Elastography of The Liver and Beyond 2021

Elastography
of the Liver
and Beyond
Mirella Fraquelli
Editor
123
Elastography of the Liver and Beyond
Mirella Fraquelli
Editor
Elastography of the Liver

and Beyond
Editor
Mirella Fraquelli
Gastroenterology and Endoscopy Unit
Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico
Milan
Italy
ISBN 978-3-030-74131-0 ISBN 978-3-030-74132-7 (eBook)

https://doi.org/10.1007/978-3-030-74132-7
© Springer Nature Switzerland AG 2021

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Foreword
In the era of precision medicine, accurate staging of a disease stands out as a must
whenever a trustable prognostication is needed and prioritization to costly therapies
is to be decided based on sophisticated cost efficacy analyses. In the liver domain,
the histopathological examination of the liver tissue via a percutaneous liver biopsy
has long been the pillar of the process of clinical staging, though its employment has
been limited by cost, sampling error, and poor agreement among pathologists and
complications. There is no question that, in patients with more than one risk factor,
the liver biopsy is a priority as it stands as the sole approach able to define the con-
tribution of each underlying comorbidity to the whole picture of the disease, thereby
providing a guide to select the proper therapeutic approach in many circumstances.
Though in other contexts involving a majority of patients with chronic viral hepati-
tis and non-alcoholic fatty liver, disease staging with the canonical histopathologi-
cal approach has come of age, being replaced either by cheap scores for disease
severity stratification that are based on simple demographic and clinical parameters
or by user friendly imaging techniques which assess liver stiffness. These noninva-
sive tests have gained popularity as they have successfully been applied to identify
and stage liver disease across multiple etiologies and proved useful to identify sub-
clinical hepatic injury not accompanied by symptoms and/or abnormalities of serum
liver chemistries, stage severity of overt chronic liver disease, and confirm resolu-
tion of an acute liver injury. On the assumption that they could fill the diagnostic gap
of the classical serum chemistries, a majority of these assays were initially con-
ceived as markers of hepatic fibrosis, the relevant determinant of prognosis of most
chronic liver disorders. Lately, the same noninvasive assays were more appropri-
ately converted into tests of disease severity, as it became clear that these tests are
also altered in the presence of necro-inflammation and degeneration of liver cell and
biliary injury. This book is devoted to elastography to assess liver stiffness, a tech-
nique which should be commended by all hepatologists for having revolutionized
the approach to liver disease staging and management of most patients with chronic
liver disorders. At the onset, the prototype FibroScan made the process of disease
severity stratification simple and user friendly as it was required for prioritizing
patients with viral hepatitis to treatment with exceedingly expensive antiviral regi-
mens. In the last decade, elastography has evolved different technical modalities in
the context of ultrasound and magnetic resonance imaging that have been applied to
cost effectively manage patients with non-alcoholic fatty liver with respect to patient
v
vi Foreword
stratification for surveillance versus therapeutic interventions. Not surprisingly, the

restless revolution started with elastography has overcome the boundaries of liver
disease, ultimately engaging the spleen for the noninvasive evaluation of portal
hypertension and the gastrointestinal tract where in cooperation with endoscopy,
elastography has proven useful to investigate pancreas, colon strictures, and inflam-
matory bowel diseases.
Massimo
Milan, Italy Colombo
Preface
Over the last two decades, the application of sono-elastographic techniques, con-
ceived to assess tissue stiffness, has experienced a dramatic boost in the field of
hepatology and gastroenterology.
Liver stiffness measured by Vibration-Controlled Transient Elastography
(VCTE), also commonly known as transient elastography (TE or Fibroscan®), has
been widely validated as an accurate tool for the indirect staging of liver fibrosis.
More recently, liver stiffness has been demonstrated to be a valid prognostic marker
of disease severity in patients with chronic liver diseases (CLDs), as it is able to
predict such clinically relevant outcomes as survival, OLT, decompensation, and
development of liver cancer.
The book is not just a simple overview of the main practical applications of sono-
elastography to date as far as hepatological and gastroenterological diseases are
concerned, but it is also specifically intended to illustrate, with a clear critical meth-
odological approach, the correct indication for the use of these diagnostic tech-
niques in specific clinical settings. We have taken into account the existing diagnostic
pathways, the actual diagnostic accuracy of elastographic techniques and their
impact on clinical practice in terms of improvement of clinically relevant outcomes
and cost-saving clinical management.
In the first part dedicated to the correct methodology to assess diagnostic accu-
racy of noninvasive techniques, we have discussed the architecture of diagnostic
research and emphasized the correct study design for each phase of a diagnostic
study development.
In the second part of this book, we have focused on clarifying the definition of
normal value for liver stiffness and the role of VTCE in dealing with patients with
liver diseases of different etiology by measuring liver stiffness towards the assess-
ment of liver fibrosis and as a prognostic marker for the development of CLD-
related complications.
We have provided a critical comparison of the different existing elastographic
techniques, i.e., VTCE vs. ARFI technologies as implemented on standard ultra-
sound machines.
In the third part of the book, the spotlight is on the role of liver and spleen stiff-
ness measurement in advanced liver diseases as predictors of portal hypertension
and as a prognostic marker of clinically relevant outcomes.
vii
viii Preface
The fourth part is devoted to the role of elastography in some fields of gastroen-
terology, such as the study of the pancreas (for instance, in chronic pancreatitis and
alcoholic abuse), the intestine (in patients with chronic inflammatory bowel dis-
eases), and of hematological and vascular diseases.
At last, the book offers a series of case studies on specific practical issues with
critical discussion to improve the appropriate use of these technologies.
We remain available to comments and suggestions on how to add to the compre-
hensiveness of the present endeavors.
Milan, Italy Mirella Fraquelli

Contents
Part I Introduction to Elastography

1 Elastographic Measures: A Methodological Approach�� 3
Agostino Colli, Mirella Fraquelli, and Giovanni Casazza
2 Liver Stiffness: Thresholds of Health�� 15
Daniele Prati, Alessandra Berzuini, Fateh Bazerbachi,
and Luca Valenti
Part II Liver Diseases

3 The Role of Transient Elastography for Fibrosis Staging
in HCV-Related Chronic Liver Disease �� 27
Marta Cilla and Emmanuel A. Tsochatzis
4 The Role of Elastography in HBV: Assessing Liver Fibrosis �� 43
Barbara Coco, Gabriele Ricco, and Maurizia Rossana Brunetto
5 The Role of Transient Elastography in NAFLD�� 61
Grazia Pennisi, Antonina Giammanco, and Salvatore Petta
6 Elastography in Liver-Transplanted Patients �� 75
Cristina Rigamonti, Carla De Benedittis,
and Maria Francesca Donato
7 Elastography in Autoimmune Liver Diseases�� 91
Laura Cristoferi, Marco Carbone, and Pietro Invernizzi
8 Transient Elastography for the Diagnosis of Liver Fibrosis
and Cirrhosis in People with Alcohol-Associated Liver Disease�� 105
Taisiia Turankova, Giovanni Casazza, and Chavdar S. Pavlov
9 Elastography After Treatment and During Follow-Up�� 119
Mirella Fraquelli, Ilaria Fanetti, and Andrea Costantino
ix
x Contents
10 Elastography Methods to Assess Chronic Liver Diseases:

A Critical Comparison�� 143
Laurent Castera
11 The Assessment of Portal Hypertension�� 159
Avik Majumdar, Giovanni Marasco, Amanda Vestito,
Massimo Pinzani, and Davide Festi
12 Assessing Disease Severity and Prognosis�� 173
Élise Vuille-Lessard, Ahmed Y. Elmahdy, and Annalisa Berzigotti
Part III Extrahepatic Diseases: Pancreas

13 Pancreas: Transabdominal Ultrasound-Based Elastography�� 193
Clara Benedetta Conti and Roberta Pozzi
14 Endoscopic Ultrasound Elastography in Pancreatic Diseases �� 205
Federica Cavalcoli, Roberta Elisa Rossi, and Sara Massironi
Part IV Extrahepatic Diseases: Bowel

15 Application of Elastography in Patients
with Inflammatory Bowel Diseases�� 219
Federica Branchi and Mirella Fraquelli
Part V Spleen Involvement in Liver and Non-Liver Diseases

16 Liver and Spleen Stiffness in Vascular Liver Disease �� 235
Federico Ravaioli, Elton Dajti, Luigina V. Alemanni,
and Antonio Colecchia
17 Liver and Spleen Stiffness in Hematological Diseases�� 257
Mariangela Giunta and Mirella Fraquelli
Part VI Case Studies

18 Case 1: Unexpected High Liver Stiffness as a Warning Sign�� 271
Ilaria Fanetti and Elisabetta Degasperi
19 Case 2: Liver and Spleen Stiffness After TIPS�� 275
Simone Segato
20 Case 3: Congestive Hepatopathy with High Liver
and Spleen Stiffness in a 17 Years Old Male Patient�� 281
Andrea Costantino, Mirella Fraquelli, Massimo Chessa,
and Vincenzo La Mura
21 Case 4: To Operate or Not to Operate? A Case of Crohn’s
Disease When Elastography Helped�� 287
Stefano Mazza and Mirella Fraquelli
Part I
Introduction to Elastography
Elastographic Measures:
A Methodological Approach 1
Agostino Colli, Mirella Fraquelli, and Giovanni Casazza
At the end of the twentieth century, such techniques as ultrasonography, computer-

ized tomography and magnetic resonance imaging were developed and made avail-
able to hepatologists enabling them to watch their patients’ liver morphology and to
detect even small focal lesions in the parenchyma. The viscoelastic properties of the
liver were still assessed by palpation: a hard liver was associated with severe fibrosis
[1]. Palpation, the use of the tactile sense to determine the characteristics of an
organ, is one of the four cardinal principles of physical examination and relies on
both qualitative and subjective estimations. So, a system for the quantitative assess-
ment of tissue stiffness was needed. Furthermore, the diagnosis and staging of
chronic hepatitis and, more generally, chronic liver diseases were mainly based on
histological scores requiring liver biopsy, which is an invasive procedure. Thus, a
non-invasive test was needed.
Over the recent years, a new method for measuring the shear velocity in soft tis-
sues through transient elastography was developed [2]. TE consists in a pulsed exci-
tation driven by a piston vibrating perpendicularly to the surface of a half-space
viscoelastic medium. The axial component of the displacements induced by the
transient shear wave is estimated with an ultrasonic transducer placed on the oppo-
site side of the medium allowing the estimates of both shear elasticity and shear
viscosity [2, 3]. Further progressive improvements have led to the development of
an easy-to-use device that allowed the measurement of liver stiffness [3, 4]. The
A. Colli (*)
Department of Transfusion Medicine and Haematology, Fondazione IRCCS Ca’ Granda
Ospedale Maggiore Policlinico, Milan, Italy
M. Fraquelli
Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
Policlinico, Milan, Italy
G. Casazza
Department of Biomedical and Clinical Sciences “L. Sacco”, Università degli Studi di
Milano, Milan, Italy
© Springer Nature Switzerland AG 2021 3

M. Fraquelli (ed.), Elastography of the Liver and Beyond,
https://doi.org/10.1007/978-3-030-74132-7_1
4 A. Colli et al.
next steps have been to evaluate this system for the diagnosis and staging of chronic
liver diseases: hepatic fibrosis was recognized as the main factor for the prognosis
of chronic liver diseases [5, 6], and many studies have aimed to evaluate the accu-
racy of transient elastography in diagnosing liver fibrosis [7, 8]. TE has proved to be
an accurate tool to evaluate liver fibrosis in different chronic liver diseases, with
accuracy estimates quite similar to those of the reference standard, i.e. liver histol-
ogy. The staging of liver disease through elastography seems even more accurate
than through histology as shown by a large-cohort prognostic study [9].
This is the story of a real success of a diagnostic test from the bench to the
bedside: a new tool that allows both a quantitative assessment of liver stiffness
overcoming old-fashioned palpation and an accurate estimate of liver disease
severity.
In this chapter, we aimed to summarize the different phases of the development
of a new diagnostic test, from bench to the bedside, outlining and discussing the
proper approaches to the different questions and the methodological prob-
lems [10].
1.1 Phase 0
This is the preclinical phase with the in-laboratory assessment of the properties of
the new diagnostic tool, not yet on patients but rather on phantoms, animals or a
small number of healthy participants. The aim is to assess:
1. Validity: the extent to which a test measures what it is intended to measure.

2. Reliability: the consistency of any variation of the test measurements with the
true variations, usually subdivided in:
(a) Repeatability: the ability to reproduce the same results in identical settings
(same device, same operator) when testing the same patient.
(b) Reproducibility: the ability to obtain the same results when testing the
same patient under changing conditions (different operators or different
devices).
The new technique, TE, measures liver elasticity using a shear elasticity probe
over a short time (less than 100 ms) reducing boundary and movement artefacts [1,
2, 11]; its reliability, as to repeatability and reproducibility, was assessed in chronic
liver disease (CLD) patients [10, 11], and the overall inter-observer and intra-
observer agreement intraclass correlation coefficients were 0.98 [12].
It is interesting to note that manual palpation with judgement of normal/hard
consistency shows low reproducibility (Cohen’s k = 0.4) which is usual for most
physical signs [13].
The answer to these preliminary questions about validity, reliability and repro-
ducibility is the first step and is necessary for furthering the evaluation of a test. The
diagnostic accuracy of a test can be estimated only if its reproducibility has been
1 Elastographic Measures: A Methodological Approach 5
considered acceptable. Moreover, the modalities of test performance, which ensure

the best validity and reproducibility, are defined and described in this phase [4, 12].
1.2 Phase 1
This phase focuses on the definition of the range of the new test results in healthy
people and the influence of sex, age, BMI and other anthropometric characteristics
(narrow intercostal spaces or overweight). The elastographic measures of the liver
are expressed as a continuous variable in the International System of Units (SI)
of pressure kiloPascal (kPa); the distribution of its values is asymmetric, and the
reference values fall between the 2.5th and 97.5th percentile of the distribution for
healthy individuals. This is the simplest way to establish a “normal” value: ignor-
ing the distribution shape and simply referring to the highest and lowest values as
“abnormal” [14]. However, the implicit assumption that all the diseases they rep-
resent should have exactly the same frequency, i.e. around 5%, is clearly a clinical
nonsense: it would mean that 5% healthy people should, by definition, have “abnor-
mal” values and should be tested further to assess whether they are true “false-
positive” or not. On the contrary, the aim of this phase should be to estimate the
clinical reference interval assessing the distribution with a sample, in general, or a
healthy population large enough to show that the observed “false-positive” propor-
tion is less than a pre-specified value. This early phase may be initially skipped, and
the pertinent studies not published. The distribution of the test results and evaluation
of the influence of patient characteristics on these results can be assessed in the next
phase, which compares healthy controls to patients affected by the disease under
investigation.
There are some examples of Phase 1 studies assessing liver stiffness in healthy
volunteers, blood donors and general population [15–17]. They have shown that the
distribution of reference values was very similar in all three groups and that the liver
stiffness values were not influenced by age and were positively related to male sex,
increased BMI, fatty liver and metabolic syndrome variables [15].
1.3 Phase 2
The studies in this phase aim to assess the diagnostic accuracy of the index test
(Fig. 1.1). Diagnostic accuracy is a measurement of the agreement between the
index test and the reference standard in discriminating diseased from non-diseased
study participants. Accuracy can be evaluated as a whole, i.e. the proportion of cor-
rect results of the index test against those of the reference standard; however, it is
more informative to assess how many participants with and without the target dis-
ease are correctly defined by the test with two other estimates, which are sensitivity
and specificity. Sensitivity is the measure of concordance between the index test and
the reference standard for diseased participants, i.e. the proportion of diseased par-
ticipants detected by the index test. Specificity is the measure of the concordance for
6 A. Colli et al.
Index test: a diagnostic test under assessment
Target disease: the pathological condition that the index test aims to identify
Reference standard: a test or procedure taken to best identify a patient’s true state (diseased or non-diseased).
Diagnostic accuracy: the proportion of correct results of the index test.
The 2-by-2 table:

Diseased Non-diseased
Positive
true positive false positive
Index test
Negative false negative true negative
Sensitivity: the proportion of true positive results (proportion of positive test results among the study participants with the target disease)
Specificity: the proportion of true negative results (proportion of negative test results among the study participants without the target disease)
Positive likelihood ratio:

the ratio of the probability of a positive test result among the participants with the target disease to the probability of a positive test result among
the participants without the target disease
Negative likelihood ratio:

the ratio of the probability of a negative test result among the participants with the target disease to the probability of a negative test result among
the participants without the target disease
Fig. 1.1 Glossary and definitions of diagnostic studies
non-diseased participants, i.e. the proportion of non-diseased participants correctly

identified by the index test.
In this phase, a logical sequence of diagnostic studies can be recognized. They
start from preliminary questions allowing the correct design of further studies,
hopefully having a progressive increase in the strength of evidence in favour of the
index test, in order to obtain an actual definition and assessment of the test’s diag-
nostic accuracy.
The first question is whether the test results obtained in affected patients differ
from those in healthy individuals. It relates not only to the distribution of test results
among diseased and healthy participants but also to the degree of their overlap. The
lower the degree of overlap, the more accurate the test is considered to be. The inter-
individual true variability within well-designed, well-conducted Phase 0 studies can
provide an explanation about the variability of test results in Phase 2 studies. The
usual design format of such Phase 2 studies is one in which affected and healthy
participants are sampled and the obtained test value is measured once (case-control
design) (Fig. 1.2). These studies are relatively simple and can readily advise on
whether a more in-depth assessment of the test accuracy should or should not be
performed.
A further preliminary question is whether the results of the index test obtained in
patients with the target disease are different from those obtained in patients in whom
the target disease could have been suspected but is not present. The study design
format is again case-control; nevertheless, “controls” are no more healthy individu-
als, but participants with some clinical suspicion of the target disease and a negative
result of the reference standard test. They are compared to “cases”, i.e. participants
with a positive reference standard test.
Study Design
Case-control studies Cross-sectional studies
Clinically relevant cohort

