What is the next best imaging study for a 63-year-old female (F) with neutropenia and chronic liver disease, who has undergone an abdominal ultrasound (Abd US) showing hepatosteatosis, and is scheduled for a FibroScan for liver assessment?

Imaging Evaluation for a 63-Year-Old Female with Neutropenia and Chronic Liver Disease

In addition to the planned FibroScan, a Doppler ultrasound of the portal system should be ordered to evaluate for portal hypertension given the finding of a diminutive spleen on the initial ultrasound.

Assessment of Current Findings

The patient presents with several concerning features that require careful evaluation:

• 63-year-old female with neutropenia referred by oncology
• Chronic liver disease of unspecified etiology
• Abdominal ultrasound showing:
  • Hepatosteatosis (fatty liver)
  • Diminutive spleen (potentially significant finding)

Recommended Imaging Approach

1. FibroScan (Transient Elastography)

• Appropriate first-line test for liver fibrosis assessment 1
• Provides quantitative measurement of liver stiffness to assess fibrosis stage
• High sensitivity (87%) and specificity (91%) for diagnosing cirrhosis 2
• Advantages:
  • Non-invasive
  • Quantifiable results
  • Can be repeated for monitoring
  • More accurate than conventional ultrasound for fibrosis staging

2. Doppler Ultrasound of Portal System

• Essential addition to evaluate:
  • Portal vein flow dynamics (velocity and direction)
  • Signs of portal hypertension
  • Splenic size and vasculature (particularly important given diminutive spleen finding)
  • Collateral vessels

3. Laboratory Tests to Complement Imaging

• Calculate FIB-4 score using:
  • AST and ALT levels
  • Platelet count
  • Age
• This provides complementary non-invasive fibrosis assessment 1, 3

Rationale for Recommendations

1. The diminutive spleen finding warrants further investigation:

   • Unusual in chronic liver disease, which typically causes splenomegaly
   • May indicate splenic atrophy from vascular compromise
   • Could represent portal vein thrombosis or other vascular abnormalities

2. Doppler assessment provides critical information:

   • Evaluates hemodynamic alterations indicative of portal hypertension 1
   • Can detect slow velocity or hepatofugal (reversed) flow in portal vein 1
   • Helps distinguish between different causes of chronic liver disease

3. Combined approach improves diagnostic accuracy:

   • The combination of FibroScan and Doppler ultrasound provides complementary information
   • Synchronous combination of elastography with other tests significantly improves diagnostic accuracy 3

Important Considerations and Pitfalls

1. FibroScan limitations:

   • May be difficult to perform in obese patients (BMI >28) with failure rates up to 4.5% 4
   • Results can be confounded by:
     • Inflammation
     • Extrahepatic cholestasis (can falsely elevate readings) 5
     • Recent food intake (patient should fast for 6 hours prior) 2
     • Hepatic congestion

2. Interpretation considerations:

   • Liver stiffness measurements should be interpreted in clinical context
   • Cutoff values:
     • <8 kPa: low risk
     • 8-12 kPa: intermediate risk

     • 12 kPa: high risk, suggesting advanced fibrosis/cirrhosis 2

3. Follow-up recommendations:

   • If FibroScan shows advanced fibrosis (>8 kPa), consider MR elastography for confirmation
   • If portal hypertension is detected, endoscopic evaluation for varices may be warranted

This approach provides comprehensive evaluation of both parenchymal liver disease and potential vascular complications, which is particularly important given the unusual finding of a diminutive spleen in the context of chronic liver disease.