1. Assistant Professor of Gastroenterology
Liver stiffness measurement (Fibroscan®) Principles - indications - results - limitations
Samir Haffar M.D.
Assistant Professor of Gastroenterology

2. Imaging (US, MRI, endoscopy)
Clinical Examination
Biological work-up
Blood markers
Fibrose
Hepatic biopsy
Imaging (US, MRI, endoscopy)
FibroScan®

3. Ideal non-invasive test for diagnosis of liver fibrosis
Simple
Reproducible
Readily available
Less expensive than biopsy
Predicts full spectrum of fibrosis
Reflects changes occurring with therapy

4. Evaluation of chronic liver injury according to health care level
Physical examination
Liver function tests
Serum Hyaluronate
APRI or other simple tests
Primary health care
Ultrasound
Fibroscan®
Serum markers & algorithms
Secondary health care
Fibroscan®
ARFI*
MR elastography*
Tertiary health care
Liver biopsy
HVPG
* Promising but currently under investigation
ARFI: Acoustic Radiation Force Impulse Imaging
HVPG: Hepatic Venous Pressure Gradient
Castéra L et al. Gut 2010 ; 59 : 861 – 866.

5. Bedossa P. Liver Int 2009 ; 29 (s1): 19 – 22.
Liver stiffness
Assessed by US (FibroScan®) & more recently by MRI
Evaluates velocity of propagation of a shock wave
within liver tissue (examines a physical parameter of
liver tissue which is related to its elasticity)
Rationale Normal liver is viscous
Not favorable to wave propagation
Fibrosis increases hardness of tissue
Favors more rapid propagation
Bedossa P. Liver Int 2009 ; 29 (s1): 19 – 22.

6. Fibroscan® (Echosens, Paris, France)
Fibroscan® device
Electronic platform
Ultrasonic signals acquisition
Numerical signal processing
Integrated computer
Stiffness measurement
Examinations database
Dedicated probes with unique technology
Vibrator (50 Hz)
US Transducer (3,5 MHz)
Fibroscan® (Echosens, Paris, France)

7. Position of probe & explored volume
Cylinder of 1 cm wide & 4 cm long
From 25 mm to 65 mm below skin surface
This volume is at least 100 times bigger than a biopsy sample

8. Interval around median Contains 50% of valid shots
Results
Stiffness (kPa)
Median value of 10 shots
3.9 Kilo Pascals
 IQR * (kPa)
Interval around median
Contains 50% of valid shots
≤ 25% of median value
 At least 10 shots
 Success Rate: ≥ 60%

9. Manufacturer’s criteria for LSM interpretation
First step Number of shots ≥ 10
Second step Success rate ≥ 60 %
Third step Interquantile range (IQR) ≤ 25%
Failure
Zero valid shot
Unreliable results
< 10 valid shots Success rate ≤ 60%
IQR ≥ 25%

10. Liver stiffness values in healthy subjects 429 subjects
5.2 ± 1.5 kPa
5.8 ± 1.5 kPa
p =
Roulot D et al. J Hepatol ; 48 : 606 – 613.

11. Roulot D et al. J Hepatol 2008; 48 : 606 – 613.
Liver stiffness values in healthy subjects with & without metabolic syndrome
5.3 ± 1.5 kPa
6.5 ± 1.6 kPa
p <
Roulot D et al. J Hepatol 2008; 48 : 606 – 613.

12. Liver stiffness cut-offs in chronic liver diseases
Matavir
F0-F1
Mild
Fibrosis F2
Sign F3
Severe F4
Cirrhosis
Liver stiffness values are expressed in kilopascals
Range from 2.5 – 75 kPa
Values around 5.5 kPa were recently shown to reflect normality
LSM 2.5 – 7 kPa → Mild or absent fibrosis is likely
LSM > 12.5 kPa → Cirrhosis is likely
Castéra L et al. J Hepatol 2008 ; 48 : 835 – 847.

13. Faria SC et al. RadioGraphics 2009 ; 29 : 1615 – 1635.
Progression of fibrosis in viral hepatitis Photomicrographs (magnification ×40; trichrome stains)
F 0
F 1
F 2
F 3
F 4
Normal portal triads with no signs of fibrosis (stage F0)
Portal fibrous expansion (stage F1)
Thin fibrous septa emanating from portal triads (stage F2)
Fibrous septa bridging portal triads and central veins (stage F3)
Cirrhosis (stage F4), which appears as nodules of liver parenchyma separated by thick fibrous bands.
Faria SC et al. RadioGraphics 2009 ; 29 : 1615 – 1635.