Reference Standard Consecutive patients suspected of
having the target disease
Disease + Disease –
Index test
Case Control
Pos Neg
Index test
Reference Standard
the sickest the healthiest
Spectrum bias Spectrum variation
Fig. 1.2 Design of diagnostic accuracy studies: case-control and cross-sectional design formats
Another preliminary question regards the results of the index test in patients with
different stages of the target disease. A case-control study can answer this question
selecting groups of patients with a known stage of the disease.
A further step aims to explore whether the abnormal results to the index test are
specifically associated with the target disease. Other diseases might produce the
same results as the target disease or patients affected by the target disease and by
another concomitant disease might present different results than patients affected
only by the target disease. Again, case-control studies can answer these questions:
two pertinent groups of participants are selected and compared.
Case-control studies will establish whether the index test can discriminate
between the affected and non-affected patients, but such studies are not yet intended
to estimate true sensitivity and specificity in a clinical context. In fact, the estimates
can be flawed as a consequence of the inclusion of participants on the basis of the
results of the reference standard test. In case-control studies, the participants have to
undergo the reference standard before the index test: people known to be affected by
the target disease (“cases”) and people who are not affected (“controls”; i.e. healthy
people or people with other diseases than the target condition) are selected accord-
ing to the results of the reference standard. Thus, a spectrum bias is potentially
introduced with a consequent overestimation of the index test’s accuracy. In fact, the
participants do not represent the actual spectrum of the severity of the target disease
as well as alternative conditions, particularly if the sickest of the sick ones are com-
pared to the healthiest of the healthy people (Fig. 1.2).
8 A. Colli et al.
Concerning elastography and liver fibrosis, there are some examples of studies
answering these preliminary questions. High values of liver stiffness, comparable to
those obtained in patients with severe liver fibrosis, have been shown in such condi-
tions as cholestasis or heart failure with increased hepatic venous pressure [18, 19].
Other studies have shown that, in patients with acute hepatitis or a flare of chronic
hepatitis, liver stiffness values paralleled those of alanine aminotransferase (ALT),
thus showing that the results of the index test are influenced by the presence of acute
hepatitis with inflammation and necrosis (concurrent disease) on chronic hepatitis
with fibrosis (the target disease) [20, 21].
Cross-sectional studies on consecutive series of participants are not flawed by
spectrum bias (Fig. 1.2). Among the enrolled participants, there should only be par-
ticipants with symptoms suggesting the target disease, but no patients with full-
blown severe manifestations of the target disease and no healthy controls. This is the
proper Phase 2A study design format, which addresses the question whether the
index test is able to detect the target condition among patients suspected of having
the target disease, and to assess the index test accuracy (sensitivity and specificity).
The accuracy of the index test is a measure of the concordance of its results
with those obtained by the reference standard (Fig. 1.1). A “reference standard” is
a test or procedure considered as best identifying the true state (diseased or non-
diseased); actually no test is perfectly accurate (a.k.a. “gold standard”), but the test
with the relatively best and accepted accuracy can be used as reference. In order
to define this concordance, two measures are needed: sensitivity and specificity.
Sensitivity is the proportion of true-positive patients, i.e. those with the target dis-
ease and positive results of the index test, among the patients with the target disease.
Specificity is the proportion of true-negative patients, i.e. those without the target
disease and with negative results of the index test, among the patients without the
target disease. The two-by-two table provided facilitates the presentation and clas-
sification of the index results: two columns, diseased and non-diseased patients,
and two rows, positive and negative index test. Sensitivity and specificity are two
properties of the index tests and they cannot be separately estimated and evaluated.
Likelihood ratios allow the simultaneous consideration of sensitivity and specific-
ity and can be interpreted as the relative risk of being positive (or negative) to the
index test for diseased compared to non-diseased patients. The likelihood ratio of
the index test can inform on how much the probability of having the target disease
varies after the test (post-test probability) if the results of the index test are positive
or negative. The higher the value of the positive likelihood ratio (LR+), the higher
the probability of having the target disease; the lower the negative likelihood ratio
(LR−), the lower this probability.
Many diagnostic tests, and elastography is one of these, produce an explicit con-
tinuous measure, which is dichotomized at some threshold value to call the result
positive or negative. Identifying the optimal threshold value to use in practice is
usually of crucial clinical importance. Youden’s J index (J = sensitivity + specific-
ity − 1) can help in defining the cut-off value associated with highest accuracy;
nevertheless, the optimal cut-off value is not always the one that ensures best
accuracy. In fact, this index assumes that sensitivity and specificity are of equal
importance, and this assumption is not true in most clinical contexts. If the test is
intended to exclude the presence of a condition, for instance, severe hepatic fibrosis
by elastography, a false-negative result could be more relevant than a false-positive
one. An alternative and more clinically oriented approach would be to consider the
downstream effects of testing in terms of false-negative and false-positive results:
such an approach would identify those patients with the minimum degree of “abnor-
mality” requiring treatment [17].
Dichotomizing test results implies that some information is lost. In fact, two
individuals close to, but on opposite sides of, the cut-off point are characterized as
being quite different rather than very similar [22]. Anyway, grouping simplifies the
statistical analysis and leads to the easy interpretation and presentation of results.
Considering the role of the index test, two cut-off values can be chosen: one to
exclude the presence of the target disease and one to confirm its presence. This
choice produces a grey zone of indeterminate results for which further testing is
needed: the more patients are in this zone, the less useful the test is.
Cut-off values are defined in cross-sectional Phase 2 studies, including consecu-
tive participants with symptoms or signs suggesting the target disease. When these
threshold values are derived from the obtained data, the accuracy of the index test is
overestimated and validation studies are needed [23].
Sometimes, the results of the index test cannot be classified as either positive or
negative. The test is unable to produce assessable results in all patients and some
results are inadequate or indeterminate. This technical failure is not rare for elasto-
graphic measurements in that obesity, ascites and hepatic steatosis may impair the
validity and reliability of the results. About 10% of patients cannot be assessed by
transient elastography [4, 12, 17], and this proportion is even higher for spleen stiff-
ness measurement [24] or ultrasound surveillance of hepatocellular carcinoma in
patients with cirrhosis [25]. Simply excluding from analysis these non-assessable
results overestimates the test accuracy: there is no consensus on how to handle this
circumstance. Applying an intention-to-diagnose approach can provide a more real-
istic picture of the clinical potential of diagnostic tests [26]. According to this
approach, also known as worst-case scenario [27], non-assessable results are classi-
fied as false-positive if they had a negative reference standard, or false-negative with
a positive reference standard.
The accuracy of the index test, once assessed, can be compared to that of other
tests (Phase 2B). The question is which of two or more tests is more or most accu-
rate? The answer is possible with two different study design formats. The first for-
mat is the cross-sectional study including consecutive participants who are likely to
harbour the target disease and who undergo the index test as well as the reference
standard. Thus, a direct comparison of sensitivity and specificity between the differ-
ent index tests is possible. An example is the direct comparison of different elastog-
raphy techniques [28]: 349 participants with liver disease underwent supersonic
shear imaging, acoustic radiation force impulse (ARFI) and TE as index tests and
liver biopsy as the reference standard. The second study design format is the
10 A. Colli et al.
randomized clinical trial (RCT): consecutive participants suspected of having the

target disease are randomized to the different index tests. This study design format
allows for only indirect comparison of sensitivity and specificity between the two
different index tests in two groups made comparable by randomization [29]. This
design is rarely used and should be selected when participants cannot undergo both
tests because of their risk of harm or costs or both.
The further phase (Phase 2C) studies explore the possible consequences of the
introduction of the index test into clinical practice. The diagnostic strategy incorpo-
rating the index test is compared with the current standard evaluation. These studies
are conducted on participants in whom it is clinically sensible to suspect the target
disease in order to assess any immediate downstream consequence of testing and
offering treatment, based on that testing [30]. These studies are designed to compare
the new diagnostic-therapeutic strategy that incorporates the index test, against the
current best diagnostic strategy for managing these patients. The studies should
mainly address safety aspects by enabling the capturing of possible harms as a con-
sequence of introducing the index test. Harms from diagnosis can result from mis-
classification with two opposite types of error (false-negative or false-positive). The
risk is not only to overlook the target disease but also to overdiagnose it. On consid-
ering the prognosis of an untreated disease and the effectiveness and possible harm
of available treatments, one has to define what types of error to avoid. The objective
is to minimize the penalty of being wrong. Sometimes, it is better to minimize the
number of false-negative results and, other times, that of false-positive results. A
direct, or even indirect, comparison between sensitivity and specificity of the index
test with existing tests makes it possible to hypothesize the role of the index test in
a new strategy to diagnose the target disease: as a replacement for the existing test,
as an add-on test after the existing test or as a triage test before the existing test [31].
In general, a more accurate (higher sensitivity and higher specificity) or safer test
can replace the existing ones. On the other hand, tests with remarkably high sensi-
tivity can rule the target disease out and could be proposed as triage tests before any
further harmful or costly testing, whereas tests with remarkably high specificity can
be purposed as add-on tests. Thus, the operative characteristics of the new test and
its risk of harm and/or costs suggest a possible role for the test. It is in this role that
the new diagnostic test should properly be evaluated in Phase 2C and subsequent
Phase 3 randomized clinical trials (RCTs), which assess the downstream effects of
the new strategy.
1.4 Phase 3
Phase 3 studies aim to assess the benefits and harms of a diagnostic test. No diag-
nostic test can, by itself, ever be of benefit for a patient. However, through a diag-
nostic test, we can reach a decision about which treatment to offer patients.
Therefore, the question posed in Phase 3 RCTs deals not only with the test accu-
racy but also with the benefits and harms of any treatment decided on the basis of
the test results. The appropriate study design format is, again, an RCT or, more
appropriately, an RCT on diagnostic plus therapeutic strategies. The most impor-
tant methodological issues are allocation sequence generation, allocation conceal-
ment, blinding, follow-up, reporting of all outcomes and transparency regarding
conflicts of interest that are central in a therapeutic RCT. They should also be
considered for the diagnostic-therapeutic RCT to secure internal and external
validity. Furthermore, the “critical comparison” between the new diagnostic-ther-
apeutic strategy and the current strategy should be identified. If the index test is
intended to improve the sensitivity of the diagnostic strategy, the benefits and
harms of the treatment in the additional positive patients should be assessed.
Provided that previous trials have shown the efficacy of the treatment among
patients detected by the current standard test, the benefits and harms of the treat-
ment in the additional patients detected by the index tests may not be the same,
and this needs to be evaluated. If the new test is intended to improve the specific-
ity of the diagnostic strategy, then the possible benefit of fewer false-positive
results has to be assessed. Furthermore, an improvement in specificity usually
entails impairment in sensitivity and vice versa. A more sensitive test is expected
to be less specific, and the consequences of this possible trade-off should be care-
fully explored. The downstream effects of the additional false-negative or false-
positive results have to be accurately assessed.
Diagnostic test-therapeutic trials are appropriate to solve the problem of the
target diseases for which there is no reference standard or the one available is
imperfect. In this case, the index test results classified as false may actually be
true ones. In fact, a result of the index test named false-positive might be a true-
positive and a false-negative of the imperfect (less sensitive) reference test. On the
contrary, a false-negative result of the index test might be a true-negative as a
consequence of a more specific index test. RCTs that compare the downstream
effects of the application of the index test versus the test regarded as the current
reference test are able to estimate which test is more effective and thus indirectly
more accurate.
1.5 Phase 4
Phase 4 studies are conducted after the index test has been introduced into clini-
cal practice to reassess the benefits and harms of the index-test treatment versus
the reference-test treatment strategies. They are designed as large RCTs or cohort
studies of patients tested with the index test; they play a role in redefining the
accuracy of the index test. This may be required in case of an imperfect reference
standard in order to verify discordant results. Through planning the adequate
follow-up of the patients with different results for the index test and the reference
standard test (i.e. classified as false-positive or false-negative), these longitudinal
studies would allow detecting the actual appearance of the target disease or its
complications.
12 A. Colli et al.
As an example, a large-cohort study compared the accuracy of liver stiffness

measurement and liver biopsy in predicting overall survival or complications and
decompensation of liver cirrhosis in participants with discordant results of the two
tests [9]. This longitudinal observation allows to answer the question: in case of
disagreement between the index test and the reference standard test, which are the
right results?
1.6 Conclusions
Looking back at the history of liver elastography, we have described the five-phase
development of a new diagnostic test from the definition of its properties and opera-
tive characteristics up to the demonstration of its value to clinical practice. The early
phases are necessary for the correct design of the later phases, hopefully progres-
sively increasing the strength of evidence in favour of the index test. However, even
if logically consecutive, the progression of diagnostic research may be non-linear.
An earlier phase may be initially skipped, or its answer be provided by later-phase
studies.
This categorization carries the advantage of being more comparable to the phases
of therapeutic research (e.g. as for drugs or medical devices). It is essential that the
diagnostic accuracy assessment should not be perceived as the final objective of
diagnostic research, but only as a necessary step in the introduction of a test to clini-
cal practice. In fact, for most tests, the clinical consequences of their application to
clinical practice are not sufficiently obvious from the definition of their sensitivity
and specificity. To address this question, we require diagnostic-treatment RCTs,
even if very few trials have been conducted to date. When two or more diagnostic-
treatment RCTs have been completed, their systematic reviews, possibly with meta-
analyses, are warranted and should be conducted before such new tests are
introduced into clinical practice. Then, large-cohort surveillance studies would
enable the determination of the actual effects. These final studies are very important
because they represent a unique opportunity to assess the real effect of the test on
the clinical practice and because such studies can reliably measure a test’s benefits
as well as identify rare instances of harm that may not be captured through RCTs.
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Liver Stiffness: Thresholds of Health
2
Daniele Prati, Alessandra Berzuini, Fateh Bazerbachi,
and Luca Valenti
2.1 Preamble: The Concept of Normality in Medicine

