![S1 [n=148] S2 [n=12] S3[n=5] S4 [n=3] S1 [n=148] S2 [n=12] S3[n=5] S4 [n=3]
ARFI Fibroscan
0.00 - 1.00 42% 36% 11% 11% 41% 38% 10% 11%
1.10 - 2.00 8% 0% 25% 67% 8% 0% 17% 75%
2.10 - 3.00 0% 0% 20% 80% 0% 0% 0% 100%
>3.00 0% 0% 0% 100% 0% 0% 0% 100%
0%
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120%
Asscoiation of ARFI & FS with their difference](https://image.slidesharecdn.com/vgn-cfhennaiisg2015latestnewfinal-150421065934-conversion-gate02/85/5-Liver-Fibrosis-Assessment-Dr-V-G-Mohanprasad-47-320.jpg)
5 Liver Fibrosis Assessment Dr. V.G. Mohanprasad
- 1. DR. V.G.MOHAN PRASAD, M.D., D.M., (GASTRO) PAST PRESIDENT OF INDIAN SOCIETY OF GASTROENTEROLOGY PAST PRESIDENT, SGEI ADJUNCT PROFESSOR TAMIL NADU DR.MGR MEDICAL UNIVERSITY CHAIRMAN VGM HOSPITAL - INSTITUTE OF GASTROENTEROLOGY COIMBATORE
- 2. Why do we need to assess fibrosis? Prognosis becomes worse F1-------F4
- 4. • F0 : lobular, no fibrous tissue • F1-F3 : fibrosis (periportal, then briding) • F4 : Cirrhosis = annular fibrosis + architectural remodeling (lobule nodule) CIRRHOSIS REVERSION // REGRESSION F4 F3, F2 or F1 (nodular lobule)
- 11. Liver biopsy- gold standard Not always easy
- 12. Poor patient compliance Limited usefulness for dynamic follow-up Risk of complications typical of invasive procedures (Pain, bleeding, mortality) Sampling errorssampling error is common because only 1/50,000 of the organ is analyzed
- 13. 3 different samples were obtained: The same result in 3 biopsy were present in: - 50% of Cirrhosis - 54% of HCC - 55% of Metastatic Cancers - 18.8% of Hepatic Granuloma
- 14. Two samples: right lobe and single needle biopsy (HAI score): - 34.5% difference≥4 in necroinflamatory score - 38% difference≥1 in fibrosis score - 20% difference≥2 in fibrosis score Mean difference for NI= 2.4 score Mean difference for FI= 0.6 score
- 15. These limitations may lead to an underestimation of cirrhosis, especially when LB specimens are small or fragmented We need a Test to be more representative of liver And less invasive
- 16. •3.5 MHz ultrasound transmitted from the vibrator toward the tissues •pulse-echo ultrasound acquisitions are performed which is directly related to tissue stiffness. •The harder the tissue, the faster the shear wave propagates •The operator, assisted by ultrasound time-motion images •liver portion at least 6 cm thick and free of large vascular structures •The measurement depth is between 25 and 65 mm below the skin surface 100 times larger than liver biopsy
- 18. Sono-elastography that evaluates liver elasticity Utilizes acoustic waves to interrogate the mechanical stiffness of liver Can be used during standard US examination of liver
- 19. Excellent tool Requires an expensive software Not available in most centres Expensive Excellent in obese
- 20. Safe Fast screening Acceptability by patients Longitudinal follow-up Efficacy of therapeutic treatments Prognostic evaluation Excellent Intera and inter observation Accurate
- 21. Hepatitis C recurrence is the first cause of graft loss in liver transplant programs Frequent liver biopsies= Routine follow-up of HCV-infected patients after LT
- 22. Optimal liver stiffness cutoff values (>8.50 kPa for fibrosis >F2, and >12.5 kPa for F4) none of the few cases with liver stiffness below the cutoff value and significant fibrosis in the liver biopsy had bridging fibrosis (F3) or cirrhosis
- 23. PHT cut of (>6 mm Hg) significant PHT (>10 mm Hg)
- 24. Pearson correlation, 0.84; P < 0.001). The area under the curve for diagnosis of portal hypertension (HVPG 6 mm Hg) was 0.93. Only a few cases with liver stiffness below 8.74 kPa had portal hypertension and, outstandingly, none of them had significant portal hypertension (HVPG 10 mm Hg) or bridging fibrosis or cirrhosis.
- 26. 7.9KP for marked fibrosis (F>2 sensitivity 72%, specificity 84%) 10.3KP for severe fibrosis (F>3, sensitivity 76%, specificity 90%) 11.9 for cirrhosis (sensitivity 91% and specificity 89%)
- 27. The overall interobserver agreement ICC was 0.98 (95% CI 0.977 to 0.987)
- 28. The intraobserver agreement ICC was 0.98 for both raters
- 29. Corresponding areas under the ROC were 0.95 (95% CI: 0.93-0.97) in the whole population 0.96 (95% CI: 0.77-0.96) 0.90 (95% CI: 0.77-0.96) 0.96 (95% CI : 0.90-0.98)
- 31. Markedly overweight or obese patients LS measurement can be influenced by hepatic inflammation (In acute HAV) Extra Hepatic cholestasis influences liver stiffness score
- 33. No Liver biopsy No Fibroscan
- 34. How are they related ? How do they measure ? Current status ?