14. No significant fibrosis
Perform LSM
≤ 6 kPa
No significant fibrosis
No biopsy F0 F1 F
Intermediate values
Grey area
Biopsy if results
influence management F2
Implementation of other NI tests
≥ 12 kPa
Advanced fibrosis
No biopsy F4
Treatment or
Follow-up F3
The experience accumulated so far suggests that the performance of LSM is optimal for advanced stages of fibrosis (ie, >F3 according to the METAVIR scoring system).
This is likely due to the proportionally reduced presence of necrosis and inflammation, which are known to affect LSM.
On the contrary, within intermediate stages of fibrosis the occurrence of inflammation, steatosis, cholestasis and passive/active congestion of the liver, may affect LSM.
Therefore, patients with advanced fibrosis or compensated cirrhosis represent an optimal setting for the use of LSM.
The ideal candidate for TE is a lean patient with severe fibrosis.
Vizzutti et al. Gut 2009;58:

15. Sandrin L. Ultrasound Med Biol 2003 ; 29 : 1705 – 1713.
Shear wave propagation velocity according to severity of hepatic fibrosis (Metavir score)
E = 3.0 kPa
F 0
E = 7.7 kPa
F 2
E = 27 kPa
F 4
Sandrin L. Ultrasound Med Biol 2003 ; 29 : 1705 – 1713.

16. Liver stiffness for each Metavir stage in CHC Box-and-whiskers plot
Gastroenterology 2005; 28:343 – 350.
Hepatology 2005;41:48 – 54.
Vertical axis is in logarithmic scale (wide range of F4 values)

17. Correlation between LSM & fibrosis stage
* Gastroentérol Clin Biol 2008;32,58-67.
** J Hepatol 2009;49: , Aliment Pharmacol Ther 2008;28:
*** Hepatology 2010;51: Gastroentérol Clin Biol 2008;32:58-67.

18. Accuracy of a diagnostic test
Dichotomous test (only 2 results)
Sensibility (Sn)
Specificity (Sp)
Positive Predictive Value (PPV)
Negative Predictive Value (NPV)
Likelihood Ratios + & – (LRs)
Diagnostic Odds Ratio (OR)
Multilevel test (> 2 results)
Receiver Operating Characteristic (ROC)
CIs
Newman TB & Kohn MA. Evidence-based diagnosis.
Cambridge University Press, Cambridge, UK, 1st edition, 2009.

19. Hypothetical ROC curve
Pines JM & Everett WW. Evidence-Based emergency care: diagnostic testing & clinical decision rules. Blackwell’s publishing, West Sussex, UK, 2008.

20. Accuracy of diagnostic test using AUC of ROC
Value
Accuracy
Excellent
Good
Fair
Poor
AUROC of a ‘‘good” test should be ≥ 0.80
Pines JM & Everett WW. Evidence-Based emergency care: diagnostic testing & clinical decision rules. Blackwell’s publishing – West Sussex – UK – 2008.

21. Meta-analysis of TE for staging liver fibrosis
50 studies – random effect – all type of CLD
Cirrhosis (F4): 0.94
(95% CI: 0.93 – 0.95)
Cut-off value: 13.0 kPa
Severe fibrosis (F3): 0.89
(95% CI: 0.88 – 0.91)
Significant fibrosis (F2): 0.84
(95% CI: 0.82 – 0.86)
Cut-off value: 7.7 kPa
Friedrich R et al. Gastroenterology 2008 ; 134 : 960 – 974.

