Is follow-up imaging warranted for patients with fatty liver disease diagnosed on ultrasound?

From the Guidelines

Follow-up imaging is warranted for patients with fatty liver disease diagnosed on ultrasound, with the timing and type of imaging depending on individual risk factors, and consideration of alternative modalities like MRI or CT scan in patients with poor ultrasound visualization, particularly those with obesity and NAFLD-related liver disease. The decision to perform follow-up imaging should be based on the patient's risk factors for advanced disease, such as obesity, diabetes, elevated liver enzymes, and age >50. For low-risk patients with simple steatosis and no evidence of advanced fibrosis, repeat ultrasound every 2-3 years is reasonable to monitor disease progression 1. However, patients with risk factors for advanced disease should undergo more comprehensive evaluation with either vibration-controlled transient elastography (FibroScan) or magnetic resonance elastography (MRE) within 6-12 months of initial diagnosis to assess for fibrosis 1.

Some key points to consider when deciding on follow-up imaging include:

• The patient's risk factors for advanced disease, such as obesity, diabetes, and elevated liver enzymes
• The quality of the initial ultrasound, with consideration of alternative modalities like MRI or CT scan in patients with poor visualization
• The potential benefits of early detection of disease progression, including more aggressive lifestyle interventions and consideration of pharmacologic therapies
• The need for surveillance for hepatocellular carcinoma in patients with advanced fibrosis, with ultrasound every 6 months 1

It is also important to note that professional society guidelines differ in their recommendations about the utility of using alpha-fetoprotein (AFP) in combination with ultrasound for hepatocellular carcinoma (HCC) surveillance, with the AASLD guidelines recommending abdominal ultrasound with or without AFP, and the EASL guidelines endorsing ultrasound alone 1. However, a recent meta-analysis found that AFP is likely of additional benefit when combined with ultrasound, with sensitivity for early-stage HCC detection increasing from 45% with ultrasound alone to 63% with the two tests in combination 1.

Ultimately, the decision to perform follow-up imaging and the choice of imaging modality should be individualized based on the patient's specific risk factors and clinical characteristics, with consideration of the potential benefits and harms of each approach 1.

From the Research

Follow-up Imaging for Fatty Liver Disease

• The use of follow-up imaging for patients with fatty liver disease diagnosed on ultrasound is a topic of interest in the medical field 2, 3, 4, 5, 6.
• Studies have shown that ultrasound can be an effective means of diagnosing and monitoring fatty liver disease, with the addition of elastography providing valuable information on liver stiffness and fibrosis 2.
• However, the performance of liver ultrasound can be modest, and its sensitivity may be limited, particularly at lower levels of liver fat content 3.
• Other imaging modalities, such as magnetic resonance spectroscopy and histology, may be more accurate in diagnosing and monitoring fatty liver disease, but ultrasound remains a widely used and accessible tool 3, 4, 5, 6.

Risk Factors and Associations

• Fatty liver disease has been associated with various risk factors, including obesity, hypertension, diabetes mellitus, and metabolic syndrome 4, 5.
• The severity of fatty liver on ultrasound has been shown to correlate with metabolic and cardiovascular risk, making it a potentially useful tool for risk stratification 5.
• Quantitative ultrasound approaches have emerged as a promising method for diagnosing and monitoring hepatic steatosis in nonalcoholic fatty liver disease, offering advantages such as universal availability, real-time capability, and relatively low cost 6.

Imaging Modalities

• Various imaging modalities are available for evaluating hepatic steatosis, including ultrasound, magnetic resonance imaging (MRI), computed tomography (CT), and serum analysis 3, 6.
• Each modality has its strengths and limitations, and the choice of imaging modality may depend on factors such as availability, cost, and patient characteristics 3, 6.
• Ultrasound elastography has been shown to be a useful tool for assessing liver stiffness and fibrosis, and may be used in conjunction with other imaging modalities to provide a more comprehensive assessment of fatty liver disease 2.