When is a fibrous scan needed in managing non-alcoholic fatty liver disease (NAFLD)?

When to Use Fibroscan in Non-Alcoholic Fatty Liver Disease Management

Fibroscan (transient elastography) should be used as a first-line non-invasive test to assess for advanced fibrosis in patients with suspected NAFLD, particularly those with risk factors for fibrosis progression. 1

Primary Indications for Fibroscan in NAFLD

• Fibroscan should be used as part of the initial risk stratification to exclude advanced fibrosis in patients with suspected NAFLD 1
• Patients with metabolic syndrome, which strongly predicts the presence of steatohepatitis, should undergo Fibroscan to assess fibrosis stage 1
• Patients with intermediate or high risk scores on non-invasive fibrosis panels (NAFLD Fibrosis Score or FIB-4) should undergo Fibroscan for further evaluation 1
• Fibroscan should be considered in diabetic patients with NAFLD, as they have a significantly higher risk of advanced fibrosis (41% prevalence) 1

Recommended Algorithm for Fibrosis Assessment in NAFLD

1. Initial Assessment: Use non-invasive methods such as transient elastography (Fibroscan), FIB-4, or NAFLD Fibrosis Score (NFS) to screen for advanced fibrosis 1
2. Risk Stratification:
   • Low risk: Continue routine monitoring 1
   • Intermediate risk: Perform additional evaluation with Fibroscan if not already done 1
   • High risk: Consider liver biopsy 1
3. Fibroscan Cut-off Values: The optimal cut-off for detecting advanced fibrosis is 7.1-7.9 kPa, with a diagnostic accuracy (AUC) of 0.90 1

Limitations of Fibroscan in NAFLD

• Fibroscan has a higher failure rate in obese patients (up to 20% in unselected European series) 1
• The XL probe should be used in obese patients to reduce failure rates, though failure rates remain high (35%) even with this probe 1
• Body habitus and degree of steatosis can limit the accuracy of transient elastography 1, 2
• Fibroscan performs better for detecting cirrhosis (F4) than for advanced fibrosis (F3) 1

Alternative Assessment Methods

• If Fibroscan is not available or fails, serum biomarker panels like NFS or FIB-4 can be used to diagnose liver fibrosis 1
• Magnetic resonance elastography (MRE) has higher accuracy than Fibroscan for fibrosis assessment in NAFLD (optimal cut-off 3.62-3.8 kPa with AUC of 0.94) but is less widely available 1
• The combination of elastography and serum markers may perform better than either method alone and might save a number of diagnostic liver biopsies 1

When to Consider Liver Biopsy After Fibroscan

• Liver biopsy should be considered when Fibroscan and other non-invasive tests suggest advanced fibrosis 1
• Biopsy is indicated when competing etiologies for hepatic steatosis cannot be excluded with non-invasive tests 1
• Patients with persistently elevated aminotransferases in whom the diagnosis remains uncertain should undergo biopsy 1
• Liver biopsy remains the gold standard for diagnosing NASH and staging fibrosis but should be reserved for those who would benefit most from diagnostic, therapeutic guidance, and prognostic perspectives 1

Monitoring Recommendations

• Monitoring of fibrosis progression in clinical practice may rely on a combination of biomarkers/scores and transient elastography at variable time intervals 1
• Patients identified as having advanced fibrosis by Fibroscan require closer follow-up and possibly more intensive therapy 1
• Longitudinal data correlating changes in histological severity with changes in non-invasive measurements are still needed 1

Remember that while Fibroscan is valuable for fibrosis assessment, it cannot distinguish NASH from simple steatosis, which requires liver biopsy for definitive diagnosis 1.