Dear Colleagues,
 
I am pleased to announce that the Fibroscan program here

at The Liver Clinic @The Practice is up and running. 

I wanted to take this opportunity to tell you about our program in more detail.
 
Referring a patient for a scan:
 
1. We have included a “Fibroscan-only” referral sheet that your office can use

to send patients for a Fibroscan.  You will see that there are requirements for recent

blood work and other background information; these are simply to help in the

interpretation of the results. This specific referral form ensures the patient case

does not end up in the general referral side of our clinic.
2. Appointment bookings will be handled like most other referrals- except that they will be expedited.
3. I will personally interpret the results within 2-5 days of the scan.
4. The interpretation of the test will be emailed back to you as a straightforward report.
5. The patient will be returned to your care and supervision after the scan is complete.
 
Fibroscan Background.
 

Fatty Liver Disease and Fibroscan

Fibroscan can quantitate fat infiltration which is reported as a CAP score and this determines the grade of steatosis. This is proving to be an important tool to motivate and monitor patients with fatty liver detected on ultrasound

​

Recent Guidelines on Fatty Liver Disease and Diabetes

Fatty Liver Disease is now referred to as Steatotic Liver Disease (SLD) which is  an overarching term to encompass the various etiologies of steatosis. Fatty liver disease associated with the Metabolic Syndrome is now called metabolic dysfunction-associated steatotic liver disease (MASLD).

The goal of screening for MASLD in diabetics  is to identify patients at risk for adverse health outcomes associated with MASLD such as cirrhosis, HCC, and death from liver disease. This risk is higher in people who have central obesity and cardio-metabolic risk factors or insulin resistance, are >50 years of age, and/or have persistently elevated plasma aminotransferases (AST and/or ALT >30 units/L for >6 months)

In a recent 2023 guideline1 the American Diabetes Association has recommended the following:

Adults with type 2 diabetes or pre-diabetes, particularly those with obesity or cardio-metabolic risk factors/established cardiovascular disease, should be screened/risk stratified for MASLD with clinically significant fibrosis using a calculated fibrosis-4 index mdcalc.com/calc/2200/fibrosis-4-fib-4-index-liver-fibrosis], even if they have normal liver enzymes.

Adults with type 2 diabetes or pre-diabetes with a Fib -4 index greater than 1.3 should have additional risk stratification by liver stiffness measurement with transient elastography (Fibroscan).

Diabetes Care 2023;46 (Supplement_1):s49–s67.2

 

Fibroscan and Fibrosis

The prognosis and management of chronic liver disease largely relies on the extent and progression of hepatic fibrosis.  To date, liver biopsy traditionally has been considered the gold standard for evaluating hepatic fibrosis. As you all know, a liver biopsy has limitations including being an invasive and painful procedure. In addition, it has a poor patient acceptance and carries a small risk of life-threatening complications.
 
One of the most important limitations for a liver biopsy is a sampling error and intra and inter observer variability that may lead to over or under estimation of liver fibrosis stage. Even in the best hands when an experienced physician performs a liver biopsy and an expert pathologist interprets the results, the error rate in disease stage may reach up to 20-30%. Finally, a liver biopsy is not the ideal procedure as a serial assessment of disease progression.
 
Fibroscan is a novel non-invasive technology that has been gaining popularity for the evaluation of hepatic fibrosis in patients with chronic liver disease of different etiologies. It measures the degree of liver stiffness. The technology utilizes ultrasonic waves hence there is no radiation exposure.
 
Fibroscan measures liver stiffness in volume then approximates a cylinder 1 cm wide and 4 cm long, between 25 mm and 65 mm below the skin surface. This volume is at least 100 larger than a biopsy sample and is therefore far more representative of liver parenchyma.
 
Diagnostic performance of transient elastography has been well validated in various liver diseases including chronic hepatitis C, chronic hepatitis B, co-infection with HIV, cholestatic liver diseases including primary biliary cirrhosis and primary sclerosing cholangitis, autoimmune hepatitis and Steatotic Liver Disease (SLD). Fibroscan has also been useful in monitoring development of liver fibrosis in patients being treated continuously with potential hepatotoxic drugs, such as patients with psoriasis being treated with methotrexate.
 
Fibroscan is a very useful tool for diagnosis of early cirrhosis. Confirmatory long term longitudinal studies are being done to confirm the validity of Fibroscan in monitoring of disease progression, screening for complications of cirrhosis such as esophageal varices and hepatocellular carcinoma and also screening for portal hypertension.
 
It has also been shown that transient elastography is useful in the prediction of the stage of liver fibrosis in patients with alcoholic liver disease.
 
I am very pleased to be able to provide your patient with this relatively new and exciting technology.  I hope with this technology at hand you will be able to provide your patients with the best therapeutic decisions and outcomes.