|Year : 2018 | Volume
| Issue : 2 | Page : 520-524
The role of fibroscan in assessment of liver cirrhosis in patients with chronic liver disease
Mohamed S Elzawawy1, Shaimaa A Hassanein1, Rasha M El Nomrosy2
1 Department of Diagnostic Radiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Diagnostic Radiology, Ashmoun Hospital, Ashmoun, Egypt
|Date of Submission||04-Feb-2017|
|Date of Acceptance||02-May-2017|
|Date of Web Publication||27-Aug-2018|
Rasha M El Nomrosy
Source of Support: None, Conflict of Interest: None
The aim of this study is to evaluate the accuracy of fibroscan in the assessment of liver cirrhosis in chronic liver disease.
Fibroscan is a noninvasive imaging study for measuring liver stiffness by transducer probe-induced elastic share wave that propagates through liver tissue to measure its velocity.
Patient and methods
The present study was conducted on 50 patients with chronic liver disease. There were 32 males and 18 females, and their ages ranged from 34 to 75 years, with mean age of 51 years. The study was conducted in the hepatology units of Menoufiya University Hospitals, and the disease was confirmed by standard diagnostic criteria. All cases were subjected to the following protocol: full history, clinical examination, laboratory investigation, and ultrasound examination. The patients were subjected to fibroscan examination. The elasticity is directly correlated with the degree of hepatic fibrosis, and 7 kPa has been proposed as a cut-off for fibrosis equal to or greater than F2, and 12.5 kPa for cirrhosis.
Liver stiffness was significantly correlated with liver cirrhosis. The fibroscan technique has high sensitivity and high specificity of 100%, with the area under the receiver operating characteristic curve (95% confidence interval) of 1.00, at the cut-off level of 14.5 kPa.
Transient elastography is a promising noninvasive method for detection of cirrhosis in patients with chronic liver disease. Therefore, fibroscan can be used regarding the decision of treatment and follow-up of patients with cirrhosis for screening and detection of the complications.
Keywords: cut-off value, fibroscan, liver stiffness measurement
|How to cite this article:|
Elzawawy MS, Hassanein SA, El Nomrosy RM. The role of fibroscan in assessment of liver cirrhosis in patients with chronic liver disease. Menoufia Med J 2018;31:520-4
|How to cite this URL:|
Elzawawy MS, Hassanein SA, El Nomrosy RM. The role of fibroscan in assessment of liver cirrhosis in patients with chronic liver disease. Menoufia Med J [serial online] 2018 [cited 2018 Sep 24];31:520-4. Available from: http://www.mmj.eg.net/text.asp?2018/31/2/520/239726
| Introduction|| |
Progressive hepatic fibrosis with the development of cirrhosis is a feature of almost all chronic liver diseases . The most common cause of chronic liver disease is hepatitis C virus (HCV), which is transmitted interfamilial followed by antischistosomal drug injection and blood transfusion . Approximately 10–20% of patients with chronic HCV infection have cirrhosis at first clinical presentation, and 20–30% of those who do not have cirrhosis will eventually develop this condition and its complications within one or more decades. These complications are liver failure, ascites, variceal bleeding, portal-systemic encephalopathy, and hepatocellular carcinoma . Liver biopsy is currently considered as the gold standard for assessing hepatic fibrosis. However, it is an invasive and painful procedure . With rare but potential life-threatening complications , livery biopsy is limited in acceptance and repetition in usually asymptomatic patients. In addition, the accuracy of liver biopsy in assessing fibrosis may be questioned because of sampling error and interobserver variability, which may lead to misstating or understating of cirrhosis .
Thus, there is a need to develop and validate noninvasive tests that can accurately reflect the full spectrum of hepatic fibrosis, cirrhosis, and its severity in liver diseases. Transient elastography is a novel, rapid, and noninvasive technique that measures liver stiffness .
This system is equipped with a probe consisting of an ultrasonic transducer mounted on the axis of a vibrator. A vibration of mild amplitude and low frequency is transmitted from the vibrator to the tissue by the transducer itself. This vibration induces an elastic shear wave that propagates through the tissue. In the meantime, pulse-echo ultrasonic acquisitions are performed to follow the propagation of the shear wave and measure its velocity, which is directly related to tissue stiffness. The harder the tissue, the faster the shear wave propagates. Recent reports showed that liver stiffness measurement using FibroScan allowed accurate prediction of hepatic fibrosis in patients with chronic HCV infection . In patients with chronic hepatitis C, liver stiffness measurements ranged from 2.4 to75 kPa, with a median value of 7.4 kPa. Based on the stiffness measurement distribution according to fibrosis stage and receiver operating characteristic (ROC) curves, the cut-off value for cirrhosis was 12.5 kPa .