All organisms extend along a line. At one end is Basedow’s disease, which implies the
generous, mad consumption of vital force at a precipitous pace, the pounding of an uncurbed
heart. At the other end are the organisms depressed through organic avarice, destined to die
of a disease that would appear to be exhaustion but which is, on the contrary, sloth. The
golden mean between the two diseases is found in the center and is improperly defined as
health, which is only a way station … This is the way it’s been made, with goiter at one end
and edema at the other, and there’s no help for it. In the middle are those who have either
incipient goiter or incipient edema, and along the entire line, in all mankind, absolute health
is missing [1]
As underlined by Agostino Colli and colleagues in Chap. 1, studies on normal (or

healthy) individuals are an essential component in the architecture of diagnostic
research [2]. Unfortunately, deciding what is normal in medicine is not so straight-
forward. The above quotation has been taken from Zeno’s Conscience, a novel by
Italo Svevo published in 1923 [1]. Taking thyroid disease as an example, the
author describes the difficulties of defining normality and abnormality when the
aim is to identify human diseases. It is not surprising that the main character of the
D. Prati (*) · A. Berzuini

e-mail: daniele.prati@policlinico.mi.it
F. Bazerbachi
Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School,
Boston, MA, USA
L. Valenti
Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy

https://doi.org/10.1007/978-3-030-74132-7_2
16 D. Prati et al.
novel is a neurotic man, who is writing his confessions at the behest of his psy-
chiatrist: the issue of how to define normality in medicine has been scientifically
addressed mainly in the field of neurosciences [3]. However, in any clinical con-
text, the concept of “normality” constitutes the central nucleus on which ideas,
theories, diagnoses, and clinical decisions are based. The term “normality” was
commonly used in medicine well before it came to its methodological systemati-
zation: it was considered equivalent to the idea of health, where “abnormality”
was synonymous with disease. These definitions are still valid, even if the concept
of biological normality has been completed and enriched following the increasing
use of mathematics in the medical field. For continuous variables, the “normal”
(or “Gaussian”) distribution model was initially developed when it was observed
for the first time that measurement errors tend to be distributed in a characteristic
and symmetrical way (“bell curve”). Later, it was extended to the classification of
the values of a variable, observed in different individuals within a particular popu-
lation. This required some simplification: actually, it was soon realized that a
perfect Gaussian distribution is rarely observed in nature. However, the model
was very successful, and the concept of “statistical normality,” supported by the
probabilistic theory, is still the fundamental basis to describe the biological phe-
nomena. For most clinical or laboratory continuous variables, those values that
are distributed in a range that includes 95% of the cases defined as “healthy” are
considered normal. To indicate an upper reference limit, the sum of the mean
value plus two standard deviations is generally used, which includes by definition
95% of cases in a Gaussian distribution. Alternatively, to overcome the problems
encountered when the distribution is not perfectly normal, for example, when it is
bimodal, the 95th percentile can be used [4, 5].
This probabilistic approach for the definition of normal values, although easy
to apply and well standardized on a methodological level, presents some concep-
tual weaknesses. First, it assumes rather artificially that the possibility of sub-
clinical disease is constant (5%) for all pathologies and for all clinical markers.
An important consequence for this simplification is that a healthy person who
undergoes multiple independent diagnostic tests (independent in the sense that
they are probing totally different organs or functions) has a likelihood of testing
normal that will be inversely related to the number of tests. For a single diagnos-
tic test, the possibility is 95% or 0.95. For two tests, it will be 0.95 × 0.95 = 0.90.
So, the likelihood of any individual being called normal is 0.95 raised to the
power of the number of independent diagnostic tests performed. Thus, a healthy
subject who undergoes 30 tests has only 0.9530, or about 1 chance in 5, of being
called normal at the end of the workup. An additional limitation of the Gaussian
theory is that the normal distribution tends by definition to infinity, and therefore
the model implicitly accepts the existence of individuals with levels of the marker
so high or so low that cannot exist in nature [4, 5]. Another main problem, how-
ever, is how to define and select the “normal” (“healthy”) population to be used
in the creation of reference standards. This requires the identification and exclu-
sion of “abnormal” (“sick”) individuals according to a process which, as we will
2 Liver Stiffness: Thresholds of Health 17
see in detail in the case of liver disease diagnostics, is often complicated and
imprecise [6].
In recent decades, the concept of normality has undergone new changes.
Increasingly, different reference standards are created (by age group, gender, race,
etc.), in an attempt to individualize the interpretation of laboratory results.
Furthermore, the development of theories related to clinical epidemiology has pro-
vided more solid bases for describing and interpreting biological variables. Bayesian
analysis, based on concepts such as sensitivity, specificity, and predictive value, has
provided very valuable tools for the evaluation of diagnostic tests. Nevertheless, it
is important to remember that each of these approaches is based on the concept of
the reference population.
2.2 Healthy Ranges in Liver Disease Diagnostics
In the case of tests for liver disease, the definition of a healthy range can be par-
ticularly problematic. First, it is very difficult to identify and exclude subjects
with liver disease from the reference population, as the reference standard remains
liver biopsy, which is not applicable for ethical reasons in those without any sign
or symptom of liver disease. In addition, it is now agreed that populations com-
posed of apparently healthy individuals (the so-called reference populations, for
example, blood donors, or subjects recruited from the general population) include
substantial proportions of individuals with subclinical liver disease (20–35%
depending on the prevalence of risk factors for liver disease in the population),
mostly related to hepatic steatosis (“fatty liver disease”). This issue was clearly
demonstrated almost 20 years ago, in a study aimed at redefining the healthy
thresholds for alanine aminotransferase (ALT) levels. The exclusion of subjects at
risk for liver disease (i.e., overweight, with high serum lipids or glucose levels)
from the reference sample caused a left shift of the ALT value distribution and a
significant reduction of the 95th percentile, chosen as the upper reference limit
[7]. In keeping with these results, Takyar et al. [8] have recently reviewed the
records of 3160 subjects who participated as healthy volunteers in 149 clinical
trials (1–29 trials per subject). They found that 1732 of these subjects (55%) were
overweight and 1382 (44%) had abnormal liver biochemistry. This underscores
the importance of an a priori definition of the criteria to select the appropriate
reference population when the aim is to set the healthy ranges for any laboratory
or instrumental test to detect the presence of liver disease. As already described in
detail elsewhere [7], individuals to be included in the reference population for
liver disease diagnostics should meet some clinical and laboratory criteria, includ-
ing the absence of specific sign and symptoms for liver disease, negative serology
for hepatitis B and C, normal body mass index (BMI) and/or waist circumference,
as well as normal parameters of lipid and carbohydrate metabolism. These criteria
ensure that only subjects at low risk for viral hepatitis and metabolic-associated
fatty liver disease (MAFLD) are included.
18 D. Prati et al.
2.3 Definition of Healthy Ranges for Liver Stiffness
The measurement of liver stiffness (LS) by transient elastography (TE) was intro-
duced in the early 2000s. Since then, several studies have confirmed its role in the
identification of different stages of liver fibrosis compared with the reference stan-
dard of liver histology. In particular, the diagnostic performance of TE has been
evaluated in cohorts of patients with hepatitis B and C, as well as in other forms
of liver disease, including MAFLD [9]. These studies allowed the identification of
diagnostic thresholds to rule in or rule out significant fibrosis and cirrhosis in
specific clinical contexts, as thoroughly discussed in the following chapters of
this book.
In normal-weight individuals, TE has good inter- and intra-observer concordance
[9, 10]. In a study including 200 patients with different liver diseases, reproducibil-
ity between two operators had intraclass correlation coefficients (ICCs) of 0.98 for
inter- and intra-observer agreement, while lower concordance was observed in the
presence of mild fibrosis, steatosis, or an increased body mass index (BMI >25 kg/
m2) [10].
A total failure rate of 3.1% was reported in a series of 13,369 transient elastog-
raphy examinations [11]. In addition, results were deemed unreliable in an addi-
tional 16%. Factors associated with unreliable results included BMI >30 kg/m2, age
>52 years, female sex, operator inexperience, and type 2 diabetes mellitus.
It is agreed that fluid and parietal adipose tissues attenuate shear wave propaga-
tion, which can result in invalid examinations in patients with anatomic distortions,
ascites, and elevated central venous pressures or in those who are obese [11, 12]. In
particular, the risk of overestimating LS values may emanate from a non-fasting
state, excess of alcohol intake, physical exercise, acute hepatitis, inflammatory
flares, congestive heart failure, hepatic parenchymal infiltration, cholestasis, and
portal vein thrombosis [11–16]. Thus, TE should be performed in fasting patients
(for at least 2 h), and results interpreted in light of potential confounders [9]. In
addition, even hepatic steatosis may decrease the accuracy of transient elastography
[17]. In a study of 253 patients with nonalcoholic fatty liver disease (NAFLD), the
stage of fibrosis was often overestimated in patients with severe steatosis [18].
However, these results were not confirmed in other studies [19]. In addition, in
healthy individuals, undernutrition and leanness, manifested by lower BMI, seem to
increase LS values in a similar way as obesity does, providing a U-shaped distribu-
tion. This finding, initially described by Das and colleagues in Indian subjects [20],
has been confirmed in a series of more than 1500 Italian blood donors (Berzuini A,
unpublished data, 2020). Thus, special probes for overweight patients (XL probe)
and children (S probe) have been developed to account for the thickness of the tho-
racic wall and depth of the liver. These probes may improve accuracy in assessing
the degree of liver fibrosis in subjects at extremes of body weight [9, 16].
The description of how LS measurement performs among healthy individuals is
of great importance as it establishes whether, and to what extent, the results among
diseased and healthy participants overlap. In this regard, the lower the degree of
overlap, the more accurate is considered the test [2]. Furthermore, studies on normal
individuals provide a necessary background to set healthy thresholds for LS to be

used in screening and epidemiological studies. Most data on LS from normal indi-
viduals have been obtained by transient elastography, and, for the sake of simplicity,
the discussion will be limited to this technique.
The main studies so far conducted in healthy subjects are summarized in
Table 2.1. They were highly heterogeneous in terms of studies design, not only for
the choice of the population base (i.e., blood or living organ donors, general popula-
tion, etc.) and the number and ethnic background of participants but also for the
selection criteria used to define a healthy status [20–32].
In particular, some studies included subjects with normal liver biochemical tests,
no history of chronic liver disease, and/or absence of hepatic steatosis on ultra-
sound. Others also included individuals with hepatic steatosis. Few studies have
considered the effects of factors and comorbidities potentially influencing the risk
for subclinical liver disease in apparently normal individuals.
The average values of LS roughly ranged between 4 and 5.5 kPa, and upper
thresholds (mostly calculated as 95th percentile of the distribution or as mean
value plus two times the standard deviation) between 6 and 8.5 kPa. Most studies
agreed that LS measurement is related to sex (values were higher in males than in
females) and with factors associated with the metabolic syndrome [20–32].
Recently, Bazerbachi et al. [33] conducted an individual participant data meta-
analysis from published studies evaluating LS by TE among healthy individuals
and in those at risk for liver disease. Twenty-six cohorts, which included 16,082
individuals, were ultimately selected. Statistically significant modifiers of stiff-
ness included diabetes, dyslipidemia, waist circumference, aspartate aminotrans-
ferase (AST), and systolic blood pressure. The mean stiffness in the subgroup of
3882 healthy nonobese individuals (BMI, <30 kg/m2) was 4.68 kPa (CI, 4.64–4.73).
The same database of healthy individuals was used to generate a threshold to rule
out fibrosis in individuals at risk. Outliers were removed using a method based on
nonlinear regression with a 1% false discovery rate [34]. In order to favor sensitiv-
ity, even at the price of a slightly lower specificity, the 90th percentile of the LS
measurement (instead of the 95th percentile) was chosen as the upper reference
limit. Thus, the healthy threshold was set at 6.47 kPa for males and 6.01 kPa for
females (Bazerbachi F, unpublished data, 2020). However, the choice of TE
thresholds in a context of a population with a low pretest probability of substantial
liver diseases should be modulated in relation to the clinical question. On the one
hand, following a screening strategy, the choice of a low threshold would be
important to maximize test sensitivity in order to reduce the rate of FN results and
avoid underdiagnosis. On the other hand, to limit the number of false-positive
cases and unnecessary investigations, it may be proposed to employ an higher
cutoff, for example, the upper limit the 95th percentile of the distribution observed
in healthy blood donors (i.e., 7.8 kPa for males, 7.4 kPa for females) [22].
However, as this approach by itself would miss a substantial proportion of indi-
viduals with significant/severe liver fibrosis, it should be applied together with
concurrent clinical evaluation of medical history, risk factors, and other biomark-
ers of liver disease.
Table 2.1 Studies on the LSM measurement by TE in healthy subjects
20
Age, years LS measurement Healthy

Mean ± SD distribution thresholds
N. of or median Reference Mean ± SD or 95th percentile
Author Country subjects (range) population(s) median (range) or mean + 2SD Other findings/observations
Prati et al. Italy 1001 39.9 ± 10.1 Blood donors at low 4.6 kPa 7.8 kPa (males) LS was independently related to
[21] (59% males) risk for liver disease (2.2–21.3 kPa) 6.3 kPa gender and ALT levels; 32% of
Colli et al. 4.1 kPa (females) those with LS values above the
[22] (2.2–14.4 kPa) 95th percentile had liver disease
Chen et al. China 799 N.A. General population 5.2 ± 1.3 kPa 7.8 kPa LS was influenced by age and
[23] (all males) (age ≤ 60) (age ≤ 60) AST in but not by alcohol
5.9 ± 1.9 kPa 9.7 kPa consumption and mass body
(age > 60 years) (age > 60) index
Fung et al. Korea 530 37 (18–63) General population, 4.11 ± 0.89 kPa 5.9 kPa Female gender and older age
[24] (26% males) blood donors at low were associated with lower LS
risk for liver disease values
Corpechot France 77 34 (18–79) Healthy persons at 5.2 ± 0.7 kPa 6.6 kPa (males) LS was not related with age, body
et al. [25] (42% males) low risk for liver (males) 6.5 kPa weight, height, and BMI, but was
disease 4.5 ± 1.0 kPa (females) significantly higher in men than
(females) in women
Roulot France 429 45.1 ± 16.7 Apparently healthy 5.49 ± 1.59 kPa 8.67 kPa (all) LS values were influenced
et al. [26] (46% males) subjects with normal 8.35 kPa independently by gender, BMI,
liver enzyme (subjects without and metabolic syndrome
metabolic
syndrome)
Colombo Italy 602 48 (22–66) Blood donors 4.4 kPa 6.7 kPa (males) Gender was the only influencing
et al. [27] (56% males) without fatty liver (2.1–17.5 kPa) 6.6 kPa variable. LS by TE had a low
(females) false-positive rate for significant
fibrosis and may have a role in
screening for liver disease
D. Prati et al.
2
Alsebaey Egypt 50 28.4 ± 5.9 Living liver donors 4.3 ± 1.2 kPa 6.8 kPa –
et al. [28] (68% males)
Das et al. India 418 37 ± 12 General population 5.4 kPa 8.5 kPa Both lean and obese healthy
[20] (64% males) (2.2–10.4 kPa) subjects have higher LS values
compared with subjects with
normal BMI. Liver stiffness
begins to increase even before
fibrosis appears in patients with
liver disease
Kim et al. Korea 242 34.1 ± 11.8 Living liver and 5.2 ± 1.2 (males) 7.0 kPa (males) Gender was independently related
[29] (50% males) (males) kidney donors 4.8 ± 1.1 6.8 kPa to LS
40.5 ± 11.5 (females) (females)
(females)
Liver Stiffness: Thresholds of Health
Sirli et al. Romania 152 45.3 ± 17.6 Healthy volunteers 5.1 ± 1.2 kPa 7.5 kPa (males) LS not influenced by age and
[30] (42% males) and patients (males) 7 kPa (females) BMI, but significantly higher in
hospitalized for 4.6 ± 1.2 kPa men than in women
non-hepatic (females)
conditions
Basnet Nepal 45 30.1 ± 5.0 Healthcare 4.24 ± 0.70 kPa 5.64 kPa Age, gender, and BMI were not
et al. [31] (66% males) personnel significantly related to LS
Conti et al. Italy 331 47 ± 9 General population 4.4 (3.7–5.2) 6.8 kPa LS was influenced by insulin
[32] (3.5% at low risk for liver resistance
males) disease
21
22 D. Prati et al.
Data on LS measurement by TE in healthy children are limited. In a group of 270

children of age, the median value was 4.5 kPa, within a range of 2.5–8.9 kPa, and
values did not vary significantly with age or gender; based on this distribution, an
upper reference limit of about 6.5 kPa was also proposed [35]. Comparable results
were obtained by Rowland et al. in 257 healthy children [36]. In the latter study,
however, TE showed inadequate reproducibility, as suggested by low concordance
between paired examinations. Thus, more evidence in the pediatric population is
required to define healthy thresholds for LS measurement.
2.4 Conclusions
Probabilistic theories are extensively being used to summarize medical observations

for diagnosis and to support clinical decisions. This approach facilitates the diagno-
sis and supports clinical decisions, but such an advantage is obtained at the price of
some conceptual compromise. The “normal” thresholds that we use daily to sepa-
rate health from disease are based on a process of statistical inference. It is, there-
fore, important to ensure that they are continuously updated and balanced to
patient needs.
Over almost 20 years, sufficient data on LS measurement by TE in healthy indi-
viduals have been collected in several cohort studies and data synthesized in sys-
tematic review and individual participant data meta-analysis. On this basis, healthy
thresholds have been proposed, improving the use of this technique in the screening
and workup of liver disease. However, results should be interpreted critically and
flexibly, taking into account the individual characteristics of the patients – gender,
age, clinical history, risk factors for the disease, comorbidities, and possible con-
founders, as well as their personal preferences. Clinical decisions on the results of a
single parameter should be avoided, especially when healthy thresholds are used to
screen low-risk individuals.
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Part II
Liver Diseases
The Role of Transient Elastography
for Fibrosis Staging in HCV-Related 3
Chronic Liver Disease
Marta Cilla and Emmanuel A. Tsochatzis
3.1 Introduction
Hepatitis C virus (HCV) infection is a major cause of chronic liver disease and con-
stitutes a major public health concern, with 71.1 million (95% uncertainty interval
62.5–79.4) chronically infected individuals worldwide [1].
HCV transmission is most commonly associated with blood transfusions and
health-care related injections in lower-income countries, while injection drug use is
the primary transmission route in countries where other methods of transmission
have mostly been eliminated [2].
The acute infection with HCV is generally asymptomatic and frequently it does
not resolve spontaneously. Approximately 50–90% of the infected individuals
become chronic carriers and may develop severe liver disease. The hepatic injury
can range from minimal histological changes to rapid development of hepatic fibro-
sis and accelerated time to cirrhosis with or without hepatocellular carcinoma
(HCC). Liver fibrosis is the excessive accumulation of extracellular matrix proteins,
including collagen, and is considered as a wound healing response to chronic liver
injury. Based on the natural history of chronic hepatitis C (CHC), it is estimated an
overall annual risk for liver failure of 2.9%, HCC 3.2% and liver-related death 2.7%
in patients with advanced fibrosis [3].
Chronic HCV infection is also accompanied by extra-hepatic manifestations
reported in two-thirds of patients, including mixed cryoglobulinaemia-type vasculi-
tis, renal disease, type 2 diabetes, cardiovascular disease (vasculitis, arterial hyper-
tension), porphyria cutanea tarda, lichen planus, lymphoproliferative disorders and
non-specific symptoms like fatigue, nausea, abdominal pain and weight loss.
Therefore, HCV infection is considered a systemic disease.
M. Cilla · E. A. Tsochatzis (*)

Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
UCL Institute for Liver and Digestive Health, Royal Free Hospital, UCL, London, UK
e-mail: e.tsochatzis@ucl.ac.uk

https://doi.org/10.1007/978-3-030-74132-7_3
28 M. Cilla and E. A. Tsochatzis
Treatment for HCV infection was revolutionized in 2014 with the development
of direct-acting antivirals (DAAs). The goal of therapy is to cure HCV infection in
order to prevent the complications of HCV-related liver and extra-hepatic diseases,
improve quality of life, remove stigma and prevent onward transmission of HCV
[4]. The endpoint of therapy is to achieve a sustained virological response (SVR)
defined as undetectable HCV RNA 12 weeks (SVR12) or 24 weeks (SVR24) after
treatment completion. An SVR corresponds to a cure of the HCV infection, with a
very low chance of late relapse [4].
In 2017, WHO set targets to eliminate HCV infection globally as a public health
threat by 2030. A decrease in both mortality and incidence in HCV could be possi-
ble through implementation of prevention, screening and treatment interventions.
Assessment of liver fibrosis is critical in the treatment decisions, prognosis and
screening strategies of CHC patients. Non-invasive tests are increasingly included
in new guidelines, leaving liver biopsy reserved for cases where there is uncertainty
or potential additional aetiologies. Transient elastography (TE) is a useful tool for
the detection of advanced fibrosis (F3) or cirrhosis (F4) and for the exclusion of
significant fibrosis (≥F2) [4].
In this review, we discuss the role of TE for fibrosis staging in CHC patients prior
to therapy, after SVR, for monitoring disease progression and determining prognosis.
3.2 Assessment of Liver Disease Severity
Liver fibrosis is the main predictor of liver disease progression in patients with
CHC. It is a dynamic non-linear process characterized by an excessive accumula-
tion of extracellular matrix (ECM) proteins, such as collagen. It is considered as a
wound healing reaction to chronic liver injury. HCV infection directly modulates
signalling and metabolic pathways by viral proteins. Moreover, it indirectly induces
host antiviral immune responses leading to chronic inflammation. Together, these
events promote liver fibrogenesis [5].
Thus, assessment of liver fibrosis is necessary prior to therapy because it is criti-
cal for clinical management, prognosis and screening strategies of CHC patients. In
fact, HCV treatment should be considered without delay in patients with significant
fibrosis or cirrhosis (METAVIR score F2, F3 or F4), although it is probably cost-
effective in all patients irrespective of their fibrosis stage [6]. In addition, patients
with advanced fibrosis (F3) or cirrhosis (F4) who achieved SVR should undergo
surveillance for HCC every 6 months by means of ultrasound and need to be
assessed for portal hypertension, including the presence of gastro-oesophageal vari-
ces (GEV) [4].
3.2.1 Role of Liver Biopsy
Histopathological examination of a liver specimen obtained by percutaneous liver

biopsy (LB) was until recently considered as the gold standard to diagnose and
stage liver fibrosis. However, LB is a costly invasive procedure, and it is associated
3 The Role of Transient Elastography for Fibrosis Staging in HCV-Related Chronic… 29
with complications including pain, serious bleeding, injury to other organs and, in
rare cases, death [7]. Moreover, LB provides a static picture of the fibrogenic pro-
cess, and, therefore, it does not permit clear prognostic indications, particularly on
the rapidity of progression towards cirrhosis [5]. There is also a significant degree
of inter- and intra-observer variability in the pathologic assessment of liver biopsy
samples despite the development of staging criteria [8]. In addition, sampling error
is common and many liver diseases do not affect the liver uniformly [9]. Finally, it
is not practical for serially repeated assessment of disease progression.
These limitations have stimulated the search for non-invasive approaches that
accurately measure the degree of liver fibrosis. Non-invasive methods for assess-
ment of liver fibrosis are gradually being incorporated into new guidelines and are
becoming standard of care, which significantly reduces the need for liver biopsy.
Liver biopsy may be required in cases of known or suspected mixed aetiologies (e.g.
metabolic syndrome, alcoholism or autoimmunity) [4].
3.2.2 Non-Invasive Assessment of Liver Fibrosis in CHC
Non-invasive methods should be used instead of liver biopsy to assess liver disease
severity prior to therapy in patients with CHC [4]. Non-invasive tests can be divided
into serum biomarkers and liver stiffness measurement (LSM) methods. The former
include several, not closely liver-specific serum parameters that have been associ-
ated with fibrosis stage, as assessed by liver biopsies. The latter measure liver stiff-
ness that corresponds to an intrinsic physical property of the liver parenchyma. The
stiffer the tissue, the faster the shear wave propagates [10].
Both LSM and biomarkers perform well in the identification of cirrhosis or rul-
ing out fibrosis; however, they perform less well in accurately identifying intermedi-
ate degrees of fibrosis [11, 12, 10].
3.3 ransient Elastography for the Assessment of Liver

T
Fibrosis Prior to Antiviral Therapy
Transient elastography (TE), performed by using FibroScan (FS), is a non-invasive,

rapid and reproducible method for assessment of liver fibrosis by measuring liver
stiffness.
The diagnostic accuracy of TE is high for diagnosing advanced fibrosis (F3) or
cirrhosis (F4); however, an important overlap in liver stiffness values is observed
among patients with lower degrees of liver fibrosis (F0, F1 and F2) [13].
The recommended cut-off levels to diagnose advanced fibrosis (F3) and cirrhosis
(F4) prior to therapy are, respectively, 10 kPa (area under the receiver operating
characteristic curve (AUROC) 0.83, sensitivity (Se) 72%, specificity (Sp) 80%,
positive predictive value (PPV) 62%, negative predictive value (NPV) 89%) and
13 kPa (AUROC 0.90–0.93, sensitivity 72–77%, specificity 85–90%, PPV 42–56%,
NPV 95–98%) [4] (see Table 3.1).
Table 3.1 Non-invasive marker cut-offs for prediction of significant fibrosis (METAVIR ≥F2),
advanced fibrosis (METAVIR ≥F3) and cirrhosis (METAVIR F4)
Test and
algorithms FibroScan Castera SAFE biopsy
Stage of ≥F3 F4 ≥F2 F4 ≥F2 F4
fibrosis
(METAVIR)
Number of 560 1.855 302 302 302 302
patients
HCV+
Cut-off 10 kPa 13 kPa FS FS APRI >1.5 APRI >2
≥7.1 kPa ≥12.5 kPa and FT and FT
and FT and FT >0.48 >0.75
>0.48 ≥0.75
AUROC 0.83 0.90–0.93 0.91 0.93 0.94 0.87
(95% CI) (0.86–0.96) (0.90–0.96) (0.90–0.98) (0.84–0.90)
Se (%) 72 72–77 85.1 89.4 100 86.4
Sp (%) 80 85–90 97.2 98.2 87.3 89.7
PPV (%) 62 42–56 98.9 95 96.3 77.6
NPV (%) 89 95–98 66.9 95.9 100 94.1
APRI aspartate aminotransferase-to-platelet ratio index, AUROC area under the receiver operating
characteristic curve, FS FibroScan, FT FibroTest, HCV hepatitis C virus, SAFE sequential algo-
rithms for fibrosis evaluation, Se sensitivity, Sp specificity, NPV negative predictive value, PPV
positive predictive value
Consideration must be given to factors that may adversely affect TE perfor-

mance: risk factors of failure, risk factors of low quality and risk factors of false
positive [5].
Risk factors of failure of LSM include obesity, narrow intercostal space and lim-
ited operator experience [14]. Myers et al. showed that in 276 patients with chronic
liver disease (42% viral hepatitis, 46% NAFLD) and a BMI >28 kg/m2, measure-
ment failures were significantly less frequent with the XL probe than with the M
probe (1.1% vs. 16%; p < 0.00005). However, stiffness values obtained with XL
probe are probably lower than those obtained with the M probe (by a median of
1.4 kPa) [15].
Criteria of acceptable exam quality include at least ten valid measurements and
interquartile range/median ratio (IQR/M) ≤0.30 [10].
Risk factors of false-positive results should also be carefully taken into account.
Necro-inflammatory activity may limit the diagnostic accuracy of TE especially in
patients with lower-intermediate stages of fibrosis. Indeed, necro-inflammatory
activity increases LSM even after adjusting for fibrosis stage in patients who do not
have cirrhosis [16]. Other confounding factors including extra-hepatic cholestasis
[17], congestive heart failure [18], excessive alcohol intake [19] and food intake
prior to the exam [20]. Instead, the extent of steatosis doesn’t influence TE within
each fibrosis stage [16].
3.3.1 Combination Algorithms
The accuracy of the different non-invasive methods developed in CHC may be

improved when they are combined [4].
Serum markers range from simple routine laboratory tests such as the AST-to-
platelet ratio index (APRI) [21] to more complex patented scores such as the
FibroTest (FT) [22], which includes γ-glutamyl transpeptidase, total bilirubin, α2-
macroglobulin, apolipoprotein A1 and haptoglobin levels.
Castѐra et al. [23] evaluated paired combination of TE, FT and APRI, and all
three markers together, for the diagnosis of fibrosis stage with liver biopsy examina-
tion results as the reference standard. The combined use of TE and FT offered the
best diagnostic performance both for significant fibrosis (≥F2, AUROC 0.88, 95%
CI 0.82–0.92) and for severe fibrosis-cirrhosis (≥F3, AUROC 0.95, 95% CI
0.91–0.97) (see Table 3.1).
In another study, Castѐra et al. [24] prospectively compared, in a large popula-
tion of CHC patients, the previous algorithm with the sequential algorithms for
fibrosis evaluation (SAFE) algorithm (combining APRI and FT) using liver biopsy
as the “gold standard” for staging fibrosis. Both algorithms were effective for the
non-invasive staging of liver fibrosis in CHC. Their use in clinical practice could
avoid the need for liver biopsy in 48–71% of cases for diagnosing significant fibro-
sis (72% with Castera vs. 48% with SAFE biopsy; p < 0.0001) and in 74–78% of
cases for detecting cirrhosis (79% with Castera vs. 75% with SAFE biopsy; p = NS).
Although, for significant fibrosis, the Castera algorithm saved 23% more liver biop-
sies than the SAFE biopsy, its accuracy was significantly lower (88% vs. 97%,
respectively; p < 0.0001). Instead, the number of saved liver biopsies for diagnosing
cirrhosis did not differ between Castera and the SAFE biopsy algorithms, but the
accuracy of Castera algorithm was significantly higher than that of the SAFE biopsy
(96% vs. 89%, respectively; p < 0.0001) (Table 3.1).
Therefore, the use of combination algorithms with the aim of reducing liver
biopsy represents a rational approach and results in higher diagnostic accuracy than
the use of standalone diagnostic tests [25].
3.3.2 TE vs. Other Elastography Techniques
Several other liver elasticity-based imaging techniques are being developed, includ-
ing ultrasound-based techniques and 3D magnetic resonance (MR) elastography.
Ultrasound elastography methods are point shear wave elastography (pSWE), also
known as acoustic radiation force impulse imaging (ARFI), and 2D-shear wave
elastography (2D-SWE). Like TE, 2D-SWE and ARFI imaging measure shear wave
velocities to provide a quantitative estimate of tissue stiffness. Different from TE,
both methods are integrated in conventional ultrasound machines and can be per-
formed with conventional ultrasound probes during an abdominal ultrasound scan.
In addition, the latter methods enable the exact localization of a region of interest
(ROI) measurement site during B-mode ultrasound and are not limited by the pres-
ence of ascites [26].
A meta-analysis [27] including 13 studies (n = 1163 patients) comparing pSWE
using ARFI with TE showed equivalent performance for detecting significant fibro-
sis and cirrhosis. The recommended cut-off levels to define an ARFI (VTQ®) posi-
tive test result for advanced fibrosis (F3) and cirrhosis (F4) prior to therapy are,
respectively, 1.60–2.17 m/s (AUROC 0.94, sensitivity 84%, specificity 90%) and
2.19–2.67 m/s (AUROC 0.91, sensitivity 86%, specificity 84%) [4]. Reliability cri-
teria for pSWE have recently been proposed [28].
2D-SWE seems to be at least equivalent to TE and pSWE/ARFI for non-invasive
staging of liver fibrosis in CHC patients [29], but quality criteria for correct inter-
pretation are not yet well defined.
Finally, comparison between MR elastography and TE has provided conflicting
results [30, 31, 32]. MR elastography seems to provide a higher diagnostic perfor-
mance than TE and pSWE for staging early stages of fibrosis [33]. However, wide-
spread use of this method will depend on cost and availability.
3.4 ransient Elastography for the Assessment of Liver

T
Fibrosis After SVR
The primary aim of HCV treatment is to achieve SVR; however, the main goal of
HCV eradication is to reduce mortality and morbidity [4]. A major advantage of TE,
compared with liver biopsy, is that it can be easily repeated over time and that it may
be useful for monitoring fibrosis regression to identify those patients with a higher
risk of developing complications during follow-up.
Several studies reported a significant decrease in LSM and non-invasive fibrosis
biomarkers values, compared with baseline values, in patients with HCV who
achieved SVR [34, 35, 36, 37]. However, it has to be taken into account that non-
invasive methods to evaluate fibrosis regression have not been validated in non-
viremic patients [10].
Pons et al. [34] demonstrated that LSM decrease very rapidly and significantly
during the first 4 weeks of DAA treatment of HCV-infected compensated advanced
chronic liver disease (cACLD) patients and that this improvement accounts for most
of the stiffness improvement observed during follow-up (48 weeks). Moreover, a
higher decrease in LSM was observed in patients with baseline ALT ≥ twofold
upper limit normal (2 X ULN) than in those with ALT <2 X ULN.
These findings suggest that the improvement of LSM after SVR cannot be inter-
preted as a reduction of liver fibrosis (at least during the first year of follow-up) but
as a suppression of liver inflammation, as a consequence of viral eradication.
D’Ambrosio et al. [35] examined reversal of cirrhosis in 33 cirrhotic patients
with pre-treatment LB and post-SVR LB and TE, demonstrating that 21% of
patients with LSM <12 kPa after 4 years of an SVR still has cirrhosis in LB. This
pilot study indicated less accuracy of TE in excluding cirrhosis in patients with
HCV clearance, as a consequence of its low sensitivity (61%), whereas its specific-
ity remains high (95%).
Therefore, routine use of non-invasive tests after SVR in cirrhotic HCV patients
has a high false-negative rate and cannot be used to establish which patients no
longer need HCC screening or for the diagnosis of cirrhosis reversal. Moreover, TE
cannot be used for staging liver fibrosis post-SVR in patients who did not have pre-
vious TE measurement. In addition, cut-off thresholds that predict low risk of liver-
related events and the best timing for repeated assessment of LSM after therapy
have not been established yet [10].
The topic is discussed in great depth in Chap. 9.
3.5 ransient Elastography for Diagnosing