22. Significance of wide range of LSM in cirrhosis 13 - 75 kPa
2.5 13 26 36 49 53 62 75
EV stage 2 or 3
Child-Pugh B or C
Additional advantage of Fibroscan is that it provides a wide range of stiffness values within the group of cirrhotic livers that would overcome one major limitation of the biopsy (i.e. one histological stage for all types of cirrhosis), and could thus provide an additional prognostic value within this group (i.e. one histological stage for all types of cirrhosis), and could thus provide an additional prognostic
value within this group.
Background: Transient elastography (FibroScan) is a new, non-invasive, rapid, and reproducible method allowing evaluation of liver fibrosis by measurement of liver stiffness. In cirrhotic patients, liver stiffness measurements range from 12.5 to 75.5 kPa. However, the clinical relevance of these values is unknown. The aim of this prospective study was to evaluate the accuracy of liver stiffness measurement for the detection of cirrhosis in patients with chronic liver disease.
Methods: A total of 711 patients with chronic liver disease were studied. Aetiologies of chronic liver diseases were hepatitis C virus or hepatitis B virus infection, alcohol, non-alcoholic steatohepatitis, other, or a combination of the above aetiologies. Liver fibrosis was evaluated according to the METAVIR score.
Results: Stiffness was significantly correlated with fibrosis stage (r = 0.73, p,0.0001). Areas under the receiver operating characteristic curve (95% confidence interval) were 0.80 (0.75–0.84) for patients with significant fibrosis (F.2), 0.90 (0.86–0.93) for patients with severe fibrosis (F3), and 0.96 (0.94–0.98) for patients with cirrhosis. Using a cut off value of 17.6 kPa, patients with cirrhosis were detected with a positive predictive value and a negative predictive value (NPV) of 90%. Liver stiffness was significantly correlated with clinical, biological, and morphological parameters of liver disease. With an NPV > 90%, the cut off values for the presence of oesophageal varices stage 2/3, cirrhosis Child-Pugh B or C, past history of ascites, hepatocellular carcinoma, and oesophageal bleeding were 27.5, 37.5, 49.1, 53.7, and
62.7 kPa, respectively.
Conclusion: Transient elastography is a promising non-invasive method for detection of cirrhosis in patients with chronic liver disease. Its use for the follow up and management of these patients could be of great interest and should be evaluated further.
Retrospective study of 711 patients with chronic liver diseases (95 with histologically proven cirrhosis).
These preliminary findings need to be confirmed in long-term prospective follow-up studies to see whether liver stiffness values can predict the occurrence of clinical events in patients with compensated cirrhosis.
Ascites
HCC ?
Variceal bleeding
Foucher J et al. Gut 2006 ; 55 : 403 – 408.

23. Cumulative incidence of HCC based on LSM 866 CHC – Mean follow-up 3 years
LSM > 25 kPa HR 45.5 (p< 0.001)
20 < LSM ≤ 25 HR 25.6 (p< 0.001)
15 < LSM ≤ 20 kPa HR 20.9 (p< 0.001)
10 < LSM ≤ 15 kPa HR 16.7 (p< 0.001)
LSM ≤ 10 kPa HR 0
Hazard ratio as compared to LSM<10 kPa ≤
LSM kPa 16.7 (95% CI, ; P<0.001
LSM kPa 20.9 (95% CI, ; P<0.001
LSM kPa 25.6 (95%CI, ; P < 0.001
LSM >25 kPa 45.5 (95% CI, ; P < 0.001
Liver stiffness, noninvasively measured by transient elastography, correlates well with liver fibrosis stage. The aim of this prospective study was to evaluate the liver stiffness measurement (LSM) as a predictor of hepatocellular carcinoma (HCC) development among patients with chronic hepatitis C. Between December 2004 and June 2005, a total of 984 HCV-RNA
positive patients, without HCC or a past history of it, visited the University of Tokyo Hospital. LSM was performed successfully in 866 patients, who gave informed consent.
During the follow-up period (mean, 3.0 years), HCC developed in 77 patients (2.9% per 1 person-year). The cumulative incidence rates of HCC at 1, 2, and 3 years were 2.4%, 6.0%, and 8.9%, respectively. Adjusting for other significant factors for HCC development, patients with higher LSM were revealed to be at a significantly higher risk, with a hazard ratio, as compared to LSM<10 kPa, of 16.7 (95% confidence interval [CI], ; P<0.001) when LSM kPa, 20.9 (95% CI, ; P<0.001) when LSM kPa, 25.6 (95%CI, ; P < 0.001) when LSM kPa, and 45.5 (95% CI, ; P < 0.001) when LSM >25 kPa.
Conclusions: This prospective study has shown the association between LSM and the risk of HCC development in patients with hepatitis C. The utility of LSM is not limited to a surrogate for liver biopsy but can be applied as an indicator of the wide range of the risk of HCC development.
LSM: Liver Stiffness Measurement – HR: Hazard Ratio
Masuzaki R et al. Hepatology 2009 ; 49 : 1954 – 1961.

