dear Pablo:

Thanks for your answer too, I thought somehow different. As the references do say that the Fibroscan's role in determining both extremes of fibrosis is good and this modality is exact in these two extremes and if the fibroscore is in the mid-range liver biopsy should be performed to confirm the fibrosis status. Do you have evidences in contrast to this comment?

Dear Boris:

Thanks for taking part in my question and answering. The important role of ultrasound - B Mode - in the diagnosis of many hepato-biliary diseases is for sure. But in the concern of NAFLD, ultrasound can just determine the existence of significant steatosis, let's say more than 10% of hepatocytes should be involved and the rating of severity of steatosis in three grades is operator dependent and has inter-observer varaitions.

Second problem is that ultrasound cannot say anything about the fibrosis, especially in its earlier stages. If we do have a case of cirrhosis ultrasound can determine the significant sequela of cirrhosis, but if we do have stages 1 of 2, what then? Can we rely of ultrasound findings in these patients?

This is a recent review in the field!

Recently there are more evidence to show many subject which previously categorized as “cryptogenic cirrhosis” were in fact subjects who have FAFLD or NASH. Result of some prospective and retrospective studies demonstrate that some NAFLD and NASH subjects my develop cirrhosis and HCC, therefore it is important to closely monitor some of NAFLD and NASH subjects who are at higher risk of developing advance liver disease. Fibroscan can recognize this high risk group. If a subject has high elasticity means need more close follow up. Also CAP helps doctors and patient to have an estimate of fat in the liver cells which I think is a good tool to see change after medical interventions.

Dear Hossein:

I do agree with you. But my main question is the inclusion criteria for performing fibroscan in these patients. Should we do it in all patients, how often should we do it? Once in a lifetime or serially?

Dear All,

Before elastography performing you must know the clinic picture and laboratory picture of the liver diffuse disease and compare results with echoghaphy (B-mode) of liver scanning. I will be happy if some radiologists could participate in this discussion.

In my experience: I have many cases with advanced liver fibrosis with scant fatty in the liver and all of other causes for liver diseases have excluded and we are sure that the NASH is responsible. I think we should do more researches in this filed.

Please note, all patients with diffuse live diseases need sharewave elastography (not only blood tests) during treatment period for understand the liver fibrosis staging

I agree with Tarasyuk,

Every case with NASH should follow with elastograpgy besides to biochemical tests in follow up.

Just a couple of practical considerations:

If you have Fibroscan you should perform the determination keeping in your mind that the accuracy of Fibroscan is good in determining both extremes of fibrosis while middle value need to be substantiated by other tests, including biopsy.

Patients with NASH are often obese and this represents a limitation for Fibroscan that you can overcome if you have the specific ultrasound probe for obese pts.

Steatosis reduces stiffness, therefore your Fibroscan values could underestimate the stage of fibrosis. For this reason, serial determinations allow to follow disease progression.

Dear Michele

I would like to thank for your great comment that the accuracy of the Fibroscan is better at the both extremes of the fibrosis in the liver.

As you probably know, the newer probe of the Fibroscan, namely the XL probe has helped in the evaluation of the more obese patients. Of course there are few studies in this field to be confident of the results.

But there is a question for me on the comment of the interaction of steatosis and underestimation of fibrosis by Fibroscan! I myself have not seen any evidence in this regard and would like to have some reference for that please.

Dear Mark

Considering the cost and availability and national guidelines, I think anyone should use a stepwise approach to the very large number of patients with NAFLD continuum. NFS score is an easy to use panel in the evaluation of NAFLD patients and has been recommended in many studies and guidelines. I myself do use it in my patients. I would like to invite you to take part in my other question entitled "Which serologic biomarker are you using in your daily practice for the management of NAFLD/ NASH cases?"