T
Liver-Related Complications
DAAs can cure CHC infection with a good safety profile; hence, most patients
achieve an SVR regardless of the stage of chronic liver disease. Therefore, it is
important to identify patients at risk of developing liver-related complications, such
as liver decompensation or HCC.
Several studies have demonstrated that cirrhotic patients are at higher risk of
complications than those without cirrhosis, although in patients with cirrhosis who
have achieved SVR after DAA therapy the incidence of liver-related events and de
novo HCC is significantly reduced [38, 39]. It is important to point out that patients
at different stages of cirrhosis have different risks of developing complications and
of dying. Accordingly, the Baveno VI workshop suggested the term “compensated
advanced chronic liver disease (cACLD)” to better reflect that the spectrum of
severe fibrosis and cirrhosis is a continuum in asymptomatic patients, and that dis-
tinguishing between the two is often not possible on clinical grounds [40]. The term
cACLD refers to patients with LSM between 10 and 15 kPa (suggestive) and patients
with LSM >15 kPa (highly suggestive).
The two major prognostic factors in cACLD are the presence of clinically signifi-
cant portal hypertension (CSPH), defined by the Baveno VI workshop as a hepatic
venous pressure gradient (HVPG) ≥10 mmHg [40], and the presence of
GEV. Measurement of HVPG through hepatic vein catheterization and oesophago-
gastroduodenoscopy (OGD) are considered, respectively, the gold-standard tests for
assessment of CSPH and GEV. However, these tests are invasive and impractical for
frequent follow-up. Non-invasive methods can be used for the risk prediction of
liver-related complications and for guiding the need of further evaluation with
HVPG measurement and OGD [41].
This matter is further dealt with in Chap. 12.
3.5.1 Portal Hypertension
Portal hypertension is the haemodynamic abnormality associated with the most

severe complications of cirrhosis, including variceal bleeding, hepatic encephalopa-
thy and ascites [42, 43]. It is a consequence of the hepatic architectural remodelling
of chronic liver diseases (“static component”) in a tissue microenvironment charac-
terized by a net predominance of vasoconstrictors (“dynamic component”) [44]. In
addition, an increased splanchnic vasodilatation and a state of hyperdynamic circu-
lation contribute to the development of the “portal hypertensive syndrome” [45]. An
HVPG ≥10 mmHg, defined by Baveno VI workshop as CPSH, is responsible for the
formation of GEV, whereas clinical decompensation may develop when HVPG
became severe (≥12 mmHg).
Elastography has been extensively assessed in patients with portal hypertension
[46]. According to the meta-analysis performed by Shi [47], TE has high accuracy
for detection of CSPH in cACLD patients (AUROC 0.93, sensitivity 0.90, specific-
ity 0.79, PPV 0.88, NPV 0.88). The cut-off values of LSM range from 13.6 to
34.9 kPa, with 81% probability of correct detection of CSPH over the threshold
value and 11% probability of disease below the threshold value, when the pre-test
probability was 50%. The absence of established cut-offs in this meta-analysis lim-
its applicability in clinical practice.
Llop [48] demonstrated that in patients with cACLD and potentially resectable
HCC, a LSM value <13.6 kPa was highly sensitive for ruling out CSPH (AUROC
0.84, sensitivity 0.91, specificity 0.57, PPV 0.59, NPV 0.90), and a value ≥21 kPa
was highly specific for diagnosing CSPH (AUROC 0.84, sensitivity 0.53, specificity
0.91, PPV 0.81, NPV 0.74) (Table 3.2). Interestingly, in HCV-infected patients, the
specificity of the information obtained by TE was 100%, suggesting that when LSM
value is ≥21 kPa (AUROC 0.857, sensitivity 0.42, specificity 1.00, PPV 1.00, NPV
0.67), this exam might be sufficient to correctly diagnose CSPH in this subgroup of
Table 3.2 Performance of TE and Baveno VI criteria (TE and PLT) for ruling-in CSPH and
ruling-out varices requiring treatment, respectively, in patients with compensated advanced chronic
liver disease (cACLD)
Test TE Baveno VI criteria (TE and PLT)
Cut-off LSM ≥21 kPa LSM <20 kPa and PLT >150.000/mm3
AUROC (95% CI) 0.840 0.746
Se (%) 53 87
Sp (%) 91 34
PPV (%) 81 6
NPV (%) 74 98
LR+ 6.24 1.31
LR− 0.51 0.39
Ref. [59] [48]
AUROC area under the receiver operating characteristic curve, LR+ positive likelihood ratio, LR−
negative likelihood ratio, LSM liver stiffness measurement, NPV negative predictive value, PPV
positive predictive value, PLT platelet, Se sensitivity, Sp specificity, TE transient elastography
patients. However, although the correlation between LSM and HVPG is excellent
for HVPG values less than 12 mm Hg, it hardly reaches statistical significance for
values ≥12 mmHg (r2 = 0.17, P = 0.02) [49]. This important observation suggests
that in advanced stages of cirrhosis, the degree of portal pressure becomes largely
independent from fibrosis (and therefore LSM), while extra-hepatic components,
such as the hyperdynamic circulation and the splanchnic vasodilatation, become
more important [50]. Therefore, in patients with virus-related cACLD, non-invasive
methods can be used to diagnose CSPH, defining the group of patients at higher risk
of developing decompensation [40]. The Baveno VI workshop suggested that the
LSM thresholds for CSPH are ≥20–25 kPa in at least two measurements on differ-
ent days, alone or combined with platelets and spleen size [51].
This topic is analysed in great depth in Chap. 11.
3.5.2 Gastro-Oesophageal Varices (GEV)
GEV are a common consequence of portal hypertension and represent a major cause
of morbidity and mortality due to the risk of bleeding. Their prevalence in cirrhosis
is approximately 50% and is correlated with liver disease severity. Variceal bleeding
occurs at a yearly rate of 5% and is related to the stage of cirrhosis, the size of vari-
ces and presence of red wale marks [52].
The utility of TE is mainly in patients with cACLD, where it can be used to spare
OGDs in a subset of patients with no history of variceal bleeding. Currently, pri-
mary prophylaxis for variceal bleeding in cACLD is only recommended in patients
with large varices. Patients with decompensated cirrhosis should receive primary
prophylaxis irrespective of the size of varices.
A correlation between LSM values and the presence of GEV has been reported
in several studies with AUROCs ranging from 0.74 to 0.85 and cut-offs from 13.9 to
21.5 kPa. Although the sensitivity for the prediction of the GEV was relatively high
(76–95%), the specificity was poor (43–78%) [49, 53–58]. As a result, the diagnos-
tic accuracy of TE alone has not been sufficient to replace OGD in the diagnosis of
varices [4, 10].
The high sensitivity and NPV values of TE, especially in combination with other
non-invasive criteria, can rule out high-risk varices in patients with Child-Pugh A
cirrhosis, who can therefore avoid an unnecessary OGD. The Baveno VI criteria
[40] define that cACLD patients with a LSM <20 kPa and a platelet count >150.000/
mm3 have a low risk of having varices requiring treatment and therefore can avoid
screening endoscopy. They advise longitudinal follow-up of such patients by yearly
repetition of TE and platelet count with the guidance that if LSM increases or plate-
let count declines, these patients should undergo screening OGD [40]. The retro-
spective study by Maurice et al. [59], which included 310 patients, reported that the
Baveno VI criteria performed well correctly identifying 98% of patients who could
safely avoid endoscopy (AUROC 0.746, sensitivity 0.87, specificity 0.34, PPV 0.06,
NPV 0.98), but could incorrectly classify 2% of patients (Table 3.2). Application of
the guidelines will have excluded the patients from endoscopic surveillance and
delayed the introduction of appropriate primary prophylaxis. Therefore, careful

consideration must be given to co-morbidities which may impact the validity of
proposed platelet cut-off.
Three additional retrospective studies validated Baveno VI criteria for the detec-
tion of GEV and demonstrated that this strategy had acceptable rates of misdiag-
nosed patients, although the proportion of unnecessary gastroscopy was very high
[60–62]. Expanded Baveno VI criteria have also been proposed [63].
In the last years, different studies evaluate the diagnostic performance of spleen
stiffness measurement by TE in identifying patients with GEV and CSPH. Colecchia
et al. [64] suggest that SS measurement, possibly associated with LSM, has a high
diagnostic accuracy for the prediction of GEV and different degrees of PH in
patients with CHC. Further validation is needed before the place of SS in clinical
practice can be defined.
This topic is analysed in great depth in Chap. 11.
3.5.3 Hepatocellular Carcinoma (HCC)
HCC is the fifth most common cancer worldwide and the third most cause of cancer
death [65]. CHC is the leading risk factor for HCC, with an annual HCC risk of
2–4% in patients with cirrhosis [66]. HCV-induced chronic inflammation is sup-
posed to be a strong promoter of tumour development, and resolution of HCV infec-
tion should translate in a reduced incidence of HCC even in patients with liver
cirrhosis [67]. Long-term post-SVR follow-up studies showed that the risk of HCC
remains in patients with cirrhosis who clear HCV, although it is significantly reduced
compared to untreated patients or patients who did not achieve an SVR [67, 68]. In
addition, patients previously treated for HCC have still a high risk of tumour recur-
rence, despite DAA treatment [69]. Thus, guidelines recommend indefinite ultra-
sound surveillance every 6 months after SVR for patients with advanced fibrosis or
cirrhosis before treatment [4]. Several studies identified that high LSM value mea-
sured by TE is significantly associated with the risk of presence of HCC [38, 69–
71]. In a multicentre retrospective study of Conti et al. [69], patients with baseline
LSM values ≥21.3 kPa were significantly more prone to develop HCC de novo
(p = 0.005; OR, 4.24; 95% CI, 1.50–11.97) and HCC recurrence in those with a his-
tory of previous HCC (p = 0.01; OR, 11.91; 95% CI, 1.33–106.78). Degasperi et al.
[70] demonstrated that baseline LSM was a predictor of de novo HCC as well (haz-
ard ratio [HR], 1.03; 95% CI, 1.01–1.06; P = 0.01), with the best cut-off being an
LSM ≥30 kPa. Take into account that both previous studies included patients with
Child-Pugh class A and B liver cirrhosis, those patients with worse liver function
also had higher LSM, which could lead to an overestimation of the effect of base-
line LSM.
Ravaioli et al. [71] found that a LSM reduction <30% (HR, 5.360; 95% CI,
1.561–18.405; p = 0.008) during a median follow-up of 15 months after DAA
treatment was an independent predictor of HCC development. A possible explana-

tion of these results could be the persistence of greater fibrosis and portal hyperten-
sion after DAA therapy in patients who developed HCC compared to those who did
not, in whom the lower reduction of LS might reflect an improvement in
inflammation.
In contrast to what has been previously reported, a multicentre prospective study
from Pons M et al. reported that neither baseline LSM nor LSM improvement pre-
dicted the occurrence of HCC. This study, including 572 patients with Child-Pugh
class A, demonstrated that albumin levels at follow-up (HR 0.08; 95% CI 0.02–0.25;
p < 0.001) and LSM <10 kPa at follow-up (HR 0.33; 95% CI 0.11–0.96; p < 0.042)
were independently associated with the risk of HCC. Combining both predictors,
they identified two groups with differing risk of HCC occurrence: those with LSM
≥20 kPa at follow-up or those with LSM between 10 and 20 kPa and albumin levels
<4.4 g/dl were at the highest risk (IR ≥1.9/100 patient-years).
According to all these results, it can be concluded that TE could be useful to
identify patients at risk of developing HCC, but more data are needed before it can
be integrated into an HCC surveillance programme [10].
This matter is further dealt with in Chap. 12.
3.6 Transient Elastography to Determine Prognosis
There is increasing evidence for the prognostic value of non-invasive tests, particu-
larly LS measurement using TE, in CHC patients [10]. Vergniol et al. [72] showed,
in a cohort of 1457 CHC patients, the prognostic value of LSM for 5-year overall
survival and survival without liver-related death, which remained after adjustment
for treatment response, patient age and estimates of necro-inflammatory grade.
In another study, Vergniol et al. [73] demonstrated that survival decreased as
delta of 3-year LSM increased, especially in patients with baseline LSM >7 kPa.
According to these results, they proposed a clinical management algorithm, using
baseline LSM (kPa, HR 5.76; 95% CI 3.74–8.87; p < 0.001), LSM evolution (kPa/
year, HR 1.19; 95% CI 1.11–1.28; p < 0.001) and SVR achievement (HR 0.19; 95%
CI 0.05–0.80; p = 0.023) for the prediction of prognosis and patient manage-
ment in CHC.
According to a meta-analysis [74] including 27 studies (n = 5874 treatment-
naïve CHC patients), LSM progression rates were consistent with fibrosis progres-
sion rates derived from biopsy in predicting time-to-cirrhosis, although there was
less consistency for early-stage progression (time-to-F2).
Therefore, the potential role of TE for predicting clinical outcomes seems to be
greater than that of liver biopsy; probably LSM is consistent with pathophysiologi-
cal processes that a biopsy cannot, but more studies are needed to obtain refined
estimates [10].
This topic is further dealt with in Chap. 12.
3.7 Conclusions
Significant progress has been made in the field of non-invasive assessment of

liver fibrosis, reducing the need of liver biopsies. The role of TE for fibrosis
staging in CHC patients is crucial prior to therapy for predicting the presence
of advanced fibrosis and cirrhosis and prioritizing patients for HCV therapy
based on disease stage. Instead, for the diagnosis of significant fibrosis, the use
of combination algorithms may provide the highest diagnostic accuracy.
Therefore, TE can be used for the risk prediction of HCC and liver-related
complications, like CSPH and GEV requiring treatment, and for guiding the
need of further evaluation with more invasive tests. In addition, there is increas-
ing evidence for the prognostic value of LS measurement using TE in patients
with cirrhosis.
Routine use of TE after SVR in CHC patients, on the other hand, has a high false-
negative rate and cannot be used to determine which patients no longer need HCC
screening or for diagnosis of cirrhosis reversal. Finally, it remains to be seen the
cut-off thresholds that predict low risk of liver-related events and the best timing for
repeated assessment of LSM after therapy.
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The Role of Elastography in HBV:
Assessing Liver Fibrosis 4
Barbara Coco, Gabriele Ricco,
and Maurizia Rossana Brunetto
4.1 Introduction
Hepatitis B virus (HBV) infection is still a global public health problem with chang-
ing epidemiology due to several factors including vaccination policies and migra-
tion [1]. Approximately 250 million people are chronic HBV surface antigen
(HBsAg) carriers, with a large regional variation between low (<2%) and high
(>8%) endemicity levels [1]. The prevalence decreased from high to low-medium
endemicity in several countries due to improvements in the socioeconomic status,
universal vaccination programs, and effective antiviral treatments. However, popu-
lation movements and migration are currently influencing the prevalence of the
infection in several low-endemic countries in Europe (e.g., Italy, Germany), because
of the high HBsAg prevalence rates in migrants from Central/Eastern Europe, Asia,
and sub-Saharan Africa [2, 3].
Chronic HBV infection is a dynamic process reflecting the interaction between
virus and host’s immune response: in the presence of an effective immune control,
a reduced transcriptional activity of the covalently closed circular viral DNA
(cccDNA) is associated with persistently low-replicative levels and the absence of
active liver disease; by converse when the immune system fails to control viral
B. Coco · G. Ricco
Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses,
Reference Center of the Tuscany Region for Chronic Liver Disease and Cancer, University
Hospital of Pisa, Pisa, Italy
M. R. Brunetto (*)
Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses,
Reference Center of the Tuscany Region for Chronic Liver Disease and Cancer, University
Hospital of Pisa, Pisa, Italy
Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
Institute of Biostructure and Bioimaging, National Research Council, Naples, Italy
e-mail: maurizia.brunetto@unipi.it

https://doi.org/10.1007/978-3-030-74132-7_4
44 B. Coco et al.
infection, the presence of florid viral replication promotes hepatitis and its progres-
sion [4–6]. Accordingly, the natural history of chronic HBV infection can be
described focusing on the presence or absence of liver inflammation, and the current
nomenclature is based on the description of the two main conditions—infection and
hepatitis—and distinguishes chronic HBV infection associated with HBV-induced
liver disease, namely, chronic hepatitis B (CHB) (either HBeAg positive or nega-
tive), from chronic HBV infection without HBV-induced liver damage, namely,
non-inflammatory HBeAg-positive and HBeAg-negative infection [2].
A correct identification of the phase of HBV infection is fundamental for the
optimal management of HBV carriers in clinical practice as patients who have
active disease require treatment intervention and more intensive monitoring,
whereas patients who have infection without hepatitis do not require antiviral treat-
ment [2, 7]. Diagnosis of the chronic HBV infection phase is based on virological
and biochemical parameters, but in a significant number of patients, particularly in
HBeAg-negative/anti-HBe-positive carriers, a single determination of HBV replica-
tion markers as well as serum transaminases does not allow an accurate classifica-
tion into one of the two phases: HBeAg-negative chronic hepatitis B or infection
(previously named inactive infection), because of the fluctuating profile of HBeAg-
negative chronic hepatitis B (CHB) [2, 8]. Thus, in case of low viremia levels
(<2000–20,000 IU/mL), a serial monitoring of serum HBV-DNA and alanine ami-
notransferase (ALT) levels is required for at least 12 months, unless additional
markers are combined [2, 9, 10].
In patients with chronic hepatitis, the persistence of high replicative levels and
liver necro-inflammation favors liver disease progression: the extent of fibrosis is a
major prognostic factor which correlates with the risk of developing cirrhosis and
liver-related complications [2]. In untreated CHB patients, the 5-year cumulative
incidence of cirrhosis ranges from 8% to 20%, and, among those with cirrhosis, the
5-year cumulative risk of hepatic decompensation is 20%, with an annual risk of
hepatocellular carcinoma (HCC) of 2–5% [6, 8, 11].
The current available antiviral therapy for CHB [short-term treatment with
pegylated interferon (Peg-IFN) or long-term suppressive therapy with oral nucleos(t)
ide analogues (NA)] prevents disease progression, reduces the risk of end-stage
liver complication, and even reverses hepatitis B virus (HBV)-induced liver fibrosis
[2]. However, because of the oncogenetic potential of HBV infection, mainly due to
the random integration of HBV-DNA sequences into the hepatocyte genome, par-
ticularly in patients with cirrhotic de-arrangement of the liver acinus (persistence of
porto-central fibrotic bridges), the risk of developing hepatocellular carcinoma
(HCC) persists even after a sustained virological response to therapy [12]. Therefore,
the definition of the stage of liver disease is crucial in the management of HBsAg
carriers.
Liver biopsy is the reference standard for both grading and staging of liver dam-
age. However, it is an invasive procedure, not suitable for tight monitoring, and
minimal specimen’s requirements are needed to allow a correct evaluation of the
liver disease: minimum length 2–2.5 cm and presence of at least 11 portal tracts [13,
14]. Its diagnostic accuracy is significantly influenced by sampling errors and the
high rate of intra- and inter-observer variability, leading to under-staging of fibrosis
4 The Role of Elastography in HBV: Assessing Liver Fibrosis 45
even in adequately sized specimens, with false-negative results in up to 30% of case

