When should a patient undergo a FibroScan (Fibrosis Scan) for liver disease?

When to Get FibroScan

FibroScan should be obtained as a second-line test after initial risk stratification with FIB-4 or NAFLD Fibrosis Score shows indeterminate or elevated results, or as a first-line assessment in patients drinking at harmful levels (≥35 units/week for women, ≥50 units/week for men). 1

Clinical Scenarios Requiring FibroScan

For Non-Alcoholic Fatty Liver Disease (NAFLD)

Use a stepwise approach starting with simple blood tests:

• First-line: Calculate FIB-4 or NAFLD Fibrosis Score in all adults with NAFLD 1

  • Low-risk patients (FIB-4 <1.3 if age <65 years, or <2.0 if ≥65 years) can be managed in primary care without FibroScan 1
  • High-risk patients (FIB-4 >3.25 or NFS >0.675) should be referred to hepatology regardless of FibroScan results 1

• Second-line (FibroScan indicated): Patients with indeterminate scores (FIB-4 1.3-3.25 or NFS -1.455 to 0.675) should undergo FibroScan or serum ELF testing 1

  • Refer to specialist if FibroScan >7.8 kPa 1
  • Values <8 kPa do not exclude early liver disease but suggest lower risk 1

For Alcohol-Related Liver Disease

FibroScan is indicated earlier in the diagnostic pathway for alcohol users:

• Immediate assessment: Patients drinking at harmful levels (≥35 units/week women, ≥50 units/week men) should proceed directly to fibrosis assessment with FibroScan 1
• GGT consideration: Patients with hazardous drinking and GGT >100 U/L warrant FibroScan evaluation 1
• Interpretation thresholds for alcohol-related disease: 1
  • <8 kPa: Does not exclude early disease
  • 8-16 kPa: Possible advanced fibrosis

  • 16 kPa: Possible cirrhosis, refer to hepatology

For Low-Prevalence Populations at Risk

Risk stratification pathways should be used rather than universal screening:

• Individuals with metabolic risk factors (obesity, diabetes, metabolic syndrome) should enter risk stratification pathways using non-invasive tests 1
• FibroScan can be used in consultation with liver specialists for populations with variable risk factors 1
• The selection of FibroScan versus other non-invasive tests should be based on local expertise and availability 1

Critical Timing Considerations

Avoid FibroScan during active inflammation or recent alcohol use:

• Recent alcohol consumption falsely elevates liver stiffness measurements; ideally perform after 2 weeks of abstinence 2, 3
• In alcoholic patients, a mean decrease of 2.7 kPa occurs after 2 weeks of abstinence, improving concordance with histology 3
• Elevated AST levels may falsely increase measurements due to alcoholic steatohepatitis 2
• ALT flares in chronic hepatitis B can produce falsely high results up to the cirrhotic range 4

Follow-Up FibroScan Timing

Repeat testing intervals depend on initial findings:

• Patients with low-risk scores and FibroScan <7.8 kPa: Repeat pathway in 3-5 years if risk factors remain 1
• Patients with mild fibrosis (F0-F1, <8 kPa): Annual monitoring recommended 5
• Stable mild fibrosis: Repeat FibroScan every 2-3 years 5
• Multiple risk factors or borderline values (7-8 kPa): More frequent monitoring every 6-12 months 5

Important Limitations and Pitfalls

FibroScan has technical limitations that affect when it should be used:

• Failed acquisition is common in obese patients; consider XL probe which has higher success rates 4
• Cannot be performed reliably in patients with ascites, narrow intercostal spaces, or extrahepatic biliary obstruction 5, 4
• Requires ≥10 successful measurements with success rate ≥60% and interquartile range <30% of median value for reliability 5
• The XL probe produces values approximately 1.2-1.3 kPa lower than the M probe, requiring adjusted cut-offs 4

When FibroScan Provides Prognostic Value

Beyond staging fibrosis, FibroScan predicts clinical outcomes:

• Values >30 kPa predict hepatic venous pressure gradient >10 mmHg with 94% specificity 3
• Values >30.6 kPa show 84% negative predictive value for ruling out esophageal varices 3
• Useful for predicting hepatocellular carcinoma development, portal hypertension, and survival 4, 6
• For patients with limited healthcare access, FibroScan provides critical prognostic information to prioritize follow-up urgency 2

The British Society of Gastroenterology and European Association for the Study of the Liver both emphasize that FibroScan should not be used as a first-line universal screening tool, but rather as part of structured risk stratification pathways after initial assessment identifies patients at risk for advanced fibrosis. 1, 2