This presentation summarizes the latest technologies for detecting early liver fibrosis and their role in healthcare today. It is aimed at primary care doctors, to help them better utilize these new developments for their patients.

1. Detecting Early Liver Fibrosis
A Nutshell for Primary Care
Dr Jarrod Lee
Mt Elizabeth Novena Hospital
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2. Stage 1: Portal Fibrosis
Stage 0: Normal
Stage 2: Periportal Fibrosis
Fibrosis to
Cirrhosis
Stage 4: Cirrhosis
Stage 3: Septal Fibrosis
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3. Importance of Measuring Fibrosis
• Determine:
– Prognosis
– Disease progression
– Need for treatment
• Monitor response to treatment
BUT
• Clinical features and lab tests can detect cirrhosis,
but not earlier fibrosis
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4. Liver Biopsy
• ‘Gold standard’ for
staging fibrosis
• Staging by accepted
classifications
• Can evaluate:
– Etiology
– Inflammation
– Steatosis
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5. Problems with Liver Biopsy
• Invasive
– 30% have pain after biopsy
– 1% severe complications
• Inter and intra observer variability
• Sampling error
– Samples 1:50,000 of liver mass
– Difference between right and left lobes
• Stage of fibrosis: 33%
• Diagnosis of cirrhosis: 15%
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6. How about using ultrasound?
• Systemic review of 21 studies (2010)
– Liver surface is most robust technique: high specificity (7895%), moderate sensitivity (51-73%)
– Poor observer agreement
• Singapore study (2012)
– Significant fibrosis: sensitivity 32%, specificity 85%
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7. Fibroscan
• Uses mild amplitude low frequency
vibration transmitted through liver
• Velocity of shear wave correlates with
liver stiffness
– Travels faster through stiffer fibrotic
tissue
• Sampled volume 1:500
• Painless bedside test; takes < 5 min
• Good reproducibility, well validated
• 90% accurate for early fibrosis (F0-1)
and cirrhosis
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8. Fibroscan
The velocity of the wave is evaluated
in a region located from 2.5 to 6.5 cm
below the skin surface.
The probe induces an elastic
wave through the liver.
25 to 65 mm
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9. Liver Stiffness
Portal fibrosis
Cholestasis
Centrolobular fibrosis
Sinusoidal fibrosis
Stiffness
Steatosis
Portal blood flow
Inflammation
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10. Limitations
• Less accurate for intermediate fibrosis (F2-4)
– Sensitivity and specificity 70-80%
– May still need biopsy for these cases
• Does not tell etiology or grade of inflammation
• Less effective in obese patients BMI > 30
• Not reliable in:
–
–
–
–
Acute hepatitis
Cholestasis
Hepatic congestion
Infiltrative liver diseases
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11. Magnetic Resonance Elastography
• Uses a vibrating device to
induce shear waves in internal
organs, which are detected by
MRI machine
• Examines whole liver
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12. Performance
• Highly accurate > 90%
• Good for intermediate
fibrosis F2-4 with 85%
sensitivity and specificity
• Overcomes limitations of
fibroscan in obesity
• Limitations:
– Cost and access
– Further validation
needed
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