NAFLD is very common liver disease in developed as well as developing countries. Assessment of fibrosis is important for management of fatty liver. In our practice in the university we do it but not in all cases. In our study fibroscan is very good to detect advance fibrosis (Stage III and IV) but failed to differentiate between absence and Stage I and II fibrosis. We do it if we suspect advance fibrosis by liver palpation, AST ALT ratio > 1, coarse liver in USG or any other clinical suspicion of Cirrhosis. As advance fibrosis is not very common recommendation to do fibroscan to every patient will invite high cost.

Dear Shahinul:

Thanks for your comment. As you told it is not wise to recommend Fibroscan for each case of NAFLD. I do see that you have a strict criteria for inclusion of these patients for the inquiry of the Fibroscan. So with this inclusion criteria for patient selection, one could suppose that after Fibroscan you will have a lot of patients that have high stages of fibrosis.

But I have two questions; what do you do with these patients in the next step? Do you recommend liver biopsy or does the result of elastography enough for you?

The second issue is that I can remember a lot of patients with a fatty liver of grade 2 or 3 and a mild abnormalities in AST/ ALT with no splenomegaly or small sized livers, who do have high stages of fibrosis in their Fibroscan. Considering this truth and the strict criteria recommend by your team, don't you that we would miss some cases and diagnose them late and in advanced stages of liver disease?

After Fibroscan I do not recommend liver biopsy, I will follow the patients and repeat the Fibroscan especially after correction of high ALT

I think you need to specify which clinical spectrum on NAFLD we are talking about. Not all patients with steatosis have NASH or are obese.

In my opinion Fibroscan is an alternative to biopsy in selected cases with high pretest probability for fibrosis and not morbidly obese.

Dear Jorge:

That's for sure that not all fatty liver patients do not have NASH. But how can you select those with "high probability for fibrosis" cases? Do use simple tests like GGT, or other panels like NFS or somehow else?

i think like other authors fibroscan is the most interesting routine test to evaluate fibrosis but it's most often difficult in patient with obesity becaus you can't perform Fibroscan

So many points of view... So many specialists who know the method.

Today we need the additional point of view from specialists from France, where this method is very popular...

Dear Colleagues:

I would like to know any pertinent opinion in this from all over the world; but as the first trials and the invention of Elastography was from France, it would be reasonable to hear from that country too.

I would like also to tell that the newer probe, "the XL probe" has been introduced for obese patients. We do not have the probe in our center; and do refer them to another center. But it has been told that the accuracy of that probe is equivalent to the usual M probe used in adults.

Always

Dear Dr Iraj

Salam

thanks a lot for your nice discussion. In our center in management of NFLD patients we usually request Elastograghy only for the cases with higher probability of advanced fibrosis (>F2) like diabetic males over age of 40 or other cases as discussed by other physicians ,but as you know we have an important problem which restricts widespread using of this method in our practice that is insurance coverage so we could not request it for many of our cases .I can appreciate you that we have had so many cases with even normal sono or mild coarse image without splenomegaly but finally liver biopsy showed advanced fibrosis ,so considering all of these I think in our culture instead of repetitive sono it is better to perform one fibroscan is more informative and really can influences life style changes in the patients, however for now in our country we should only select the cases

Best wishes

Dear Eskandar:

I do understand the financial problem with our patients, that are not covered with their insurance programs for performing elstography. That is why I began to ask this question to find an inclusion criteria for high risk population who will benefit from the elastography most.

To my surprise the issue of selecting people for elastography is present in many other countries as well. As you see, some of our colleague do it for all of their patient too.

You mentioned a high risk group namely diabetic men over 40 yrs old. Can we mention other high risk groups as well.

This question is open for all who participate in this group and all who are working in the field.

In general, ultrasound techniques are not very accurate to differentiate fat from fibrosis. The new fibroscan machine and probes (small, medium, large and extra large), which adjust to patient's size, as well as the newer Supersonic Imagine(R) and ARFI, are better to assess among patients with high and low stages of fibrosis, but intermediate stages fall in a grey zone. They are useful as a gross measurement of fibrosis, but a biopsy will always give you histopathologic information that other methods can't. At the U of Miami, we have Fibroscan and SuperSonic available, which are useful especially on those patients who would be riskier to biopsy, or just refuse to have a liver biopsy done.