[13, 14]. Therefore, major efforts had been made to identify noninvasive diagnostic
tools providing a quantitative index of fibrosis for an appropriate diagnosis and
management of CHB patients.
Liver fibrosis can be indirectly quantified by serum markers: fibrosis-4 (FIB-4)
index (age x aspartate aminotransferase [AST])/(platelet square root of alanine ami-
notransferase [ALT]), direct serum markers related to extracellular matrix forma-
tion (e.g., hyaluronic acid), degradation, cytokines (e.g., transforming growth
factor), or fibrinolytic pathways (e.g., tissue inhibitor of metalloproteinases-1) or a
combination of several markers, such as the enhanced liver fibrosis or ELF-test [15].
Also ultrasound (US)-based tests including transient elastography (TE), acoustic
radiation force impulse imaging (ARFI), and splenic Doppler impedance index have
been implemented [15, 16]. Finally, transient elastography (TE) measured by
FibroScan® (Echosens, Paris, France) provides a direct, rapid, and reproducible
assessment of liver stiffness (LS) that is a reliable fibrosis index currently recom-
mended by the European Association for the study of the liver (EASL), provided
that its values are adequately contextualized [2, 17]. We briefly reviewed the use of
TE in the management of chronic HBsAg carriers, providing evidences about the
importance of combining the serum virologic and biochemical pattern with the liver
stiffness value to achieve an accurate assessment of liver disease at the single
patient level.
4.2 Liver Stiffness Cofactors and Confounders
Liver stiffness is a physical parameter that primarily results from liver fibrosis; how-
ever, its values are influenced also by other factors that modify liver elasticity, such
as the inflammatory infiltrate, edema, vascular congestion, cholestasis, and, even if
still controversial, steatosis [17, 18]. Therefore, for a proper interpretation of TE
values, the interference of such factors, particularly of inflammation, has to be con-
sidered, given the disease profile of CHB. It is known that HBeAg-negative CHB
patients frequently display fluctuations of necro-inflammation and biochemical
activity (hepatitis flares) followed by prolonged spontaneous virological and bio-
chemical remission that mimic the pattern of HBeAg-negative infection [8]. We
firstly observed that in patients with CHB, there was a significant correlation
between LS and ALT levels and significant fluctuations of TE values paralleled ALT
values during hepatitis flares, in patients with acute or chronic hepatitis [19].
Independent studies [20–24] confirmed these observations in patients with acute
liver damage of different etiology. Interestingly, in patients with acute hepatitis or
CHB with ALT flare LS peak values frequently exceeded the threshold values pro-
posed for cirrhosis even in patients with absent or mild fibrosis [19]. Thus, intrahe-
patic inflammation has important implications for LS values, and the ALT pattern
has to be taken into account when interpreting the results of TE measurements to
avoid an overestimation of liver fibrosis in patients with elevated ALT [17]. Chan
et al. have proposed an algorithm which uses higher cutoffs in patients with elevated
ALT levels, to avoid the overestimation of fibrosis because of the inflammation.
46 B. Coco et al.
However, adapting cutoffs on ALT did not improve the overall percentage of patients
correctly classified [24]. In agreement with the major interference of liver necro-
inflammation on LS values is the rapid decline of LS paralleling that of ALT during
the early phase of treatment [24].
The influence of steatosis on LS measured by FibroScan in chronic hepatitis B
patients is still controversial, but it appears less relevant as compared to steatosis in
CHC. Gaia et al. studied 219 patients with CHB with or without steatosis to deter-
mine the reliability of TE for the detection of fibrosis. In the subgroup of 72 patients
with moderate steatosis (≥33%) and advanced fibrosis, LS values were lower than
expected and similar to fibrosis stages 1 and 2 [25]. Kim et al. recruited 162 CHB
patients and demonstrated that mild to moderate steatosis (5–66%) did not have
significant impact on LS values [26]. Cai et al. showed that in subjects with low-
grade fibrosis (S0–S2/S0–S3), mean LS values were significantly higher in subjects
with severe steatosis or controlled attenuation parameter (CAP) ≥287 dB/m com-
pared with those without [27]. These findings are in agreement with the previously
published data by Boursier et al. who found that, in chronic hepatitis C (CHC)
patients, the influence of liver steatosis disappeared in patients with significant
fibrosis [28]. The authors concluded that steatosis increases liver stiffness as mea-
sured by FibroScan only in patients without severe fibrosis, whereas the influence of
steatosis disappears in the presence of severe fibrosis.
Finally, Fraquelli et al. made a comprehensive evaluation of the factors respon-
sible for any discrepancies in diagnostic accuracy between TE and liver biopsy in
both CHB and CHC patients [29]. The results of the study showed that fibrosis stage
and liver cell necro-inflammatory activity were independently associated with LS
values in both HBV and HCV patients, whereas steatosis was independently associ-
ated with TE only in HCV. Fibrosis overestimation was predicted by severe/moder-
ate necro-inflammatory activity in HBV and by older age (41–60 years or >60 years
vs <40 years), >2 upper limit of normal (ULN) AST and >2 ULN GGT, whereas
severe/moderate necro-inflammatory activity and severe/moderate steatosis in
CHC [29].
In conclusion, all these data demonstrate that LS results in multiple intrahepatic
conditions, where fibrosis and necro-inflammation are the major drivers: therefore,
as TE provide a quantitative index of fibrosis/inflammation, the relative impact of
each of the two on the overall TE value at any given time point of the patient history
has to be evaluated in strict relation with the time-specific clinical pathologic
conditions.
4.3 TE in Untreated HBV Carriers
4.3.1 HBsAg Carriers Without Liver Disease
Individuals with HBeAg-negative infection are conventionally defined as HBsAg

positive, hepatitis B e antigen (HBeAg) negative, anti-HBe-positive individuals
with normal alanine aminotransferase (ALT), and HBV-DNA persistently
<2000 IU/mL [2]. Long-term follow-up studies showed that such virological pro-
file is a favorable and benign condition, leading to a progressively control of HBV
replication and fostering transition to occult hepatitis B infection (OBI) in a sig-
nificant proportion of cases [7, 9, 10, 30–33]. Similarly, growing evidences sug-
gest that carriers with viremia levels persistently <20,000 IU/mL have a benign
outcome as well as high rate of transition to inactive infection (43% of subjects
followed for 6 years, on our experience) [10]. Therefore, in this subset of HBeAg-
negative carriers without active liver disease, there is not any need for an invasive
assessment of liver histology. However, the diagnostic challenge remains to timely
identify HBeAg-negative CHB patients who show a similar virological and bio-
chemical profile because of a temporary remission of both viral replication and
disease activity [8]. A tight monitoring of HBV-DNA for at least 1 year or a com-
bination of different serum viral markers (HBsAg; total anti-HBc and HBcrAg)
has been proposed [9, 10, 30–33]. Alternatively, to avoid a costly and time-con-
suming monitoring, several studies have investigated the accuracy of TE to dis-
criminate between HBeAg-negative infection and CHB [10, 20, 34–36]. We firstly
reported low LS values in 68 genotype D carriers of HBeAg-negative infection
(TE = 5.0 ± 1.8 kPa), showing that in carriers with metabolic liver disease, mean
LS values were significantly higher than in those without liver disease cofactors
(6.9 ± 2.3 kPa in 17 patients with histologically proven steatohepatitis or steatosis
vs 4.3 ± 1.0 kPa in 57 subjects with normal ALT and without cofactors) [20].
Many studies subsequently confirmed that carriers of HBeAg-negative infection
have mean LS values comparable to those of normal controls and significantly
lower than those of CHB patients [34–37]. Overall, all these studies confirmed
that median TE values are less than 5 kPa in low-replicative HBeAg-negative car-
riers, with an upper range reaching 7.9 kPa values in some studies [34, 35]. Thus,
high LS values (with or without serum ALT elevations) in carriers with viremia
persistently <2000 IU/mL suggest the presence of liver damage due to causes
other than HBV with the need for further investigations, eventually with
liver biopsy.
Monitoring LS values can also contribute to confirm the benign course of
infection. Castera et al. reported that LS measurements did not differ signifi-
cantly over time in 82 low-replicative carriers (median follow-up, 21.7 months;
range, 3.3–49.1 months) confirming the clinical usefulness of TE in these sub-
jects [35]. Consistently with the previous reports, Wong et al. studied LS at base-
line and after a 3-year follow-up in an Asian cohort of 361 HBeAg-negative HBV
carriers: the liver disease progression (which was arbitrarily defined as “an
increase in LS by at least 30% to a value suggestive of advanced fibrosis”)
appeared to be rare among patients with a HBV-DNA level <20,000 IU/mL
(2.8%) and extremely rare in inactive carriers (0.8%) [36]. Similarly in our cohort
of 133 low viremic carriers with uneventful outcome for over 60 months, liver
stiffness values remained stable throughout the follow-up (baseline median stiff-
ness values of HBeAg-negative carriers and low viremic carriers 4.9 (2.7–5.8)
and 5.2 (3.1–6.1) kPa vs 4.6 (2.5–6.2) kPa vs 4.6 (3.2–5.9) kPa at the end of
follow-up) [10].
48 B. Coco et al.
4.3.2 Untreated CHB Patients
Both European and Asian studies showed that the natural course of HBV infection
varies between geographical areas and is affected by several factors such as age at
primary infection, gender, host genomics, HBV genotype, mutant strains, and pres-
ence of cofactors of liver disease [6, 7, 11]. However, high levels of HBV replica-
tion, independent of HBeAg status, and sustained disease activity are the strongest
predictors of adverse clinical outcomes, increasing the risk of cirrhosis and liver-
related mortality, due to the development of HCC and liver failure [2, 6, 8].
Therefore, in CHB patients, the assessment of the disease stage is crucially impor-
tant to take appropriate therapeutic decisions, monitoring treatment response, and
disease progression and to evaluate the need for HCC surveillance.
Several studies have analyzed the diagnostic accuracy of TE in predicting the
stage of fibrosis in CHB patients; a summary of the most relevant studies is reported
in Tables 4.1 and 4.2.
The proposed LS thresholds to diagnose significant fibrosis (F ≥ 2 or S ≥ 3)
range from 5.2 to 8.7 kPa, with highly variable sensitivity (64–93%), specificity
(38–92%), and AUROC ranging from 0.82 to 0.96. The range of the LS thresh-
olds to identify cirrhosis (F ≥ 4) is even higher, ranging from 9.4 to 17.5 kPa;
nevertheless, many studies suggested values around 11 kPa, with AUROC >0.90
(Table 4.2).
The wide variations of LS thresholds are influenced by several factors: the het-
erogeneity of the different cohorts, with unbalanced distribution of patients in terms
of phases of HBV infection, disease activity, and stages of fibrosis. Furthermore, in
many studies, an accurate stratification according to the stage of portal hypertension
is missing. Finally, since TE provide a fibrosis/inflammation index without
Table 4.1 Transient elastography performance for the diagnosis of significant fibrosis
(F ≥ 2) in CHB
Patients Cutoff Sensitivity Specificity AUROC (95%
Ref. Country (n) (kPa) (%) (%) CI)
Oliveri et al. Italy 188 7.5 93 88 0.96
[20] (0.94–0.99)
Marcellin France 173 7.2 70 83 0.81
et al. [38] (0.73–0.86)
Chan et al. China 161 8.4 84 76 0.87
[24] (0.82–0.93)
Degos et al. France 284 5.2 89 38
[39]
Viganò et al. Italy 217 8.7 64 92
[37]
Cardoso et al. France 202 7.2 74 88 0.86
[40]
Jia et al. [41] China 486 7.3 66 83 0.82
(0.78–0.85)
Table 4.2 Transient elastography performance for the diagnosis of cirrhosis (F4) in CHB
Patients Cutoff Sensitivity Specificity AUROC
Ref. Country (n) (kPa) (%) (%) (95% CI)
Oliveri et al. Italy 188 11.8 93 88 0.97
[20] (0.95–0.99)
Marcellin France 173 11.0 70 83 0.93
et al. [38] (0.82–0.98)
Chan et al. China 161 13.4 79 92 0.93
[24] (0.89–0.97)
Viganò et al. Italy 217 9.4 100 82
[37]
Kim et al. Korea 99 10.3 59 78 0.80
[42]
Cardoso et al. France 202 11.0 75 90 0.93
[40]
Jia et al. [41] China 486 17.5 60 93 0.90
(0.87–0.94)
dissecting the relative values of these two components, the inclusion of patients dur-
ing an ALT flare might have caused an overestimation of fibrosis in a subset of
patients reducing the overall diagnostic performance of TE in predicting fibrosis.
A few studies have carried out direct comparisons between CHB and chronic
hepatitis C (CHC) patients. Cardoso et al. and Verveer et al. have assessed—in a
cross-sectional study—treatment-naive patients with CHB or CHC who under-
went TE measurement and liver biopsy, showing that the overall TE diagnostic
performance was similar in the two groups of patients [40, 43]. In a meta-analy-
sis including 17 studies on CHC patients and ten studies on CHB patients,
Tsochatzis et al. reported that LS cutoffs were globally lower in CHB as com-
pared to CHC group (on average 7.0 vs 7.6 for F ≥ 2, 8.2 vs 10.9 for F ≥ 3, and
11.3 vs 15.3 for F4) [44]. Similar findings were reported by Chon et al. in another
meta-analysis of 18 studies assessing HBV patients, which showed the estimated
cutoff of 7.9 (range 6.1–11.8) kPa for F ≥ 2, 8.8 (range 8.1–9.7) kPa for F ≥ 3,
and 11.7 (range 7.3–17.5) kPa for the identification of F = 4 [45]. A possible
explanation for this finding is the evidence that fibrosis septa are usually thinner
in CHB patients resulting in cirrhosis with larger nodules (macronodular cirrho-
sis) as compared to CHC [14, 46]. However, many additional cofactors can influ-
ence the LS values, and their different prevalence in CHC and CHB patients may
well explain the results.
In clinical practice, TE contributes to identify chronic HBV carriers without
liver disease (LS values ≤5 kPa and comparable to healthy subject) or patients
without significant fibrosis (LS values ≤8 kPa). By converse, LS values ranging
from 8 to 11 kPa are indicative of significant liver disease, but they need to be
contextualized to rule out a possible interference of necro-inflammation.
Similarly, values >11 kPa, in the absence of an ALT flare, are indicative of severe
fibrosis (Fig. 4.1).
50 B. Coco et al.
Infection
without liver damage Chronic hepatitis Cirrhosis
2.5 ≤5 ≤ 9* ≤ 11* 15* 75 kPa
Moderate/severe Fibrosis
*Mandatory correlation with
biochemical activity
Adapted and modified from Bonino F et al. Antiviral Therapy 2010
Fig. 4.1 FibroScan values and stage of liver disease in untreated HBV carriers. Schematic dia-
gram of FibroScan values in untreated HBV carriers. For values in the range of 5–15 kPa, a cor-
relation with the biochemical activity of disease is mandatory for the correct interpretation of the
data. Adapted and modified from Bonino et al. [18]
4.4 TE in Treated CHB Patients
4.4.1 LS Kinetics During Antiviral Treatment
Antiviral therapy in CHB is aimed to prevent its progression to cirrhosis or, when
cirrhosis is already present, to avoid or delay the development of the end-stage com-
plications of liver disease and HCC [2]. Disease progression is promoted by persis-
tent liver necro-inflammation that results from the inability of the host’s immune
system to control viral replication effectively. Two different therapeutic approaches
can be attempted to suppress disease activity: (1) to shift the host-virus equilibrium
from the pathogenic active to the nonpathogenic low-replicative phase with a time
limited course of antiviral treatment capable of inducing a sustained off-therapy
control of HBV replication and (2) to suppress viral replication persistently with
continuous antiviral treatment [2]. Interferon (IFN) is the major player of the former
strategy, even if also nucleos(t)ide analogues (NA) treatment can achieve a persis-
tent control of the infection in a proportion of patients, usually after prolonged treat-
ment. However, in many patients, mainly HBeAg negative with advanced fibrosis, a
long-term, eventually lifelong, treatment is preferred to warrant a persistent phar-
macological control of viral replication [2]. Since the early 1990s, several studies in
IFN treated patients showed that an effective treatment is associated with the clear-
ance of intrahepatic necro-inflammation and reduction of fibrosis, with an overall
improvement of liver histology [8, 47–49]. More recently, the follow-up of patients
in long-term NA treatment showed a similar picture, with the evidence of a signifi-
cant reduction of fibrosis, eventually with cirrhosis reversal [50]. Actually, cirrhosis
results not only from diffuse fibrosis but also from nodular parenchymal regenera-
tion (architectural distortion) and major vascular derangements, including intrahe-
patic portosystemic shunts [51]. A full reversal of such alterations in patients with
long-lasting cirrhosis is unlikely: even if resorption of fibrosis can occur, it remains
to be clarified to which extent the plasticity of the vascular structures could favor the
resolution of the abnormal vascular shunts [51]. Nevertheless, long-term NA treat-
ment is associated with lower rates of liver decompensation, HCC development, and
overall improvement of patients’ survival [12, 50, 52, 53]. Therefore, mainly in
patients with advanced fibrosis, it is mandatory to monitor antiviral therapy not only
in terms of viral and biochemical response but also of liver disease improvement.
Liver biopsy, as discussed previously, is unsuitable for multiple evaluations that
would be required to monitor the changes in liver disease during NAs. Therefore,
alternative noninvasive and reliable tools for longitudinal follow-up of these patients
are required in clinical practice. Accordingly, TE had been widely used to monitor
treated CHB patients, and the LS dynamic changes in patients undergoing NAs
treatment show a significant decrease of its values overtime. Nevertheless, since TE
provides a combined fibrosis/inflammation index, it is difficult to differentiate the
LS reduction resulting from the clearance of necro-inflammation from that due to
the fibrosis regression. Several studies, mainly retrospective, investigated the role of
necro-inflammation on LS changes during NAs, with conflicting results (Table 4.3).
Some studies suggested that a decrease in LS values was a consequence of fibrosis
regression because on-treatment LS decline was independent from baseline ALT
levels or unrelated with ALT changes [54–56, 61, 64, 65]. On the contrary, other
studies reported either a correlation between LS and ALT decline or a significant LS
decline only in patients whose ALT levels were elevated at baseline [57, 58].
Interestingly, Wong et al. in their prospective study recruited 71 CHB patients
with paired liver biopsy and transient elastography before and after week 48 of
antiviral treatment in two randomized clinical trials. The authors reported ALT nor-
malization in 82% of patients and LS decrease, defined as a decline >30% of base-
line value, in 39%. Among patients with decreased LS values, only 11 (39%) had
histological regression of fibrosis, while 14 and 3 had unchanged or progression of
Metavir staging, suggesting that the decrease in LS values was more likely associ-
ated with the reduction of both intrahepatic necro-inflammation and ALT rather
than a change in liver fibrosis [59].
More recently, Liang et al. studied the dynamics of LS every 6 months in 534
CHB patients treated with entecavir (ETV). Histological reassessment in a subset of
164 patients showed a regression of fibrosis in about 60% of cases after 2 years of
ETV. Median LS values declined in parallel with ALT levels in the first 24 weeks;
thereafter, from week 24 to 104, a slower but persisting decline of median LS was
observed, in spite of stable ALT values. Interestingly, LS values declined indepen-
dently of baseline ALT values, but their decline was greater in patients with more
severe necro-inflammation and fibrosis at baseline as well as in patients with better
virological response [63].
Overall, these findings and longitudinal studies with 3–5 years of follow-up
confirm that LS is a measure of both liver inflammation and fibrosis: LS kinet-
ics show a biphasic pattern with an initial phase of more rapid decline, fol-
lowed by a subsequent slower decline [60, 62, 63]. The rapid-to-slow decline
observed within the first 24–48 weeks of treatment suggests that in the early
phase, the remission of biochemical activity and the progressive reduction of
Table 4.3 Studies on LS reduction following antiviral treatment with NAs
52
Time
Ref. Year Study type NAs (years) Patients (n) bx LS-BL (kPa) LS-EOF (kPa) Pa
Kim et al. [54] 2010 Retrospective LAM/ADV 1 23 4 13.7 ± 8.0 11.3 ± 5.3 0.018
ETV 2 18 12.1 ± 9.6 not given 0.017
Enomoto et al. [55] 2010 Retrospective ETV 1 20 2 11.2 7.8 0.0090
(7.0–15.2) (5.1–11.9)
Osakabe et al. [56] 2011 Retrospective LAM/ETV 3 29 / 12.9 4.7 0.006
(6.2–17.9) (3.1–7.9)
Fung et al. [57] 2011 Prospective LAM/ADV 3 110 / 7.3 6.1 <0.001
ETV/TDF
Lim et al. [58] 2011 Retrospective ETV 1 62 / 15.1 8.8 <0.001
(5.6–75.0) (3.0–33.8)
Wong et al. [59] 2011 Prospective CLV/ADV 1 71 71 8.8 6.6 <0.001
(3.1–26.3) (3.3–18.8)
Ogawa et al. [60] 2011 Retrospective LAM/ETV 3 22 / 8.2 5.3 <0.001
(4.2–28.5) (2.5–18.0)
Kim et al. [61] 2014 Prospective ETV 3 121 / 14.3 7.3 <0.001
(9.0–23.5) (5.3–11.8)
Chon et al. [62] 2017 Prospective LAM/ETV 5 120 / 14.5 8.3 <0.001
Liang et al. [63] 2018 Prospective LdT/ 2 534 164 8.6 5.3 <0.001
LdT + ADV (2.6–49.5) (2.7–36.8)
Rinaldi et al. [64] 2018 Retrospective ETV/TDF 2 149 / 12.4 ± 9.3 8.2 ± 4.9 <0.001
Li et al. [65] 2018 Retrospective ETV 3 104 / 8.2 (5.9–9.7) 5.6 (4.5–8.5) <0.001
ADV adefovir; bx, liver biopsy, CLV clevudine, ETV entecavir, LAM lamivudine, LdT telbivudine, LS-BL liver stiffness at baseline, LS-EOF liver stiffness at
end of follow-up, NAs nucleos(t)ide analogues, TDF tenofovir disoproxil fumarate
a
Comparison between baseline and follow-up LS values
B. Coco et al.
LS ALT
0
-20
mean % Variation
-40
-60
-80
-100
0 52 104 156 208 260
Time (weeks)
Week 0 Week 24 Week 52 Week 104 Week 156 Week 260