24. Reproducibility of TE in assessing hepatic fibrosis. Bland Altman Plot
Upper limit
Lower limit
Mean
95% limit of agreement
200 patients with chronic liver disease
2 different operators within 3 days (800 exams)
8 patients scored outside limits of agreement
Fraquelli M et al. Gut 2007 ; 56 : 968 – 973.

25. Cost of FibroScan® versus liver biopsy
Cost of liver biopsy 703 – € in a French hospital
with a one day observation period
Fibroscan® **
FibroScan equipment €
Low running cost except probe calibration twice/year
Cost per FibroScan exam 100 € with 150 exams annually
* Blanc J et al. Hepatol Res 2005 ; 32 : 1 – 8.
** Canadian Agency for Drugs and Technologies in Health (CADTH).
Transient Elastography (FibroScan) for Non-invasive Assessment of Liver Fibrosis; 2006.

26. AASLD guidelines. Hepatology, 2009 ; 49 : 1017 – 1044.
Liver biopsy size
Because grading, & staging of nonneoplastic diffuse
parenchymal liver disease is dependent on adequate
sized biopsy, a biopsy of at least 2-3 cm in length
& 16-gauge in caliber is recommended
Presence of fewer than 11 complete portal tracts in
pathology report may be incorrect in recognition of
grading, & staging due to insufficient sample size
In a study of liver biopsies, Bedossa demonstrated that the stage of fibrosis was correctly diagnosed in
65% of biopsies with length of 15 mm
75% of biopsies with length of 25 mm
Bedossa P et al. Hepatol 2003 ; 38 : 1449 – 57.
AASLD guidelines. Hepatology, 2009 ; 49 : 1017 – 1044.

27. Limitations of liver biopsy
Sampling errors
Extremely small portion of liver (1/50 000)
Intraobserver & interobserver variation
Even when widely validated systems used for score
Invasive procedure
Morbidity: pain in 20% of patients
Major complications: bleeding or hemobilia in 0.5%
Mortality:

28. Grading & staging systems for chronic hepatitis
IASL1
Batts–Ludwig2
Metavir3
Grading system
Minimal activity
Mild activity
Moderate activity
Marked activity
Marked activity & bridging
Grade 1
Grade 2
Grade 3
Grade 4 A1 A2 A3
(kappa 0.2 – 0.6)
Staging system
No fibrosis
Fibrous portal expansion
Few bridges or septa
Numerous bridges
Cirrhosis
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4 F0 F1 F2 F3 F4
(kappa 0.5 – 0.9)
1 Desmet VJ et all. Hepatology 1994;19:
2 Batts KP et all. Am J Surg Pathol 1995;19:
3 Bedossa P et all. Hepatology 1996;24:

29. Interpretation of different values of kappa Kappa from Greek letter κ
Value of kappa
Strength of agreement
0 – 0.20
Poor
0.21– 0.40
Fair
0.41– 0.60
Moderate
0.61– 0.80
Good
0.81–1.00
Very good
kappa score ≥ 0.6 indicates good agreement
Perera R, Heneghan C & Badenoch D. Statistics toolkit.
Blackwell Publishing & BMJ Books, Oxford, 1st edition, 2008.

30. Liver biopsy is not the “gold standard” but is the “best available gold standard”

31. Contraindications of liver biopsy
Uncooperated patients
Disorders in coagulation profile
Severe ascites
Cystic lesions
Vascular tumors (hemangiomas)
Amiloidosis
Congestive liver disease

32. R0C curves for FibroScan, FibroTest, & APRI for cirrhosis (F0 – F3 vs F4)
Castera L et al. Gastroenterology 2005 ;128 : 343 – 50.
Castera L et al. Lancet 2010 ; 375 : 1419 – 20.

33. Pitfalls of liver stiffness measurement
 Obesity
 Operator experience
 Acute liver injury
 Extrahepatic cholestasis
 Increased CVP
 Ascites
 Narrow intercostal spaces

34. Obesity & operator experience

35. Unreliable results (16%)
Limitations of liver stiffness measurement examinations – 5 year prospective study – 5 operators
BMI > 30 kg/m2 (OR 7.5)
Operator experience (OR 2.5)
Age > 52 years (OR 2.3)
Type 2 diabetes (OR 1.6)
Failure (3%)
BMI > 30 kg/m2 (OR 3.3)
Operator experience (OR 3.1)
Age > 52 years (OR 1.8)
Female sex (OR 1.4)
Hypertension (OR 1.3)
Type 2 diabetes (OR 1.1)
Unreliable results (16%)
Waist circumference 80 cm in women or 94 cm in men.
Specific probe is developed for obese patients.
LSM uninterpretable in one of five cases
Main raisons: obesity ( WC) – operator experience
Castéra L et al. Hepatology 2010 ; 51 : 828 – 835.

