Vibration-controlled Transient Elastography

A Practical Approach to the Noninvasive Assessment of Liver Fibrosis

Elliot B. Tapper; Nezam H. Afdhal

Disclosures

Curr Opin Gastroenterol. 2015;31(3):192-198. 

In This Article

Abstract and Introduction

Abstract

Purpose of review Therapeutic advances for hepatitis C and the increasing prevalence on nonalcoholic fatty liver disease are reshaping the diagnostic approach to disease staging in clinical hepatology. Well tolerated, inexpensive and reliable alternatives to liver biopsy are a critical need for clinicians and patients alike.

Recent findings Vibration-controlled transient elastography (VCTE, also known as 'transient elastography') is a robust, point-of-care tool for the noninvasive assessment of liver fibrosis. This tool efficiently prioritizes the treatment for patients with viral hepatitis at risk for advanced liver disease and identifies the subgroups with metabolic or cholestatic liver disease who are at the highest risk. Rather than staging fibrosis, VCTE provides an accurate risk estimate of advanced fibrosis. In addition, it is increasingly recognized that elastography can predict outcomes including hepatic decompensation and mortality. The ideal use of this tool is to perform it in conjunction with a serologic marker of fibrosis to confirm its findings.

Summary When combined with serologic markers of fibrosis, VCTE allows the vast majority of patients to avoid a liver biopsy.

Introduction

Recent advances in the treatment of hepatitis C virus (HCV) combined with increased screening of 'baby-boomers' for HCV has had a profound impact on the diagnostic algorithm for the evaluation of HCV. In addition, the near epidemic proportion of patients with nonalcoholic fatty liver disease (NAFLD) is increasing with more patients presenting with clinically significant liver disease and likely to constitute the bulk of liver-related morbidity and mortality moving forward.[1–3] There is a need in both HCV and NAFLD to accurately stage liver disease to identify those patients who will most likely benefit from more urgent intervention and those with cirrhosis who need to be screened for varices and hepatocellular carcinoma.

The emergence of highly effective all oral therapies for HCV[4,5] and the large patient demand for therapy generated by both their over 90% cure rates and tolerability has resulted in prioritization of therapy being recommended by the American Association for the Study of Liver Diseases-Infectious Diseases Society of America (AASLD/IDSA) guidelines and instituted by third party payers.[6] Treatment is primarily recommended based on the stage of fibrosis requiring the identification of patients with stage 2 or greater disease and particularly those with stage 3 and 4 disease, bridging fibrosis and cirrhosis. In nonalcoholic steatohepatitis (NASH) patients, although lifestyle modification with weight loss and exercise remain the mainstay of management, increasingly new therapeutic agents are being tried particularly for those with more advanced disease. Although differentiating simple steatosis from NASH still requires a liver biopsy, noninvasive tools such as vibration-controlled transient elastography (VCTE, also known as 'transient elastography') can still be useful for fibrosis staging. These two forces are reshaping the diagnostic approach to disease staging in clinical hepatology. In the short-term, while clinicians are forced to prioritize patients for HCV therapy, the role of well tolerated and reliable risk stratification tools are paramount. In the long-term, the volume of patients with liver disease will overwhelm the clinical capacity of gastoenterologists and hepatologists. Determining the patients at highest risk for the complications of advanced liver disease will be essential.

In April of 2013, the Food and Drug Administration approved the use of VCTE. Commonly delivered by FibroScan (Echosens, Paris, France), VCTE is a valuable clinical tool that can assist the clinician in the management of clinical liver disease. Herein, we will describe how VCTE can be integrated into clinical practice.

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