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American Gastroenterological AssociationGastroenterology2020advanced

Role of Elastography in the Evaluation of Liver Fibrosis

Published by American Gastroenterological Association Institute · GRADE

11Recommendations
19References
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Summary

AI-generated

This guideline provides evidence-based recommendations on utilizing noninvasive imaging tools, specifically vibration-controlled transient elastography (VCTE) and magnetic resonance elastography (MRE), for evaluating liver fibrosis, diagnosing cirrhosis, and ruling out varices across various chronic liver diseases.

liver fibrosisVCTEMREAGA Institutegastroenterologyguidelinescirrhosis detectionchronic hepatitis C

Key Takeaways

  • 1
    VCTE is superior to APRI and FIB-4 for detecting cirrhosis in chronic hepatitis C and B.
  • 2
    A VCTE cutoff of 12.5 kPa is suggested to detect cirrhosis in HCV and chronic alcoholic liver disease.
  • 3
    A VCTE cutoff of 11.0 kPa is suggested to detect cirrhosis in HBV.
  • 4
    A post-treatment VCTE cutoff of 9.5 kPa can rule out advanced fibrosis in HCV patients who achieved sustained virologic response (SVR).
  • 5
    VCTE cutoffs can help stratify risk for high-risk esophageal varices (19.5 kPa) and clinically significant portal hypertension before nonhepatic surgery (17.0 kPa).
  • 6
    MRE is suggested over VCTE for detecting cirrhosis in high-risk NAFLD patients.

Key Recommendations

Question 1 and 2

  • 1

    In patients with chronic hepatitis C, the AGA recommends VCTE, if available, rather than other nonproprietary, noninvasive serum tests (APRI, FIB-4) to detect cirrhosis.

    StrongEvidence: ModerateDiagnostic

Question 3

  • 2

    In patients with chronic hepatitis C, the AGA suggests a VCTE cutoff of 12.5 kPa to detect cirrhosis.

    ConditionalEvidence: LowDiagnostic

Question 4

  • 3

    In noncirrhotic patients with HCV who have achieved SVR after antiviral therapy, the AGA suggests a post-treatment vibration controlled transient elastography cutoff of 9.5 kPa to rule out advanced liver fibrosis.

    ConditionalEvidence: Very-lowDiagnostic

Question 5 and 6

  • 4

    In patients with chronic hepatitis B, the AGA suggests VCTE rather than other nonproprietary noninvasive serum tests (ie, APRI and FIB-4) to detect cirrhosis.

    ConditionalEvidence: LowDiagnostic

Question 7

  • 5

    In patients with chronic hepatitis B, the AGA suggests a VCTE cutoff of 11.0 kPa to detect cirrhosis.

    ConditionalEvidence: LowDiagnostic

Question 8 and 9

  • 6

    The AGA makes no recommendation regarding the role of VCTE in the diagnosis of cirrhosis in adults with NAFLD.

    No recommendationEvidence: Knowledge gapDiagnostic

Question 10

  • 7

    In patients with chronic alcoholic liver disease, the AGA suggests a VCTE cutoff of 12.5 kPa to detect cirrhosis.

    ConditionalEvidence: LowDiagnostic

Question 11

  • 8

    In patients with suspected compensated cirrhosis, the AGA suggests a vibration controlled transient elastography cutoff of 19.5 kPa to assess the need for esophagogastroduodenoscopy to identify high risk esophageal varices.

    ConditionalEvidence: LowDiagnostic

Question 12

  • 9

    In patients with suspected chronic liver disease undergoing elective nonhepatic surgery, the AGA suggests a VCTE cutoff of 17.0 kPa to detect clinically significant portal hypertension to inform preoperative care.

    ConditionalEvidence: LowDiagnostic

Question 13

  • 10

    In adult patients with chronic hepatitis C, the AGA suggests using VCTE rather than MRE for detection of cirrhosis.

    ConditionalEvidence: Very-lowDiagnostic

Question 14

  • 11

    In adults with NAFLD and a higher risk of cirrhosis, the AGA suggest using MRE, rather than VCTE, for detection of cirrhosis. In adults with NAFLD and a lower risk of cirrhosis, the AGA makes no recommendation regarding the role of MRE or VCTE for detection of cirrhosis.

    Conditional / No recommendationEvidence: Low / Knowledge gapDiagnostic

Scope & Objectives

Clinical Topic

Liver Fibrosis

Objectives

To provide clinicians with evidence-based guidance on the specific role of vibration-controlled transient elastography (VCTE) in clinical practice.

Target Patient Population

Adults with chronic liver disorders

Diagnostic Criteria

Diagnostic cutoffs for VCTE: 12.5 kPa for cirrhosis in HCV and alcoholic liver disease; 11.0 kPa for cirrhosis in HBV; 19.5 kPa to assess need for endoscopy for high-risk varices; 17.0 kPa for clinically significant portal hypertension; 9.5 kPa to rule out advanced fibrosis post-SVR in HCV.

Target Providers

GastroenterologistsHepatologistsPrimary Care Physicians

Patient Criteria & Setting

Therapeutic Area

Hepatology

Guideline Scope

DiagnosisEvaluationRisk Stratification

Inclusion Criteria

  • Adults
  • Chronic hepatitis C
  • Chronic hepatitis B
  • Nonalcoholic fatty liver disease (NAFLD)
  • Chronic alcoholic liver disease

Exclusion Criteria

  • Acute alcoholic hepatitis
  • Decompensated cirrhosis (for varices screening cutoff)
  • Known esophageal varices or portal hypertension

Care Settings

Ambulatory office settingPrimary care clinicsSpecialty liver clinics

Special Populations

Obese patientsPatients with excessive alcohol usePatients with HIV or Hepatitis B co-infection

Evidence Grading

System: GRADE

Recommendation Strength

strongStrong recommendation
conditionalConditional recommendation

Safety & Contraindications

Contraindications

  • Acute hepatitis
  • Alcohol abuse
  • Food intake within 2-3 hours
  • Congestive heart failure
  • Extrahepatic cholestasis
  • Limited intercostal space
  • Obesity (may require XL-probe)

Monitoring Guidance

In noncirrhotic patients with HCV who have achieved sustained virologic response (SVR), a post-treatment VCTE cutoff of 9.5 kPa can be used to rule out advanced liver fibrosis and guide decisions on discharging patients from specialized liver clinics.

Authors & Contributors

Joseph K. LimSteven L. FlammSiddharth SinghYngve T. Falck-Ytterand the Clinical Guidelines Committee of the American Gastroenterological Association

Guideline Features

Based on systematic review

Learning Context

Difficulty

advanced

Exam Relevance

GastroenterologyHepatologyInternal Medicine

Learning Paths

ElastographyLiver FibrosisCirrhosisHepatologyGastroenterologyVCTEMRENoninvasive Liver Testing