ALT (U/L) 212 ± 452.6 33 ± 22.3 24.8 ± 9.1 21.2 ± 8.0 19.6 ± 7.5 18.3 ± 5.53
LS (kPa) 10.6 ± 6.6 8.7 ± 5.3 7.6 ± 3.4 6.1 ± 2.6 5.4 ± 1.4 5.2 ± 1.9
Data are expressed as mean values ± SD
Fig. 4.2 Dynamic changes in liver necro-inflammation and liver stiffness in CHB patients under-
going NAs. Dynamic changes of ALT and liver stiffness values in 50 CHB patients on long-term
(>5 years) antiviral therapy with NAs. Personal unpublished data
intrahepatic necro-inflammation play a major role in LS values variation. Later

during treatment, particularly after ALT normalization, the more gradual LS
reduction reflects the regression of fibrosis (Fig. 4.2). Since fibrosis is more
likely to regress if it is recent (such as in case of the unregulated wound-heal-
ing response induced by active necro-inflammation) [66], it remains to be dem-
onstrated whether a greater LS decline could reflect mainly a regression of a
more recent fibrosis.
In our previous experience of 35 treated patients monitored with TE for
48 months, LS showed a mean yearly decline of about 0.2-folds reaching values
below the cirrhosis cutoff (11.8 kPa) in patients who maintained the histologic
evidence of cirrhosis [20]. As a consequence, it remains open the question whether
the LS thresholds currently used to identify the different stages of fibrosis in
patients with active liver disease can be automatically applied to patients with a
complete and long-lasting resolution of disease activity (i.e., necro-inflamma-
tion). In fact, studies where LS values are compared with the histological picture,
in an adequate number of both patients with active and inactive cirrhosis, are
missing. Therefore, in patients on long-term NA treatment, without a baseline
characterization of liver disease stage, the LS values must be always interpreted
on the light of the other biochemical and instrumental information, to rule out the
presence of cirrhosis.
54 B. Coco et al.
4.4.2 orrelation Between LS Changes During Treatment

C
and CHB Outcomes
Chronic HBV infection, as previously discussed, is a major cause of HCC world-

wide with an annual incidence of 2–3% for HBsAg-positive carriers with com-
pensated cirrhosis and less than 1% for those without cirrhosis [11]. It is now
widely accepted that the risk of HCC development is reduced by an effective and
prolonged viral load suppression such as that obtained under NAs. However, the
risk of HCC is not eliminated, probably due to pathophysiological events that
occurred before therapy start or to oncogenetic mechanisms that are not influ-
enced by antivirals [12]. Therefore, surveillance for HCC is recommended in
CHB patients, but reliable tools for risk stratification are of crucial importance in
order to sustain cost- effectiveness [67]. Accordingly, several risk prediction
scores have been developed in the past decade, initially in untreated cohorts of
Asian patients, based on multiple factors that were found associated with HBV-
related HCC, such as gender, age, fibrotic stage, and HBV-DNA levels [68]. Most
of them in addition to demographic and biochemical parameters include HBV-
DNA as the major prediction variable: the CU (Chinese University)-HCC score,
which was derived from 1005 untreated CHB patients (38% with cirrhosis), uti-
lizes age, albumin, bilirubin, HBV-DNA levels, and presence or absence of cir-
rhosis [69], and the REACH-B score (risk estimation for HCC in CHB), derived
from 3584 non-cirrhotic CHB patients, is based on sex, age, ALT, HBeAg, and
HBV-DNA levels [70]. However, since high genetic barrier NAs were introduced
in the treatment of CHB, the prognostic significance of serum HBV-DNA levels
loses power because most of the treated patients achieve and maintain a complete
virological response. Actually, several studies demonstrated that a stratification
according to fibrotic burden could be more prognostic, since the degree of fibrosis
was associated with HCC development [71], hepatic decompensation [72], and
portal hypertension-related complications [73].
In 2014, Wong et al. refined the CU-HCC score in a training cohort of 1035 sub-
jects, including 390 patients under antiviral treatment, where the clinical definition
of cirrhosis was replaced by a stratification of the population in three groups accord-
ing to the increasing levels of LS (≤8.0 kPa, 8.1–12.0 kPa, and >12.0 kPa). The new
score (LSM-HCC) was superior in predicting the 3- and 5-year risk of HCC devel-
opment, with an AUROC in the validation cohort of 0.89 at 3 years and 0.83 at
5 years. Using a cutoff of 11 points to stratify the population, the HCC rates at
5 years were 0.3% and 7.6% in the low- and high-risk group, respectively [74]. In
same year, Lee et al. demonstrated that a reduction ≥25% in LS values from BL at
complete virological response was associated with favorable outcomes in CHB
patients treated with ETV. Therefore, they developed a modified REACH-B score
(mREACH-B) in which the HBV-DNA level of the original score was substituted
with the LS value stratified into three groups (<8.0 kPa, 8.0–13.0 kPa, and >13.0 kPa)
[75]. Finally, the authors compared all the available predictive scores in a cohort of
1308 patients (848 undergoing antiviral treatment) and found that the AUROC of
mREACH-B at 3 and 5 years in the prediction of HCC development were higher
than those of the other models, both overall and in the subgroup of treated patients
[76]. More recently, the same group developed another LS-based HCC prediction
model, including US features of cirrhosis, age, gender, platelet count, albumin, and
LS ≥ 11 kPa (CAMPAS), in 1511 patients receiving NAs. The CAMPAS model was
validated in an external independent cohort of 252 treated patients and showed a
significantly higher prognostic performance compared to the mREACH-B [77].
Overall, these findings are very promising; however, the modified score using LS
needs to be validated in non-Asian cohorts, to rule out possible bias from confound-
ing factors that can influence LS values in different patients’ populations [68].
Currently, the HCC predictive score developed in Caucasian patients treated with
ETV or TDF, the PAGE-B, does not take into account the cirrhosis or LS values
[16]. Therefore, additional prospective studies are needed to investigate the role of
LS in the prediction of HCC development in Western CHB patients. In addition,
liver rehashing during NA therapy is a multistep process where clearance of necro-
inflammation is the first and early one, whereas fibrosis regression is a later and
slower process that could have a different impact on liver anatomical structure
depending on the extent of vascular alterations. Therefore, future prospective stud-
ies should more accurately analyze the kinetics of LS during NA therapy to identify
not only absolute LS values but also their on-treatment delta variation possibly cor-
relating with different HCC risk.
4.5 Conclusions
In carriers with chronic HBV infection, the noninvasive measure of LS provides a

reliable noninvasive index of liver disease burden that combines both fibrosis and
inflammation. In carriers of HBeAg-negative infection, who do not have active liver
disease, LS values are comparable with those of normal controls and significantly
lower than in CHB patients. Therefore, in this subset of chronic HBsAg carriers,
elevated LS values suggest the presence of liver disease due to factors different from
HBV. In untreated CHB patients, ALT flares (and the extent of necro-inflammation
at histology) are factors that significantly influence LS in addition to fibrosis.
Therefore, LS values should be interpreted with caution in patients with elevated
ALT, especially in those with significant ALT flare (>10 × ULN). TE appears to be
a reliable method to identify CHB patients with advanced fibrosis or cirrhosis.
Interestingly, LS cutoff associated with cirrhosis in CHB is lower than in CHC
patients, possibly because of a different cirrhotic derangement.
In CHB patients responding to antivirals, the LS decline shows a biphasic pattern
that might be explained by the combined kinetics of an earlier and faster decline of
necro-inflammation and a later and slower decline of fibrosis. Lower LS values
achieved during antiviral therapy are associated with a lower risk of HCC develop-
ment, at least in Asian cohorts. Future studies should validate the finding in Western
CHB patients and investigate whether the lack of a significant second-phase long-
term decline of LS would predict a higher residual HCC risk in responders to anti-
viral therapy.
56 B. Coco et al.
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The Role of Transient Elastography
in NAFLD 5
Grazia Pennisi, Antonina Giammanco, and Salvatore Petta
5.1 Fibrosis in NAFLD: The Burden
On the ground of its rising prevalence, nonalcoholic fatty liver disease (NAFLD) is
nowadays the most relevant liver disease worldwide, affecting about 25% of the
general population [1].
Liver fibrosis represents a milestone of the progression toward end-stage liver
disease in NAFLD, and it is currently the strongest predictor of liver-related com-
plications [2–5], including hepatocellular carcinoma (HCC) [6–8], and of all-cause
mortality [2–4, 9–14]. However, natural history studies of patients who underwent
paired liver biopsies did not show a linear rate of fibrosis progression while observ-
ing patients with stable disease, patients with impairment of liver fibrosis, and also
patients with improvement in fibrosis stage [15–17]. Furthermore, a recent meta-
analysis, among patients with fibrosis progression, also discriminated slow versus
rapid progressors [17].
Moreover, liver fibrosis progresses in patients with simple fatty liver and with
nonalcoholic steatohepatitis (NASH) [17–19].
Consistently, stratification of fibrosis at baseline and its changes during follow-
up are required to predict clinical outcomes in NAFLD.
Despite histology holding the “gold standard” diagnostic tool, liver stiffness
measurement (LSM) assessed by FibroScan (vibration controlled transient elastog-
raphy, VCTE, also commonly known as transient elastography, TE) was validated
G. Pennisi · S. Petta (*)

Section of Gastroenterology and Hepatology, PROMISE, University of Palermo,
Palermo, Italy
e-mail: salvatore.petta@unipa.it
A. Giammanco
Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and
Medical Specialities, University of Palermo, Palermo, Italy

https://doi.org/10.1007/978-3-030-74132-7_5
62 G. Pennisi et al.
as accurate to exclude the presence of advanced liver fibrosis in NAFLD [20], and
its changes over time have been also found reliable to noninvasively predict fibrosis
progression during follow-up having histology as standard [15].
5.2 Transient Elastography: The Technique
Transient elastography, developed in 1992, was the first ultrasound-based elastogra-

phy technique [21]. TE measures the velocity of an elastic shear wave via propaga-
tion of ultrasound waves through the liver. Transient elastography is a noninvasive,
simple, highly reproducible method and allows examination of at least 100 times
larger volume of liver tissue compared to a liver sample obtained through liver
biopsy [22], with consequent sampling error less than with liver biopsy [23].
TE requires a one-dimensional probe and an ultrasonic transducer. The probe is
placed between two intercostal spaces, inducing the propagation of an elastic shear
wave from the probe to the liver. The mechanical pulse is transmitted with a low
amplitude (50 Hz). The propagation velocity measured is positively related to the
liver stiffness, within the range of 1.5 to 75 kPa [24].
5.2.1 The Procedure
TE is assessed using FibroScan® equipment (Echosens, Paris, France). The exam is

conducted after a fasting of at least 3 h. The procedure is performed in a supine posi-
tion with the right arm abducted and placed under the patient’s head. The probe was
applied on the skin surface overlying the right liver lobe (Fig. 5.1a, b). After press-
ing the button on the probe, a pulse wave is transmitted across the liver parenchyma.
The velocities of the propagation of two waves in the liver parenchyma are calcu-
lated using the Doppler technique (Fig. 5.1c) [25, 26], and, as it is known from
physical principles, it increases with the stiffness of the liver parenchyma, correlat-
ing with severity of fibrosis (Fig. 5.1d).
A minimum of ten measurements are required to obtain a reliable liver stiffness
measurement. They will be considered valid if the interquartile range (which reflects
the variability of measurements) is <30% of the median LSM [27].
5.2.2 Probes
The probe utilizes pulse-echo ultrasound to follow the shear wave propagation to
measure velocity (m/s) and to provide a liver stiffness measurement [28].
Three different probes can be used to make measurements under various circum-
stances. A standard M probe (3.5 MHz) and XL probe (2.5 MHz) are frequently
used for adults, and an S probe (5.0 MHz) is used for children. Since lower-frequency
probes are suitable to reduce wave attenuation in patients with a high degree of
abdominal adiposity or a long distance between the skin and liver surface, XL probe
5 The Role of Transient Elastography in NAFLD 63
a 25 mm
65 mm b
Skin
3 cm3
c d
Ultrasound echo
Shear
wave
Ultrasound pulse
Fig.5.1 (a) The probe analyzes a little quote of liver tissue overlying the skin surface. (b) After
pressing buttons on the probe, the pulse wave is transmitted across the liver parenchyma. (c) The
ultrasound pulse propagates in the liver and its echo will be recorded and processed. (d) Liver stiff-
ness increases progressively with severity of fibrosis
could be used for overweight patients with a similar diagnostic accuracy [29]. The
AUROC values using FibroScan M and XL probes for diagnosing advanced fibrosis
are 0.88 and 0.85, respectively [30].
5.2.3 The Role of Controlled Attenuation Parameter (CAP)
The amplitude of ultrasound waves decreases more rapidly in a steatotic liver.

