What does a FibroScan result showing a median liver stiffness of 42.2 kPa, an IQR of 35, and an IQR/Med ratio of 7% indicate for a patient with chronic liver disease?

FibroScan Result Interpretation: Median 42.2 kPa with IQR 35 and IQR/M 7%

Technical Validity Assessment

This FibroScan result is technically valid and reliable for clinical decision-making. The IQR/median ratio of 7% is well below the 30% threshold required for reliable measurements, indicating excellent measurement consistency 1. This low IQR/M ratio places this result in the highest accuracy category, where diagnostic performance is optimal regardless of the absolute liver stiffness value 1.

• The measurement meets all three technical validity criteria: the IQR/M is <30% (actually 7%, which is exceptional), and this indicates the individual measurements were highly consistent 2, 3
• An IQR/M ≤10% represents the highest reliability category for FibroScan results, providing maximum diagnostic accuracy 1
• Despite the high absolute IQR value of 35 kPa, what matters clinically is the ratio to the median (7%), not the absolute IQR number 1

Clinical Interpretation: Advanced Cirrhosis with Portal Hypertension

A median liver stiffness of 42.2 kPa indicates advanced cirrhosis with clinically significant portal hypertension (CSPH). This value far exceeds all diagnostic thresholds for cirrhosis and enters the range predictive of portal hypertension complications.

Fibrosis Stage Classification

• This result is well above the 12.5 kPa threshold for cirrhosis used across all chronic liver disease etiologies 1
• For NAFLD specifically, values >12.0-12.5 kPa indicate F4 cirrhosis requiring urgent hepatology referral and hepatocellular carcinoma (HCC) screening 1, 4
• For viral hepatitis, the threshold is >12.5 kPa for cirrhosis, and this patient's value of 42.2 kPa is more than three times higher 1, 4

Portal Hypertension Assessment

• Liver stiffness >20-25 kPa diagnoses clinically significant portal hypertension (CSPH) with high accuracy (AUROC 0.93), and this patient's value of 42.2 kPa substantially exceeds this threshold 2
• Values ≥21 kPa predict clinical decompensation events with accuracy equal to invasive hepatic venous pressure gradient (HVPG) measurements 2
• This level of liver stiffness indicates high risk for variceal bleeding and need for endoscopic surveillance, regardless of platelet count 2

Immediate Clinical Actions Required

This patient requires urgent hepatology referral within 2-4 weeks, immediate initiation of HCC surveillance, and upper endoscopy for variceal screening.

Mandatory Interventions

• Urgent hepatology referral for comprehensive cirrhosis management and treatment of underlying liver disease 1, 4
• Initiate HCC surveillance with ultrasound ± AFP every 6 months, as this is mandatory for all patients with cirrhosis 1, 4
• Upper endoscopy for variceal screening given the high likelihood of CSPH at this liver stiffness level 2
• Calculate APRI score [(AST/ULN)/platelets × 100] to provide additional prognostic information, as values >1.5 suggest cirrhosis even with normal absolute laboratory values 2

Risk Stratification for Decompensation

• In patients with alcohol-related liver disease, liver stiffness values in this range (>20 kPa) are associated with significantly increased risk of decompensation and mortality 5
• The patient should be counseled about the high risk of clinical decompensation and the critical importance of addressing modifiable risk factors 5

Critical Confounding Factors to Exclude

Before finalizing this interpretation, verify the patient was fasting for at least 3-4 hours before the test and exclude acute confounding conditions that can falsely elevate liver stiffness.

Conditions That Falsely Elevate Liver Stiffness

• Active hepatic inflammation or acute hepatitis can produce falsely cirrhotic-range values independent of fibrosis 1, 4
• Extrahepatic cholestasis (check bilirubin, alkaline phosphatase, and imaging for biliary obstruction) 1
• Right heart failure or hepatic congestion (assess for elevated jugular venous pressure, peripheral edema, or cardiac history) 1
• Recent alcohol intake within 2 weeks can falsely elevate measurements in alcohol-related liver disease 1
• Non-fasting state (food intake within 3-4 hours) falsely elevates liver stiffness regardless of measurement method 1, 4

Laboratory Correlation

• Check ALT level immediately, as ALT >80 IU/L can cause stiffness in the cirrhosis range despite minimal fibrosis 6
• Review AST, platelet count, bilirubin, INR, and albumin to assess for laboratory evidence of cirrhosis and synthetic dysfunction 1
• If ALT is markedly elevated (>5× upper limit of normal), consider repeating FibroScan after inflammation subsides 1

Prognostic Implications

This liver stiffness value carries significant prognostic weight for predicting clinical outcomes.

• Liver stiffness ≥21 kPa predicts first clinical decompensation with accuracy equal to invasive HVPG measurements 2
• In alcohol-related liver disease cohorts, patients with baseline LSM >20 kPa had significantly higher rates of decompensation and mortality compared to those with lower values 5
• Serial monitoring with repeat FibroScan is recommended to assess disease trajectory and response to interventions 5

Common Pitfalls to Avoid

• Do not dismiss this result based on normal platelet count or albumin, as these laboratory parameters have insufficient accuracy for excluding CSPH or advanced cirrhosis 2
• Do not delay HCC surveillance while awaiting hepatology consultation, as surveillance should begin immediately upon cirrhosis diagnosis 1, 4
• Do not rely on FibroScan alone to exclude other causes of liver disease, as it only measures stiffness and cannot diagnose etiology 6
• Do not repeat FibroScan in the short term unless there is strong suspicion of a confounding factor (acute hepatitis, non-fasting, etc.), as the result is technically valid 1, 2