36. Castéra L et al. Hepatology 2010 ; 51 : 828 – 835.
Failure rates according to BMI patients at the time of first examination
Castéra L et al. Hepatology 2010 ; 51 : 828 – 835.

37. Castéra L et al. Hepatology 2010 ; 51 : 828 – 835.
Unreliable results according to BMI patients at the time of first examination
Castéra L et al. Hepatology 2010 ; 51 : 828 – 835.

38. Feasibility of LSM with FibroScan® using XL probe New probe for obese patients
Feasibility of liver transient elastography with FibroScans using a new probe for obese patients
de Lédinghen V et al. Liver International 2010 ; : 1043 – 1048.
Background & Aims: Liver stiffness measurement (LSM) failure when using transient elastography occurs in 2–10% of patients, and is generally related to obesity. The aim of this prospective study was to assess the feasibility of LSM when using a new XL probe on patients with a body mass index(BMI)Z30 kg/m2.
Methods: For each patient, LSM was performed using both M probe (currently available and dedicated to patients with standard
morphology) and XL probe (dedicated to overweighed patients). A blood sample was taken to assess usual biological variables and simple readily available fibrosis blood tests.
Results: Ninety-nine patients were included (27 men, mean age 52 years, mean BMI 40.5 kg/m2). LSM was successful (10 valid measurements) in 45% of the cases with the M probe, vs 76% of the cases with the XL probe (P<0.001). Fifty-nine percent of those who could not be measured (< 10 valid measurements) using the M probe could successfully be measured using the XL probe. In the 44 patients successfully measured with both probes, LSM was correlated with the platelet count, prothrombin time, g-glutamyltransferase, aspartate aminotransferase, fasting glucose, AST platelet ratio index, Forns score and FIB-4.
Conclusion: The new XL probe allows providing a higher rate of LSM than the M probe in patients with an increased BMI and shows promising results for the evaluation of liver fibrosis.
60% not measured by M probe successfully measured by XL probe
de Lédinghen V et al. Liver International 2010 ; : 1043 – 1048.

39.  Acute liver injury

40. Arena U et al. Hepatology 2008 ; 47 : 380 – 384.
Acute viral hepatitis increases liver stiffness 18 patients with acute viral hepatitis
When interpreting LSMs, the clinical question should be defined and LSM should be interpreted in the context of a defined diagnosis, biochemical data and appropriate cutoff points.
Conclusion:
LSM does not represent a reliable instrument to detect the presence of advanced fibrosis and cirrhosis in patients presenting with a clinical picture of acute hepatitis.
I Peak increase in aminotransferase
II Aminotransferase ≤ 50% of the peak
III aminotransferase levels ≤ 2 ULN
Arena U et al. Hepatology 2008 ; 47 : 380 – 384.

41. Arena U et al. Hepatology 2008 ; 47 : 380 – 384.
Acute viral hepatitis increases liver stiffness 18 patients with acute viral hepatitis
When interpreting LSMs, the clinical question should be defined and LSM should be interpreted in the context of a defined diagnosis, biochemical data and appropriate cutoff points.
Conclusion:
LSM does not represent a reliable instrument to detect the presence of advanced fibrosis and cirrhosis in patients presenting with a clinical picture of acute hepatitis.
I Peak increase in aminotransferase
II Aminotransferase ≤ 50% of the peak
III aminotransferase levels ≤ 2 ULN
Arena U et al. Hepatology 2008 ; 47 : 380 – 384.

