The document discusses methods for detecting early liver fibrosis, emphasizing the importance of measuring fibrosis for prognosis and treatment decisions. It compares traditional liver biopsy with non-invasive techniques like ultrasound, Fibroscan, and magnetic resonance elastography, highlighting their benefits and limitations. Fibroscan is noted for being a painless and accurate tool for detecting early fibrosis, although it may not be suitable for individuals with obesity or certain liver conditions.

1. Detecting Early Liver Fibrosis
A Nutshell for Primary Care
Dr Jarrod Lee
Mt Elizabeth Novena Hospital
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2. Stage 1: Portal Fibrosis
Stage 0: Normal
Stage 2: Periportal Fibrosis
Fibrosis to
Cirrhosis
Stage 4: Cirrhosis
Stage 3: Septal Fibrosis
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3. Importance of Measuring Fibrosis
• Determine:
– Prognosis
– Disease progression
– Need for treatment
• Monitor response to treatment
BUT
• Clinical features and lab tests can detect cirrhosis,
but not earlier fibrosis
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4. Liver Biopsy
• ‘Gold standard’ for
staging fibrosis
• Staging by accepted
classifications
• Can evaluate:
– Etiology
– Inflammation
– Steatosis
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5. Problems with Liver Biopsy
• Invasive
– 30% have pain after biopsy
– 1% severe complications
• Inter and intra observer variability
• Sampling error
– Samples 1:50,000 of liver mass
– Difference between right and left lobes
• Stage of fibrosis: 33%
• Diagnosis of cirrhosis: 15%
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6. How about using ultrasound?
• Systemic review of 21 studies (2010)
– Liver surface is most robust technique: high specificity (7895%), moderate sensitivity (51-73%)
– Poor observer agreement
• Singapore study (2012)
– Significant fibrosis: sensitivity 32%, specificity 85%
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7. Fibroscan
• Uses mild amplitude low frequency
vibration transmitted through liver
• Velocity of shear wave correlates with
liver stiffness
– Travels faster through stiffer fibrotic
tissue
• Sampled volume 1:500
• Painless bedside test; takes < 5 min
• Good reproducibility, well validated
• 90% accurate for early fibrosis (F0-1)
and cirrhosis
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8. Fibroscan
The velocity of the wave is evaluated
in a region located from 2.5 to 6.5 cm
below the skin surface.
The probe induces an elastic
wave through the liver.
25 to 65 mm
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9. Liver Stiffness
Portal fibrosis
Cholestasis
Centrolobular fibrosis
Sinusoidal fibrosis
Stiffness
Steatosis
Portal blood flow
Inflammation
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10. Limitations
• Less accurate for intermediate fibrosis (F2-4)
– Sensitivity and specificity 70-80%
– May still need biopsy for these cases
• Does not tell etiology or grade of inflammation
• Less effective in obese patients BMI > 30
• Not reliable in:
–
–
–
–
Acute hepatitis
Cholestasis
Hepatic congestion
Infiltrative liver diseases
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11. Magnetic Resonance Elastography
• Uses a vibrating device to
induce shear waves in internal
organs, which are detected by
MRI machine
• Examines whole liver
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12. Performance
• Highly accurate > 90%
• Good for intermediate
fibrosis F2-4 with 85%
sensitivity and specificity
• Overcomes limitations of
fibroscan in obesity
• Limitations:
– Cost and access
– Further validation
needed
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