| Aim|| |
The aim of this study is to evaluate the accuracy of fibroscan in the assessment of liver cirrhosis in chronic liver disease.
| Patient and Methods|| |
This study was approved by the Ethical Committee of Faculty of Medicine, Menoufia University, and the decisions of the patients were respected at all stages of involvement. After explaining the consequence of proceedings to the patients, if any patient asked us to stop using his/her result in the research, we complied with it. Moreover, we respected all the rights of patients, and all the patients underwent a safety and caution measure agreement. A total of 50 patients with chronic liver disease were included, with 32 males and 18 females. Their ages ranged from 34 to 75 years, with mean age of 51 years. The study was conducted in hepatology units in Menoufia University Hospitals, and the disease was confirmed by standard diagnostic criteria.
Inclusion and exclusion criteria
All cases were subjected to the following protocol: full history, clinical examination, laboratory investigation (serum markers of infection with hepatitis B or C virus), alcoholic hepatitis or nonalcoholic steatohepatitis identification, and ultrasound examination. As in case of ascites, there is a physical limitation to the technique, because elastic waves do not propagate through liquids. Patients with ascites, patients with morbid obesity, and patients with decompensated cirrhosis were excluded.
Liver stiffness measurement
Measurements were performed on the right lobe of the liver through intercostal spaces, with the patients lying in the dorsal decubitus position with the right arm in maximal abduction. The tip of the probe transducer was covered with coupling gel and was placed on the skin between the rib bones at the level of the right lobe of the liver. The operator, assisted by an ultrasonic time-motion image, located a liver portion of at least 6-cm thick free of large vascular structures (FibroScan; Echosens France, Manufacturing & Services, 5 Rue Jean Lemoine 94000 Creteil - France). Once the measurement area had been located, the operator pressed the probe button to start an acquisition. Measurement depth was between 25 and 65 mm below the skin surface. Measurements that did not have a correct vibration shape or a correct follow-up of the vibration propagation were automatically rejected by the software. Up to 10 successful measurements were performed on each patient. Success rate was calculated as the ratio of the number of successful measurements over the total number of acquisitions. The results are expressed in kilopascal (kPa). Median value of the successful measurements was kept as representative of liver stiffness. The whole examination duration was less than 5 min. Only liver stiffness measurements obtained with at least ten successful measurements, with at least a success rate of 30%, were considered reliable.
Description of quantitative variables was in the form of the mean, SD, minimum, maximum, and SEM.
On the contrary, the qualitative variables were in the form of numbers and percentage. Comparison between quantitative variables was achieved by repeated measurements. Analysis of variance (χ2) was used for comparing between more than two groups of independent variables, and its results were expressed in the form of P values.
The significance of the results was assessed in the form of P values, which were differentiated into the following: non-significant at P more than 0.05, significant at P 0.05 or less, and highly significant at P 0.001 or less.
The diagnostic performance of liver stiffness measurement was assessed using ROC curve. A subject was assessed as positive or negative according to whether the noninvasive marker value was greater than, less than, or equal to a given cut-off value. Associated with any cut-off value was the probability of a true positive (sensitivity) and the probability of a true negative (specificity). The ROC curve is a plot of sensitivity versus specificity for all possible cut-off values. The most commonly used index of the accuracy is the area under the receiver operating characteristic (AUROC) curve, and its values close to 1.0 indicate a high diagnostic accuracy. METAVIR scoring system was used to indicate fibrosis stage of 3 or more (F > 3) and cirrhosis (F = 4).
| Results|| |
Of the examined 50 cases, 32 (64%) were male and 18 (36%) were female.
Of the examined 50 cases, the degree of cirrhosis detected by fibroscan indicated 15 (30%) cases were F3, 28 (56%) were F4, and only seven (14%) cases were F3–F4, as tabulated in [Table 1]. The fibroscan showed a positive correlation with ultrasound finding (texture, size, and surface).
With respect to the hepatic size (liver span), 60% of F3 patients had hepatomegaly and 40% of F3 patients had normal liver. Moreover, 75% of F4 patients had hepatomegaly, 14% had normal liver size, and only 11% of F4 patients had shrunken liver. There was a highly statistically significant correlation between hepatic size and fibroscan results (P < 0.001). All these results have been tabulated in [Table 2].
[Table 3] shows the results of hepatic surface, where 100% of F3 patients had a regular hepatic surface. Overall, 71% of F4 patients had a regular hepatic surface and 29% had an irregular hepatic surface. Regarding F3–F4, all the patients had a regular hepatic surface. There was a statistically significant correlation between hepatic size and fibroscan results (P < 0.05).