Yes, yes and yes - Leopoldo! Just now we use elastography equipment (like SuperSonic ) in pediatric practice. We do not need biopsy in many cases. You understand me - in pediatric practice!

I agree with you, Boris, even though many American children with NAFLD are bigger and more obese than some adults. If we want to measure fibrosis, regardless of the baseline liver disease, ultrasound-based methods are very practical, especially because it allows risk- free longitudinal follow-up.

Dear Leopoldo

As I see you are preferring biopsy over Fibroscan, which is completely evidence based, as liver histology is the gold standard for the diagnosis and evaluation of NAFLD.

But which percentage of your patients do agree with your suggestion of liver biopsy? Do they accept the risks and the discomfort? And for the follow up can you make them for re-biopsy?

What do you need in NAFLD group? calculation of fibrosis degree. Our in press showed that Fibroscan results are similar to liver biopsy.

Both methods have advantages and challenges. An ultrasound-based method can sample a larger amount of liver and give you a gross estimation of the fibrosis stage, as well as allowing an easy longitudinal follow up. Biopsies give us histopathological details that other methods can't including a second unsuspected pathology and elucidation between fat and fibrosis, which has always been difficult. I take patient's preference to choose the method. Some people are phobic about a biopsy, while others demand a laparoscopy with video and tissue sampling. Most people allow me to decide for them. When things are not clear, I may have both done, a biopsy and a fibroscan or SuperSonic within a short period of time and then follow up with the same ultrasound-based studies over time. I do not have a preference, I just try to choose the test that can answer my question the best.

Dear All:

Let's see it from another aspect. Let's imagine you have a patients and for a whatever reason you have made a Fibroscan for him/her. You are faced with a F2 fibrosis.

What is your suggestion at this point?

Do you suggest a liver biopsy for further evaluation of the liver?

Do you repeat the Fibroscan in a reasonable time in respect to the etiology and treatment to see the follow-up status and decide later?

Or what else do you recommend for this patient?

We need some other data about this patient: HCV and HBV markers, autoantibodies, insulin resistance, ferritin and ceruloplasmin as well as hepatocellular damage (ALT), cholestasis (gamma GT, bilirubin) and liver function (albumin, prthrobin time, cholesterol, cholinesterase). I think that every choice for a further follow up cannot be independent from these parameters.

Really I follow the case with F2 by Fibroscan as NASH and I do the protocol for control of it. Liver biopsy can not add anything to me now!

I am doing, like in other diseases, once a year.

I cannot understand whether the topic is the use of Fibroscan in NAFLD, NASH or Metabololic cirhhosis as evolutive step of NASH (and not NAFLD). I think that everywhere a yearly follow up in a patient with F2 score at Fibroscan may be a accurate timing, however it is presumably that a cirrhosis is already present at this stage, when I agree that liver biopsy is not more useful. My problem is to evaluate also liver damage and function by serological investigations!

It seems from all comments that having a F2 score in the setting of NAFLD in the Fibroscan is safe enough to follow the patient with yearly Fibroscan. I do myself exactly in the same manner.

Let's talk about another situation. You have a middle aged man with a BMI over 30 with a pre-diabetic stage and liver enzymes in the range of 50-60, grade 2-3 fatty liver at ultrasound. In the Fibroscan you find a S3 steatosis and F4 fibrosis.

What do you recommend in this stage? You go on with weight reduction and serial lab? Do you search for signs of portal hypertension? Do you recommend endoscopy in the evaluation of esophageal varices? Do you recommend aggressive treatments like bariatric surgery?

