FibroScan Has No Role in Decompensated Cirrhosis
FibroScan should not be used in patients with known decompensated cirrhosis, as major guidelines explicitly exclude this population from elastography-based risk stratification. 1
Why FibroScan Is Not Indicated
Guideline Exclusions Are Explicit
The 2017 American Gastroenterological Association guidelines on elastography explicitly state that patients with decompensated cirrhosis were not considered in their analyses, and therefore "standard clinical practice should be pursued in the care of these patients" without consideration of FibroScan cutoffs 1
Endoscopic evaluation should be pursued as per standard clinical practice in decompensated cirrhosis patients, regardless of any elastography values 1
The diagnosis is already established clinically—you know the patient has cirrhosis and it is decompensated—so measuring liver stiffness adds no actionable information 1
The Clinical Question Has Already Been Answered
FibroScan is designed to diagnose the presence and stage of fibrosis in patients where this is uncertain 1, 2
In decompensated cirrhosis, the diagnosis is already confirmed by clinical manifestations (ascites, variceal hemorrhage, hepatic encephalopathy, jaundice with synthetic dysfunction) 1
Management decisions in decompensated cirrhosis are driven by Child-Pugh score, MELD score, and clinical parameters—not by elastography values 1
Technical and Physiological Limitations
Ascites prevents reliable FibroScan measurements and is an absolute technical contraindication to transient elastography 3, 4
Active inflammation, cholestasis, and hepatic congestion—all common in decompensated cirrhosis—falsely elevate liver stiffness independent of fibrosis 1, 5, 6
In acute liver injury, FibroScan frequently yields falsely cirrhotic-range values (>12.5 kPa) even in patients without any fibrosis on biopsy 5
Elevated bilirubin, which defines decompensation in many cases, correlates with falsely elevated stiffness measurements 5
What You Should Do Instead
Standard Clinical Management
Use Child-Pugh and MELD scores to assess prognosis and guide transplant listing 1
Perform upper endoscopy to screen for varices and determine need for primary prophylaxis with non-selective beta-blockers or band ligation 1
Initiate hepatocellular carcinoma surveillance with ultrasound ± AFP every 6 months 1
Manage complications (ascites, hepatic encephalopathy, spontaneous bacterial peritonitis) according to standard protocols 1
When Elastography Might Have Been Useful (But It's Too Late Now)
FibroScan is validated for compensated cirrhosis to risk-stratify for clinically significant portal hypertension using cutoffs of 17.0 kPa (for any varices) or 19.5 kPa (for high-risk varices) 1
In compensated cirrhosis without known varices, a FibroScan <19.5 kPa combined with platelet count >150,000/µL can potentially defer endoscopy per Baveno VI criteria 1
But once decompensation occurs (ascites, variceal bleeding, encephalopathy), these risk-stratification algorithms no longer apply 1
Common Pitfall to Avoid
Do not order FibroScan reflexively in all patients with cirrhosis 1
The test was designed for pre-cirrhotic fibrosis staging and compensated cirrhosis risk stratification—not for managing established decompensated disease 1, 2
If a FibroScan is inadvertently performed and shows very high values (e.g., >50 kPa), this does not change management or provide prognostic information beyond what is already known clinically 7, 3