What is the next step in managing a patient with fatty liver disease and who should undergo a FibroScan (Fibrosis Scan)?

Management of Fatty Liver Disease and FibroScan Indications

For patients with fatty liver disease, the next step should be risk stratification using the FIB-4 score followed by liver stiffness measurement with FibroScan for those at intermediate or high risk of advanced fibrosis. 1

Risk Stratification Algorithm

Step 1: Identify At-Risk Patients

Patients who should be screened for fatty liver disease include:

• All patients with type 2 diabetes
• Patients with ≥2 metabolic risk factors (obesity, hypertension, dyslipidemia, prediabetes)
• Patients with incidental finding of hepatic steatosis on imaging or elevated aminotransferases 1

Step 2: Initial Assessment

• Complete history focusing on alcohol intake (>14 drinks/week for women, >21 drinks/week for men)
• Laboratory tests: liver function tests, complete blood count
• Calculate FIB-4 score: https://www.mdcalc.com/fibrosis-4-fib-4-index-liver-fibrosis 1

Step 3: Risk Stratification Based on FIB-4 Score

1. Low Risk: FIB-4 <1.3 (<2.0 for patients >65 years)

   • No immediate need for FibroScan
   • Repeat FIB-4 in 2-3 years
   • Management by primary care provider

2. Indeterminate Risk: FIB-4 1.3-2.67

   • Proceed to FibroScan/transient elastography
   • Further risk stratification based on liver stiffness measurement (LSM)

3. High Risk: FIB-4 >2.67

   • Proceed to FibroScan/transient elastography
   • Refer to hepatologist 1

Step 4: FibroScan/Transient Elastography Assessment

Based on liver stiffness measurement (LSM):

1. Low Risk: LSM <8 kPa

   • Low likelihood of advanced fibrosis
   • Management by primary care
   • Lifestyle modifications
   • Repeat assessment in 2-3 years

2. Indeterminate Risk: LSM 8-12 kPa

   • Refer to hepatologist
   • Consider additional testing
   • Re-evaluation in 2-3 years

3. High Risk: LSM >12 kPa

   • High likelihood of advanced fibrosis
   • Refer to hepatologist
   • Consider liver biopsy or MR elastography
   • Screening for complications of cirrhosis 1

Indications for FibroScan

FibroScan is indicated for:

1. Patients with indeterminate or high FIB-4 scores (1.3-2.67 or >2.67)
2. Patients with metabolic syndrome components (diabetes, obesity, hypertension) and abnormal liver tests 2
3. Diabetes patients with any liver function test abnormality 2
4. Patients with persistent elevation in liver enzymes for >3 months 2
5. Patients with hepatic steatosis on ultrasound who are indeterminate or high risk based on FIB-4 1

Management Based on Risk Stratification

Low Risk (FIB-4 <1.3 or LSM <8 kPa)

• Lifestyle modifications (weight loss 5-10%, Mediterranean diet, 150-300 minutes/week physical activity)
• Management of metabolic comorbidities
• Repeat assessment in 2-3 years 1, 2

Intermediate/High Risk (FIB-4 >1.3 or LSM >8 kPa)

• Refer to hepatologist
• More intensive lifestyle intervention (target 7-10% weight loss)
• Consider pharmacotherapy for NASH in non-cirrhotic patients
• For patients with diabetes: prefer medications with efficacy in NASH (pioglitazone, GLP-1 receptor agonists)
• Screening for complications in advanced disease 1

Pitfalls and Caveats

1. Age affects FIB-4 interpretation: Use higher cutoffs (FIB-4 <2.0) for patients >65 years 1

2. Obesity can affect FibroScan accuracy: Use XL probe for patients with BMI >30 kg/m² 3

3. FibroScan limitations: Technical failure rates of 10-15% in obese patients; XL probe improves success rates to 88-100% 3

4. Non-invasive tests have limitations: FIB-4 and FibroScan are more accurate for excluding advanced fibrosis than for confirming it 4

5. Sequential testing is superior: Using FIB-4 followed by FibroScan for indeterminate/high scores is more accurate than using either test alone 1

6. Normal liver enzymes don't exclude disease: Advanced fibrosis can present with normal liver function tests 2

By following this structured approach to risk stratification and appropriate use of FibroScan, clinicians can identify patients at highest risk for advanced liver disease and ensure they receive appropriate management to reduce morbidity and mortality.