- 36. L. Caste´ra et al. /
- 39. AST/ALT ratio (AAR) APRI test: uses platelet count and AST “FIB 4 index” utilizes age, AST, ALT, and platelet count “NAFLD fibrosis score” includes: - BMI - Presence of DM - Albumin
- 40. “Fibrotest” (BioPredictive) taking into account: - GGT - Haptoglobulin - Bilirubin - Apolipoprotein A1 - α2 macroglobulin “Fibro Spect” taking into account: - Hyaluronic acid - Tissue inhibited matrix metalloproteinase Inhibitor1 - α2 macroglobulin
- 42. 168 patients with Fatty liver on Ultrasound underwent Fibroscan (TE) and Philips shear wave elastography (SWE) Mean Fibroscan TE score was 9.2 Mean Philips SWE score was 9.1
- 43. By paired t test, the correlation of TE and SWE values was highly significant (p-0.000).
- 44. 0 10 20 30 40 50 60 70 80 1 11 21 31 41 51 61 71 81 91 101 111 121 131 141 151 161 Series 1 Series 2
- 47. S1 [n=148] S2 [n=12] S3[n=5] S4 [n=3] S1 [n=148] S2 [n=12] S3[n=5] S4 [n=3] ARFI Fibroscan 0.00 - 1.00 42% 36% 11% 11% 41% 38% 10% 11% 1.10 - 2.00 8% 0% 25% 67% 8% 0% 17% 75% 2.10 - 3.00 0% 0% 20% 80% 0% 0% 0% 100% >3.00 0% 0% 0% 100% 0% 0% 0% 100% 0% 20% 40% 60% 80% 100% 120% Asscoiation of ARFI & FS with their difference
- 49. In 17.85% (30/ 168) patients, Fibroscan TE and Philips SWE detected F3 / F4 Fibrosis missed by ultrasound (showed only fatty liver)
- 50. NO FIB32ROSCAN TE PHILIPS SWE USG ABDOMEN 1 20.4 18.2 GR I FATTY LIVER 2 48 50.2 GR I FATTY LIVER 3 38 36.4 GR I FATTY LIVER 4 28.4 26.4 GR II FATTY LIVER 5 75 74.6 GR II FATTY LIVER 6 45.7 46.2 GR II FATTY LIVER 7 24 22.3 GR II FATTY LIVER 8 29.1 26.3 GR II FATTY LIVER 9 21.5 19.6 GR I FATTY LIVER 10 19.2 20.2 GR II FATTY LIVER 11 23.3 22.2 GR II FATTY LIVER 12 16.9 16.2 GR I FATTY LIVER 13 26.3 25.6 GR II FATTY LIVER 14 43.5 40.2 GR II FATTY LIVER 15 20.9 20.1 GR I FATTY LIVER 16 14.8 12.3 GR I FATTY LIVER 17 11.5 12.5 GR I FATTY LIVER 18 13.1 12.3 GR I FATTY LIVER 19 14 13.6 GR I FATTY LIVER 20 12.6 13.4 GR I FATTY LIVER 21 10.9 9.8 GR I FATTY LIVER 22 10.2 10.1 GR I FATTY LIVER 23 11.5 12.5 GR I FATTY LIVER 24 11.9 11 GR I FATTY LIVER 25 10.1 10.1 GR I FATTY LIVER 26 10.4 11.1 GR I FATTY LIVER 27 11.3 10.2 GR I FATTY LIVER 28 11.3 12 GR I FATTY LIVER 29 10.1 11.2 GR I FATTY LIVER 30 11.7 10.3 GR I FATTY LIVER
- 51. Fibroscan and SWE, are thus able to detect patients with significant fibrosis in many cases, where ultrasound showed only Gr I-II fatty liver.
- 53. Case1- Treatment of NAFLD which included hepatoprotectives Caused a reduction of fibroscan score from 8 to 5.7 after 10 months.
- 54. 31/10/2013 Height-173 Weight-70 BMI-23.39 BP-120/80 Pulse-80 27/08/2014 Height-173 Weight-78.6 BMI-25.37 BP-150/100 Pulse-78
- 56. Case 2- Treatment of NAFLD caused reduction in fibroscan score from 9.6 to 7.9 after 12 months.
- 58. 12/15/14 Baseline •Mrs.K-48yrs/F •CLD-HCV-Genotype-3 •Rxed with PEGIFN for 24wks •Baseline HCV Viral load- 1.2million/ml •ETVR: HCVNot Detected 6Mo Post Rx
- 59. 12/15/14 Mr.K-46/M ETOH+HCV related Cirrhosis with PHT, UGI Bleed Fundal Glue+EVBL Rxed with Hepatoprotectives and ETOH abstinence PresentBaseline
- 60. Liver Biopsy is still the gold standard for assessing fibrosis HOWEVER TE will suffice in the vast majority , avoiding further invasive investigations (ie, hepatic hemodynamics or biopsy). TE is a useful tool for initial screening and on- treatment follow-up of NAFLD ,AFLD, HBV and HCV subjects and has been validated in several trials.
- 61. See you in Ooty in August 2015 for Mid Term Rural CME…. See you in Coimbatore for Endoscopy Workshop in October 2015….!