When is a fibro scan (Fibrosis Scan) indicated for a patient?

When to Order a FibroScan

FibroScan should be ordered as a second-line test after initial risk stratification with simple blood-based scores (FIB-4 or NAFLD Fibrosis Score) shows indeterminate results, or as a first-line test in patients with alcohol-related liver disease drinking at harmful levels. 1

Primary Indications by Disease Category

Non-Alcoholic Fatty Liver Disease (NAFLD)

• Calculate FIB-4 first in all adults with NAFLD using routine labs (AST, ALT, platelet count, age) 2
• Order FibroScan for patients with indeterminate FIB-4 scores (1.3-3.25, or 2.0-3.25 if age >65 years) 1, 3
• Refer directly to hepatology without FibroScan if FIB-4 >3.25 or NAFLD Fibrosis Score >0.675, as these patients are already high-risk 1
• Do not order FibroScan if FIB-4 <1.3 (<2.0 if age >65), as these patients reliably have no advanced fibrosis with ≥90% negative predictive value 3

Alcohol-Related Liver Disease

• Order FibroScan immediately for patients drinking at harmful levels (≥35 units/week for women, ≥50 units/week for men) without requiring initial blood-based risk stratification 1
• Ensure 2 weeks of abstinence before testing when possible, as recent alcohol consumption falsely elevates liver stiffness measurements 1
• FibroScan cutoff <8 kPa reliably rules out advanced fibrosis in this population 2

Chronic Viral Hepatitis B and C

• Order FibroScan for staging fibrosis in patients with confirmed chronic hepatitis B or C to guide treatment decisions 2
• Use APRI score >0.5 or FibroScan >7.0 kPa to identify significant fibrosis (≥F2) 2
• Use APRI score >1.0 or FibroScan >12.5 kPa to identify cirrhosis 2
• FibroScan has sensitivity/specificity of 70%/84% for significant fibrosis and 87%/91% for cirrhosis in viral hepatitis 2

Populations Where FibroScan Should Be Used

Order FibroScan in patients at risk of advanced liver fibrosis, not in unselected general populations 2. Specific at-risk groups include:

• Patients with metabolic risk factors (obesity, diabetes, metabolic syndrome) 2, 1
• Patients with harmful alcohol use 2, 1
• Patients with confirmed chronic viral hepatitis 2
• Patients with persistently elevated liver enzymes of unclear etiology 2

Critical Timing and Technical Requirements

When NOT to Order FibroScan

• During active hepatic inflammation or ALT flare, as this causes falsely elevated readings up to the cirrhotic range 4
• Within 2 weeks of alcohol consumption in alcohol-related liver disease 1
• In patients with ascites, as FibroScan is unreliable in this setting 2, 5
• In patients with morbid obesity (though XL probe may overcome this limitation) 2

Technical Validity Requirements

A FibroScan result is only reliable if it meets all three criteria: 2, 3, 5

• ≥10 successful measurements obtained
• Success rate ≥60%
• Interquartile range <30% of median value

Interpretation Thresholds for Clinical Decision-Making

For NAFLD and Most Chronic Liver Diseases

• <8.0 kPa: Rules out significant fibrosis; repeat testing in 2-3 years if risk factors persist 1, 3, 5
• 7.0-8.0 kPa: Borderline zone; consider more frequent monitoring every 6-12 months 5
• 8.0-12.0 kPa: Significant to advanced fibrosis; refer to hepatology 3, 5
• >12.5 kPa: Cirrhosis; urgent hepatology referral and HCC screening 2, 3

For Alcohol-Related Liver Disease

• <8.0 kPa: Rules out advanced fibrosis 2
• Higher thresholds may be needed if ALT is elevated up to 5× upper limit of normal 4

Follow-Up Testing Intervals

• Low-risk patients (FibroScan <7.8 kPa): Repeat pathway in 3-5 years if risk factors remain 1
• Stable mild fibrosis: Repeat FibroScan every 2-3 years 5
• Borderline values or multiple risk factors: Monitor every 6-12 months 5

Common Pitfalls to Avoid

• Do not use FibroScan as a first-line test in NAFLD—always calculate FIB-4 first, as sequential testing is more accurate than either test alone 3, 5
• Do not order FibroScan in patients with narrow intercostal spaces, acute hepatitis, or extrahepatic biliary obstruction, as these conditions compromise accuracy 3, 5
• Do not rely on FibroScan alone to rule out other causes of liver disease—it only measures stiffness, not inflammation or alternative diagnoses 2
• Ensure ALT, AST, and platelet count are part of routine investigations so simple non-invasive scores can be calculated before ordering FibroScan 2