The fibroscan showed a positive correlation with the hepatic echo-texture. Overall, 67% of F3 patients had a bright texture and 33% had coarse echogenic texture; no cirrhotic cases were detected in F3 patients. Moreover, 43% of F4 patients had coarse echogenic texture. On the contrary, patients with bright texture and cirrhotic liver represented the same percentage at 28.5%. Of F3–F4 patients, 43% had bright texture and 57% coarse echogenic texture, whereas no cirrhotic cases were detected in F3–F4 patients. There was a statistically significant correlation between echo-texture and fibroscan results (P < 0.05), as presented in [Table 4].
In [Table 5], the mean reading of fibroscan was 25.9 kPa with success rate of 98%, the maximum reading was 65.4 kPa with success rate of 100%, and the minimum was 9.5 kPa with success rate of 69%.
The results of ROC curve as shown in [Figure 1] state that the fibroscan technique has a high sensitivity and a high specificity; with the area under the curve of 1.00. It means it is identical with the cut-off value is 14.5 kPa. US findings regarding texture show that the sensitivity was 71% and the specificity was 40%, with area under the curve of 0.7; regarding size shows that sensitivity was 25% and the specificity was 45%, with area under the curve of 0.37; and regarding the surface shows that sensitivity was 28% and the specificity was 100%, with area under the curve of 0.64. These results of the ROC curve were tabulated in [Table 6].
|Figure 1: Receiver operating characteristic curve for fibroscan and ultrasound finding.|
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| Discussion|| |
Epidemiological studies identified a number of factors that contribute to the risk of developing cirrhosis. Age older than 50 years and male sex are examples that increase cirrhosis risk . Moreover, this goes withthe results of Demographic Health Survey 2008. The incidences in males were more than females, and it is likely because of higher exposure of HCV among males.
In our study, the fibroscan showed a positive correlation with the hepatic size (liver span) as 60% of F3 patients had hepatomegaly and 40% of F3 patients had normal liver, whereas75% of F4 patients had hepatomegaly. The first finding of enlargement of cirrhotic liver in HCV co-infected patients was reported by Simonovský . In more advanced stages of liver disease, the liver becomes small with a multinodular surface . Patients with cirrhosis of non-alcoholic fatty liver disease may have hepatomegaly on clinical or imaging evaluation , which approved with our study.
In the current study, the fibroscan showed positive correlation with the hepatic surface as 100% of F3 patients had regular hepatic surface. Moreover, 71% of F4 patients had regular hepatic surface and 29% had irregular hepatic surface. The most common US features in patients with cirrhosis were the presence of irregularity (irregular surface and liver nodules) and liver atrophy reported by Simonovský .
Moreover, the fibroscan had positive correlation with the hepatic echo-texture, as 67% of F3 patients had bright texture and 33% had coarse echogenic, whereas no cirrhotic cases were detected in F3 patients. Overall, 43% of F4 patients had coarse echogenic texture, whereas patients who had bright texture and cirrhotic liver represented the same percentage at 28.5%. In addition, 43% of F3–F4 patients had bright texture and 57% had coarse echogenic texture, whereas no cirrhotic cases were detected in F3–F4 patients.
The coarse pattern increases liver echogenicity, causing some difficulty in differentiation between cirrhosis and steatosis . In steatosis and many forms of NAFLD, both fatty and fibrotic liver signs present during their course, thus making their differentiation difficult .
In our study, for detection of significant cirrhosis by fibroscan at the cut-off level of 14.5 kPa, the AUROC was 1.00, sensitivity was 100%, and specificity was 100%which differed compared with Castera et al.  who reported at the cut-off level of 12.5 kPa, AUROC of 0.95, sensitivity of 97%, and specificity of 91%, and also with Foucher et al.  who reported at a cut-off level of 17.6 kPa, sensitivity of 77% and specificity of 97%. This difference in results may be attributed to, significant fibrosis, type of patients, schistosomal coinfection, fat distribution in Egyptian patients, and the number of patients with cirrhosis in each study. Indeed, the prevalence of cirrhosis varied in studies between 14 and 25%.
On the contrary, our study agreed with Ziol et al.  who rreported at a cut-off level of 14.6 kPa, sensitivity of 86%, and specificity of 96%.
Two meta-analysis have been published reporting the best results of transient elastography at differentiating cirrhosis versus no cirrhosis with a mean diagnostic accuracy AUROC of 94–96% , and pooled sensitivity and specificity of 87 and 91%, respectively. According to these results, fibroscan can be used in clinical practice as a diagnostic tool for the diagnosis or exclusion of liver cirrhosis when other clinical signs and examinations are indecisive.