42.  Extrahepatic cholestasis

43. Obstructive jaundice due to GIST occluding CBD
Bilirubin 3.5 mg/dL
Stiffness 5.7 kPa
Stent placement
Stent occlusion
Bilirubin 8 mg/dL
Stiffness 10 kPa
Bilirubin 2 mg/dL
Stiffness 5 kPa
Transient elastography (FibroScan [FS]) is a novel non-invasive tool to assess liver fibrosis/ cirrhosis. However, it remains to be determined if other liver diseases such as extrahepatic cholestasis interfere with fibrosis assessment because liver stiffness is indirectly measured by the propagation velocity of an ultrasound wave within the liver. In this study, we measured liver stiffness immediately before endoscopic retrograde cholangiopancreatography and 3 to 12 days after successful biliary drainage in patients with extrahepatic cholestasis mostly due to neoplastic invasion of the biliary tree. Initially elevated liver stiffness decreased in 13 of 15 patients after intervention, in 10 of them markedly. In three patients, liver stiffness was elevated to a degree that suggested advanced liver cirrhosis (mean, 15.2 kPa). Successful
drainage led to a drop of bilirubin by 2.8 to 9.8 mg/dL whereas liver stiffness almost normalized (mean, 7.1 kPa). In all patients with successful biliary drainage, the decrease of liver stiffness highly correlated with decreasing bilirubin (Spearman’s , P < 0.05) with a mean decrease of liver stiffness of 1.2± 0.56 kPa per 1 g/dL bilirubin. Two patients,
in whom liver stiffness did not decrease despite successful biliary drainage, had advanced liver cirrhosis and multiple liver metastases, respectively. The relationship between extrahepatic cholestasis and liver stiffness was reproduced in an animal model of bile duct ligation in landrace pigs where liver stiffness increased from 4.6 kPa to 8.8 kPa during 120 minutes of bile duct ligation and decreased to 6.1 kPa within 30 minutes after decompression.
Conclusion: Extrahepatic cholestasis increases liver stiffness irrespective of fibrosis. Once extrahepatic cholestasis is excluded (e.g., by liver imaging and laboratory parameters) transient elastography is a valuable tool to assess liver fibrosis in chronic liver diseases.
Millonig G et al. Hepatology 2008 ; 48 : 1718 – 1723.

44. Millonig G et al. Hepatology 2008 ;48 : 1718 – 1723.
Liver stiffness as a function of bile duct ligation 10 German landrace pigs: 5 controls – 5 BD ligation
120 min after
Bile duct ligation
8.8 kPa
30 min after
decompression
6.1 kPa
Control
4.6 kPa
Conclusion:
Extrahepatic cholestasis increases liver stiffness irrespective of fibrosis. Once extrahepatic cholestasis is excluded (e.g., by liver imaging and laboratory parameters) transient elastography is a valuable tool to assess liver fibrosis in chronic liver diseases.
Millonig G et al. Hepatology ;48 : 1718 – 1723.

45.  Increased CVP

46. Representation of clamping site of the IVC 5 German landrace pigs
Experiment approved by local committee for Animal Welfare
University of Heidelberg – Germany
Millonig G et al. J Hepatol 2010 ; 52 : 206 – 210.

47. LSM after clamping & reopening of IVC 5 anesthesized landrace pigs
27.8 kPa
5 min after clamping
5 min after reopening
5.1 kPa
Before clamping
3.1 kPa
Millonig G et al. J Hepatol 2010 ; 52 : 206 – 210.

48. Millonig G et al. J Hepatol 2010 ; 52 : 206 – 210.
Liver stiffness directly influenced by CVP 10 patients with CHF before & after recompensation
Median 40.7
Median 17.8
p = 0.004
Median weight loss of 3.0 kg
LS is a direct function of central venous pressure which should be considered when assessing the degree of fibrosis.
The presence of enlarged liver and/or hepato-jugular reflux on physical examination together with dilated hepatic veins and inferior vena cava, suggestive of chronic heart failure, would have helped to anticipate the findings of liver
biopsy.
Millonig G et al. J Hepatol 2010 ; 52 : 206 – 210.

49.  Ascites

50. Ascites in liver cirrhosis
Diagnosis of
cirrhosis is obvious
Ascites grade 1: detectable only by ultrasound

51.  Narrow intercostal spaces

52. Position of FibreScan® probe
Dorsal decubitus position
Right arm in maximal abduction

53. Interpretation of the results of LSM should
always be done by expert clinicians according
to clinical context

54. Transient elastography in clinical practice
Examination quality 10 shots at least Success rate ≥ 60% IQR ≤ 25% of median value Liver disease Not used in acute hepatitis Not used in acute exacerbation Not used in ascites & EH cholestasis Choice of cutoff point Cutoffs different for each CLD Range of value rather than cutoff
De Lédinghen V et al. Gastroentérol Clin Biol 2008 ; 32 : 58 – 67.

55. Questions

56. Thank You