At the stage of F4 fibrosis, it is presumable that portal hypertension may be present and, therefore, needs to be detected by both Doppler of portal district vessels and esophagogastrodudenoscopy for esophageal varices. Serial lab are also necessary to assess liver damage and function. A correction by diet of pre-diabetic stage could be necessary as well as an insulin assay for Hona index calculation and, if possible, correction by drugs which do not damage diseased liver. In this case I do not think that aggressive treatments like bariatric surgery may be very safe. I followed a sinilar patient, who underwent liver transplantation for both hapatocarcinoma and repeated haemorragic complication of esophageal varices. At the moment, this patient has a good general status.

I think it is important to perform a fibroscan at the first observation of the patient and to repeat it every year during the follow-up. Anyway, it's my opinion that it must remember that fibroscan has a grey zone between 6 and 12 KPa where it is difficult to distinguish th end of the steatosis and the beginning of the fibrosis.

What do you think about my opinion?

Caterina Furlan

i use fibroscan for patients with nafld who have more than 2 feature s of the metabolic syndrome, whe have bmi>30, persistent alt elevation, and evidence of NASH by LNB ( Balloning and mallory body)

On using Fibroscan for following liver fibrosis it is sure and well known that it has the best predictive value at the extremes of fibrosis in the liver. When it is shown that the the patent has F0-F1 you can be sure that he or she does not have any significant fibrosis, on the other when you find a F3-F4 you can also be really sure that the patient has significant fibrosis. This has been also told by other participants in the previous discussions.

For steatosis the CAP score is installed in the latest versions of Fibroscan. I think that there is no real problem with its accuracy. If there is any comment on it, I will be glad to hear it from other colleagues.

Another issue that has been proposed is the use of Fibroscan in the follow-up of patients that have been biopsied. I think that it is for sure an indication to overcome the complication and non-compliance.

I do not understand the usefulness of Fibroscan in patients with a simple steatosis, whilst I strongly agree with its used in the follow-up of patients who have undergone liver biopsy once in their life and had a diagnosis of chronic hepatitis or early stages of liver cirrhosis. In these cases, the investigation is a very useful instrument for the follow-up of the progression of liver disorder.

Simple steatosis does not seem to result in long term morbidity and mortality.

Thus, the patient with confirmed to have a NASH is a good candidate for applying FibroScan in the management.

Now, we have been using always. We can repeat it and help us to motivate patients to give up drinking and weight loss. It can be used in children obesity. It can be used in GPs to help to motivate the parents and chidren to this huge problem.

In regard of the second question by Iradi, I fully agree with the response by Nimer, in the case of F4 fibrosis by fibroscan and in the absence of viruses and other liver diseases, I prefer this data to be confirmed by a liver biopsy that gives more precise information especially for perform a correct diagnosis of NASH when clinically is confirmed NAFLD.

Fibroscan does not provide good performance in NAFLD / NASH, I think it is actually a good alternative to biopsy only in HCV positive patients.

Dear Claudio

There are many papers on the usefulness of Fibroscan in fatty liver disease. Why do you think that Fibroscan does not have a good performance in these patients? Do you have a personal experience? Can you share it with us?

I believe that patients with NAFLD and fibrosis on Fibroscan should have a liver biopsy to confirm this data and also to diagnose NASH. Fibroscan do not diagnose NASH.

At the same time I would look for signs of portal hypertension in doppler ultrasound and endoscopy.

Dear Cristiane

How much is the acceptance rate of liver biopsy in your patients? I mean when offer to perform liver biopsy, how many per cent of your patients do come for liver biopsy?

In our practice the above mentioned acceptance is not so high!

I use elastography when I want to assess if the patient has cirrhosis and a liver biopsy is not possible or inconclusive, as part of a more ample evaluation. Depending on the situation, history, physical, blood tests (fibroTest,fibroSure), imaging studies (including SuperSonic, CT or MR) are all integrated to give the closest possible guess on fibrosis stage. Fibroscan using the XL probe can give better results in obese patients and allows for longitudinal follow up.

fibroscan good for diagnosis the NAFLD but requir the experiance some time the probe put in the wrong site this give the stage wrong especialy in the obese patient although the used xl prob.

absolutely agree withHiba Abid Al-Hussein Hassan