Is a fibroscan (fibrosis scan) necessary for every patient with hepatic steatosis (fatty liver disease)?

Fibroscan is Not Necessary for Every Patient with Hepatic Steatosis

Not every patient with hepatic steatosis requires a fibroscan; instead, a risk-stratified approach based on clinical factors and simple blood tests should be used to determine who needs advanced fibrosis assessment. 1

Risk Stratification Approach for Patients with Hepatic Steatosis

Step 1: Identify Patients at Higher Risk for Advanced Fibrosis

Patients with hepatic steatosis who have any of the following risk factors should undergo further evaluation:

• Type 2 diabetes
• Two or more metabolic risk factors (obesity, hypertension, dyslipidemia, prediabetes)
• Elevated liver enzymes (especially ALT)
• Age ≥40-45 years 1

Step 2: Initial Non-Invasive Assessment

For patients with risk factors, calculate the FIB-4 score using:

• Age
• AST and ALT levels
• Platelet count

Interpret FIB-4 results:

• FIB-4 <1.3 (<2.0 in those >65 years): Low risk of advanced fibrosis
  • Action: Repeat FIB-4 in 2-3 years
• FIB-4 1.3-2.67: Indeterminate risk
  • Action: Proceed to liver stiffness measurement (LSM)
• FIB-4 >2.67: High risk of advanced fibrosis
  • Action: Refer to hepatology 1

Step 3: Liver Stiffness Measurement (Only for Indeterminate or High-Risk Patients)

For patients with indeterminate or high FIB-4:

• LSM <8 kPa: Low risk of advanced fibrosis
  • Action: Repeat assessment in 2-3 years
• LSM 8-12 kPa: Indeterminate risk
  • Action: Refer to hepatology for monitoring
• LSM >12 kPa: High risk of advanced fibrosis
  • Action: Refer to hepatology for liver biopsy or MR elastography 1

Evidence Supporting This Approach

The 2021 Gastroenterology clinical care pathway for NAFLD strongly recommends this risk-stratified approach. Studies suggest that only about 11% of patients with incidentally discovered hepatic steatosis might be at high risk for advanced hepatic fibrosis 1. This is particularly true in patients with elevated aminotransferases.

The European Association for the Study of the Liver (EASL) guidelines also support using non-invasive tests in a stepwise manner, starting with simple fibrosis scores like FIB-4 before proceeding to more specialized tests like fibroscan 1.

Important Considerations

• FIB-4 has a negative predictive value of ≥90% for excluding advanced fibrosis, making it an excellent initial screening tool 1
• Transient elastography (FibroScan) has good accuracy for detecting both steatosis and fibrosis but is not necessary as a first-line test for all patients 2, 3
• Patients with normal liver enzymes and no metabolic risk factors have a very low risk of clinically significant fibrosis 1, 4
• Obesity can affect FibroScan results, and the XL probe should be used in obese patients 5

Common Pitfalls to Avoid

1. Overutilization of FibroScan: Ordering FibroScan for all patients with steatosis leads to unnecessary testing and healthcare costs
2. Ignoring metabolic risk factors: Type 2 diabetes significantly increases the risk of advanced fibrosis (up to 20% prevalence) 6
3. Relying solely on liver enzymes: Normal ALT does not exclude advanced fibrosis; many patients with advanced fibrosis have normal liver enzymes 1
4. Neglecting follow-up: Even low-risk patients should be reassessed every 2-3 years as fibrosis can progress 1

By following this evidence-based, risk-stratified approach, you can appropriately identify which patients with hepatic steatosis truly need fibroscan evaluation, ensuring that resources are directed to those most likely to benefit while avoiding unnecessary testing in low-risk individuals.