In the present study, ultrasound reported cirrhosis in 21 patients. Ultrasound sensitivity for detection of cirrhosis is 71%; however, sensitivity of fibroscan in detection of cirrhosis is 100%. From these results, we can say that ultrasound overestimates the presence of cirrhosis and that it is not a sensitive tool to detect fibrosis or cirrhosis, but fibroscan is a good method for detection of cirrhosis because of its high sensitivity. These results were in agreement with Tchelepi et al.  who reported that ultrasound can assess hepatic parenchyma composition qualitatively, but it is subjective and operator dependent. Moreover, fibrosis and steatosis can have similar appearances and can be present at the same time in a fatty or fibrotic pattern.
| Conclusion|| |
Liver stiffness measurement is a good method for the diagnosis of fibrosis and cirrhosis, irrespective of the cause of liver disease. Values in patients with cirrhosis ranged from 14.6 to 75.4 kPa. Liver stiffness measurement may be accurate for assessing the severity of cirrhosis and taking decisions without the need of liver biopsy. However, a longitudinal cohort study needs to be performed to predict the complications of cirrhosis, using fibroscan, so that screening for complications of cirrhosis, and close follow-up, could be performed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Ikeda K, Saitoh S, Suzuki Y, Kobayashi M, Tsubota A, Koida I, et al
. Disease progression and hepatocellular carcinogenesis in patients with chronic viral hepatitis: a prospective observation of 2215 patients. J Hepatol 1998; 28
Badr RS, Korah AE, Tawfeek AR, Mohamed KA. A study on how patients catch hepatitis C virus. Menoufia Med J 2016; 29
Benvegnù L, Gios M, Boccato S. Natural history of compensated viral cirrhosis: a prospective study on the incidence and hierarchy of major complications. Gut 2004; 53
Cadranel JF, Rufat P, Degos F. Practices of liver biopsy in France: results of a prospective nationwide survey. For the Group of Epidemiology of the French Association for the Study of the Liver (AFEF). Hepatology 2000; 32
Bravo AA, Sheth SG, Chopra S. Liver biopsy. N Engl J Med 2001; 344
Maharaj B, Maharaj RJ, Leary WP. Sampling variability and its influence on the diagnostic yield of percutaneous needle biopsy of the liver. Lancet 1986; 1
Sandrin L, Tanter M, Gennisson JL. Shear elasticity probe for soft tissues with 1D transient elastography. IEEE Trans Ultrason Ferroelectr Freq Control 2002; 49
Saito H, Tada S, Nakamoto N. Efficacy of non-invasive elastometry on staging of hepatic fibrosis. Hepatol Res 2004; 29
Castera L, Vergniol J, Foucher J. Prospective comparison of transient elastography, Fibrotest, APRI, and liver biopsy for the assessment of fibrosis in chronic hepatitis C. Gastroenterology 2005; 128
Poynard T, Bedossa P, Opolon P. Natural history of liver fibrosis progression in patients with chronic hepatitis C. The OBSVIRC, METAVIR, CLINIVIR and DOSVIRC groups. Lancet 1997; 349
Simonovský V. The diagnosis of cirrhosis by high resolution ultrasound of the liver surface. Br J Radiol 1999; 72
Monto A, Kakar S, Dove LM, Bostrom A, Miller EL, Wright TL. Contributions to hepatic fibrosis in HIV-HCV co-infected and HCV mono-infected patients. Am J Gastroenterol 2006; 101
Palmentieri B, de Sio I, La Mura V, Masarone M, Vecchione R, Bruno S, et al
. The role of bright liver echo pattern on ultrasound B-mode examination in the diagnosis of liver steatosis. Dig Liver Dis 2006; 38
Zardi EM, Caturelli E. May sonography distinguish between liver fibrosis and liver steatosis? Dig Liver Dis 2007; 739
Foucher J, Chanteloup E, Vergniol J. Diagnosis of cirrhosis by transient elastography (fibroscan): a prospective study. Gut 2006; 55
Ziol M, Handra Luca A, Kettaneh A. Non invasive assessment of liver fibrosis by measurement of stiffness inpatients with chronic hepatitis C. Hepatology 2005; 41
Friedrich-Rust M, Ong MF, Martens S. Performance of transient elastography for the staging of liver fibrosis: a meta-analysis. Gastroenterology 2008; 134
Talwalkar JA, Kurtz DM, Schoenleber SJ, West CP, Montori VM. Ultrasound based transient elastography for the detection of hepatic fibrosis: systematic review and meta-analysis. Clin Gastroenterol Hepatol 2007; 5
Tchelepi H, Ralls PW, Radin R. Sonography of diffuse liver disease. J Ultrasound Med 2002; 21
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]