This explains why deeper tissues are less clear when one uses ultrasonography
to examine a patient with NAFLD. Controlled attenuation parameter (CAP) by
vibration-controlled transient elastography makes use of this physical phenome-
non to measure the attenuation of ultrasound waves and thereby estimates the
severity of hepatic steatosis. Overall, CAP has moderate accuracy in detecting
fatty liver, but there is considerable overlap of CAP values among steatosis
grades [31].
Because vibration-controlled transient elastography is a point-of-care test, its
role as a monitoring tool during NASH treatment deserves further evaluation.
Similar to ultrasonography, CAP is affected by obesity. Above all, failed exami-
nations are more common in obese patients [32], though this problem is largely
mitigated by the development of the XL probe [33]. Studies from Malaysia and
Japan suggest that the accuracy of CAP for the detection of hepatic steatosis
was also lower in obese patients [34, 35]. Moreover, significant liver fibrosis
may affect ultrasound attenuation and lower the diagnostic performance of CAP
[35]. Although food intake and active hepatitis are well-known causes of false-
positive liver stiffness measurement, these factors do not appear to affect CAP
[36, 37].
5.2.4 Limitations
As expected, TE has some limitations. First of all, some of these are insite of proce-
dure, such as normal measurements’ variability and operator inexperience. However,
TE cannot be used in the presence of significant fat or fluid between the chest wall
and the liver. Failures or unreliable results were found in 5% of patients, particularly
in people with obesity and with narrow intercostal spaces. Furthermore, results
should be interpreted with caution in case of high transaminase levels, sinusoidal
congestion, and extrahepatic cholestasis [38]. Limitations are summarized in
Table 5.1.
5.3 Transient Elastography in NAFLD: The Quote
In 2007, Yoneda et al. [39] first reported the usefulness of TE for estimating the
severity of liver fibrosis in patients with NAFLD. Then, TE became the first Food
and Drug Administration-approved US-based elastography technique in a few years.
As discussed above, in patients with NAFLD, repeated measurements of liver
stiffness could be useful for long-term monitoring and the prediction of liver-related
complications and cardiovascular events [40, 41]. Furthermore, repeated measure-
ments of liver stiffness can reduce false-positive diagnosis of advanced fibrosis [42,
43]. The benefits of TE are its extensive validation, availability, high patient accep-
tance due to non-invasiveness, and good intra- and interobserver reproducibility
(intra-class correlation coefficient (ICC) = 0.98) [44].
Table 5.1 Advantages and limitations of TE in patients with nonalcoholic fatty liver disease
Advantages Limitations
Painless No discriminations of different etiologies
Rapid and low-cost procedure Confounders (obesity, inflammation, ascites, cholestasis,
hepatic congestion)
Lower inter- and intraobserver Narrow intercostal space
variability
Good availability Technical failure (<5% by using both M and XL probes)
Straightforward and rapid training Operator inexperience
of operators
Samples a volume 100 times larger Samples a volume lower than MR-based techniques
than biopsy
5.3.1 Diagnostic Accuracy
Tsochatzis et al. [45], in a meta-analysis of 40 studies based on liver biopsy as a

reference standard, reported a sensitivity and specificity of 0.79 (95% CI 0.74–0.82)
and 0.78 (95% CI 0.72–0.83) for F2 stage and 0.83 (95% CI 0.79–0.86) and 0.89
(95% CI 0.87–0.91) for cirrhosis. Authors concluded that TE performed with a good
sensitivity and specificity profile for cirrhosis although it was not possible to con-
firm the same for the lower degrees of fibrosis.
Wong et al. have performed a large study in 246 patients with confirmed
NAFLD by liver biopsy (128 French and 118 Chinese patients) and have identi-
fied the best LSM cutoff values to discriminate significant fibrosis, severe fibro-
sis, and cirrhosis (respectively 7.0 kPa, 8.7 kPa, and 10.3 kPa), with AUROC of
0.84 for the identification of moderate fibrosis, 0.93 for severe fibrosis, and 0.84
for cirrhosis [46]. In addition, FibroScan has shown a good diagnostic perfor-
mance for both significant and severe fibrosis (AUC = 0.84 and 0.94, respec-
tively) in another meta-analysis [11], and it has been considered the best
performing and predictive test together with FibroMeter (V2G) compared to
blood fibrosis tests, as exhibited in a cross-sectional study of 452 biopsy-proven
NAFLD patients [38].
In 2014, a meta-analysis of 50 studies [47] has evaluated the performance of TE
according to the stage of fibrosis, showing mean AUROC of 0.84, 0.89, and 0.94 for
the diagnosis of significant fibrosis, severe fibrosis, and cirrhosis, respectively. As
predicted, the diagnostic accuracy progressively decreased in the differentiation of
severe fibrosis (stages 3 and 4) and significant fibrosis (stages 2, 3, and 4) from
milder stage of fibrosis. The diagnostic achievement of TE for advanced fibrosis and
cirrhosis in NAFLD was higher than AST/ALT ratio, APRI, FIB-4, BARD and
NAFLD fibrosis scores, and other noninvasive serum markers, with AUROC values
of TE for significant liver fibrosis (stages 2, 3, and 4) being 0.84, 0.93, and 0.95,
respectively.
Kwok et al. [48] performed the first systematic review and meta-analysis of 854
patients studied with M probe. Sensitivity and specificity for the diagnosis of stages
2, 3, and 4 fibrosis were 0.79 and 0.75, 0.85 and 0.85, and 0.92 and 0.92, respec-
tively. In 2017, Xiao et al. [20] performed a meta-analysis of the use of the XL
probe. The meta-analysis included three studies involving 318 patients with NAFLD
and showed that the AUROC for the diagnosis of stages 2, 3, and 4 fibrosis were
0.82, 0.86, and 0.94, respectively.
Jiang et al., in a recent meta-analysis of TE (M probe), based on 11 studies and
1753 patients with NAFLD, showed an AUROC for the diagnosis of stages 2, 3, and
4 fibrosis of 0.85, 0.92, and 0.94, respectively [49]. The authors concluded that TE
is useful for the staging of liver fibrosis in patients with NAFLD, particularly for
those with advanced fibrosis and cirrhosis. Meta-analyses of TE with sensitivity,
specificity, and AUROC for the diagnosis of liver fibrosis are summarized in
Table 5.2.
Table 5.2 Meta-analyses of transient elastography for the diagnosis of liver fibrosis in patients
with nonalcoholic fatty liver disease
Authors Year Studies Fibrosis stage Sensitivity Specificity AUROC
Tsochatzis et al. 2011 40 ≥2 0.74–0.82 0.72–0.83
[45]
≥3 0.78–0.86 0.82–0.89
≥4 0.79–0.86 0.87–0.91
Musso et al. [11] 2011 32 ≥3 0.88–0.99 0.89–0.99 0.90–0.99
Kwok et al. [48] 2014 8 ≥2 0.67–0.94 0.61–0.84 0.79–0.87
≥3 0.65–1.00 0.75–0.97 0.76–0.98
≥4 0.78–1.00 0.82–0.98 0.91–0.99
Xiao et al. [20] 2017 16 ≥2 0.90–0.94 0.42–0.80 0.79–0.86
≥3 0.76–0.88 0.63–0.88 0.83–0.90
≥4 0.78–1.00 0.82–0.90 0.90–0.94
Jiang et al. [49] 2018 11 ≥2 0.60–0.94 0.61–1.00 0.79–0.88
≥3 0.57–1.00 0.76–0.97 0.76–0.99
≥4 0.65–1.00 0.76–0.98 0.87–0.99
5.3.2 The Issue of Rule-In and Rule-Out
Ideally, the diagnostic cutoff values of noninvasive diagnosis should have a high
negative predictive value (NPV) and low negative likelihood ratio (LR−) to rule out
a diagnosis as well as a high positive predictive value (PPV) and high positive likeli-
hood ratio (LR+) to confirm a diagnosis. So, it should be necessary to adopt cutoffs
(low and high) to exclude or to confirm the diagnosis. The main problem of liver
stiffness measurement occurs when values fall in the gray zone and liver biopsy is
still necessary [50, 51]. In a meta-analysis of 40 studies, the LR- was 0.12 at a cutoff
value of 7.9 kPa for the diagnosis of F3 fibrosis and 0.09 at a cutoff value of 10.3 kPa
for the diagnosis of cirrhosis. The LR+ was 8.9 at a cutoff value of 9.6 kPa for the
diagnosis of F3 fibrosis [46].
In another recent study that included 104 patients, considering three different
cutoff values (7.9, 8.7, and 9.6 kPa), TE showed the highest sensitivity values (95%,
90%, and 85% respectively), and the highest NPV (98%, 96.4%, and 95.1% respec-
tively) for the diagnosis of advanced fibrosis, with a high AUROC (0.87; CI 95%
0.78–0.97) [52].
These evidence shed a light on the most relevant diagnostic limit of the proce-
dure. It should be surely used as a noninvasive diagnostic tool in patients with
advanced fibrosis, especially in the presence of cirrhosis, and it could be considered
a reliable rule-out.
Very recently, Newsome et al. [53] have developed and suggested a score to
identify, in a noninvasive manner, patients with NAFLD at risk of progressive
NASH, elevated NAFLD activity score (NAS ≥ 4), and advanced fibrosis (stage 2
or higher [F ≥ 2]): the FibroScan-AST (FAST) score. This tool is based on the com-
bination of liver stiffness measurement (LSM) by vibration-controlled transient
elastography and controlled attenuation parameter (CAP) measured by FibroScan

device with aspartate aminotransferase (AST), alanine aminotransferase (ALT), or
AST/ALT ratio. FAST was tested in a large prospective study on 350 patients, was
subsequently validated in seven cohorts, and seemed able to avoid unnecessary liver
biopsy in subjects unlikely to have significant fibrosis. Furthermore, the FAST score
was configured to have two thresholds, a rule-out (LR− 0·2) and a rule-in (LR+ 5)
cutoff showing a good performance in testing more than 70% patients eligible for
clinical trials or new pharmacotherapies.
5.3.3 Confounding Factors
Although these results demonstrated a very interesting role of FibroScan for the
assessment of liver fibrosis in NAFLD, several factors might influence the perfor-
mance and the reliability of LSM in clinical practice. Indeed, it has been shown in a
cohort of 253 biopsy-proven NAFLD patients that the presence of severe steatosis
could overestimate LSM values, mainly in patients with low stages of fibrosis (F0–
F1 and F0–F2). In these patients, median LSM values were significantly higher in
those with severe steatosis (≥66% at liver biopsy) compared to those without, and
this observation was also confirmed when liver steatosis was defined by ultrasound
instead of histology [54]. In this line, the use of controlled attenuation parameter
(CAP), a parameter associated with steatosis and provided by the same machine
used for LSM, should be taken into account in the interpretation of LSM values. It
has been demonstrated that among patients with F0–F2 fibrosis, mean LSM values
significantly increased according to CAP tertiles, leading to an increase of the rate
of false-positive LSM results for F3–F4 fibrosis according to CAP tertiles [55]. At
the same time, AUROC of LSM for F3–F4 fibrosis was progressively reduced from
lower to higher CAP tertiles, suggesting that steatosis assessed by CAP has a sig-
nificant impact on the diagnostic accuracy and reliability of TE.
Moreover, in a prospective study were analyzed 79 chronic liver disease patients
who performed liver biopsy, FibroScan, ultrasonography, and hepatic steatosis
index (HSI): as previously, it was confirmed the importance of CAP in ascertaining
steatosis, even in the early stages, with reliable results strongly accordant with his-
tological data [56].
More recently, a cross-sectional study assessed the diagnostic accuracy of LSM
by TE for fibrosis and of CAP for steatosis in 450 histologically proven NAFLD
patients [57]. Although steatosis was associated with LSM by univariate analysis,
multivariate analysis demonstrated an independent association between fibrosis
stage and LSM and did not confirm the independent association between steatosis
and LSM. However, it should be considered that fibrosis was evaluable with NASH
CRN scoring system in only 373 patients. Chi-Wang Loong et al. evaluated 215
patients with NAFLD, and they have proven that liver stiffness measurement alone
can reliably exclude significant and advanced fibrosis [58]. The use of FM VCTE in
patients with high liver stiffness might raise the positive predictive value to rule in
F2–F4 and F3–F4.
Body mass index (BMI) represents another factor which decreases the diagnostic
performance of FibroScan, since obesity is very frequent in patients with NAFLD. In
details, TE didn’t result reliable in 5–15% of patients with NAFLD using the stan-
dard probe. A possible way to reduce the impact of obesity on the feasibility and on
the reliability of FibroScan is the use of XL probe. In a multicenter study of 276
patients with chronic liver disease (46% with NAFLD), FibroScan failure was less
frequent using XL probe, and AUROC for F2–F4 fibrosis and cirrhosis were similar.
However, median LSM values were significantly lower in comparison with M
probe, suggesting that lower liver stiffness cutoffs should be necessary in the inter-
pretation of LSM values obtained with XL probe [59]. For this reason, the XL probe
is a useful tool to improve the limitations of FibroScan [60]. A newer version of
VCTE (FibroScan 502 Touch, Echosens™) overcomes some of its prior limitations,
and it was assessed in a cross-sectional study of 992 patients with histological diag-
nosis of NAFLD, using both M+ and XL+ probes [61].
A cross-sectional study on 496 biopsy-diagnosed NAFLD patients analyzed the
chance of a unified interpretation of VCTE by M and XL probe when used accord-
ing to BMI [62]. The AUROC of M and XL probe for the diagnosis of F3–F4 fibro-
sis were similar (0.86 and 0.84, respectively), and in the same patient, LSM by XL
probe resulted lower than that by M probe. Using M probe in nonobese patients and
XL probe in obese patients, they yielded nearly identical median LSM at each fibro-
sis stage and similar diagnostic performance. However, cutoffs used for rule-in and
rule-out F3–F4 fibrosis (10 and 15 Kpa, respectively) were different from those
proposed by the same group in another study, which requires further validation. It
has been recently reported by Petta et al. that LSM by FibroScan is better than
FIB-4 and NFS for diagnosis of F3–F4 fibrosis, but only in nonobese patients and in
subjects with ALT increase [63].
Petta et al. suggested a serial approach consisting in the execution of FibroScan
as second-line exam in patients with FIB-4 or NFS values falling in the gray zone,
which could be better than a single tool strategy also in patients with high ALT and
obesity, although the accuracy in obese patients is poor. Hence, the consecutive
combination of LSM by FibroScan with other noninvasive biomarkers of fibrosis
(i.e., blood tests) could represent an interesting way to overcome some of the limita-
tions of FibroScan in the prediction of fibrosis. A cross-sectional study conducted
on 938 patients with biopsy-proven NAFLD confirmed the diagnostic accuracy for
F3–F4 fibrosis of LSM by VCTE and noninvasive scores (NFS, FIB4, FibroTest,
Hepascore, FibroMeter) and combination in a single score of FibroMeter and LSM
(FibroMeterVCTE) [64]. LSM by TE resulted significantly more accurate than
blood test with an AUROC of 0.840, but, more interestingly, the combination of
FibroMeter with VCTE outperformed LSM and blood tests (AUROC 0.866,
p ≤ 0.005), and the sequential combination of FIB-4 with FibroMeterVCTE or
LSM and then with FibroMeterVCTE provided a diagnostic accuracy of 90% for
advanced fibrosis, decreasing the need for liver biopsy to confirm the diagnosis to
only 20% of cases. These data suggest that these sequential algorithms could be
more accurate than the pragmatic algorithms currently proposed. Similar results
were obtained in 3202 biopsy-proven NAFLD patients who underwent screening
for STELLAR trials (2262 with F3–F4 fibrosis): the sequential use of FIB-4 and
then LSM by VCTE reduced the misclassification rate of F3–F4 fibrosis stage to
20%, although it should be considered that the prevalence of F3–F4 patients was
extremely high [65].
In addition, Kao et al. have recently developed an easy, clinical scoring system
combining FibroScan and aspartate aminotransferase/platelet ratio index (APRI) to
predict significant liver fibrosis in severe obese patients [66]. Furthermore, age and
diabetes represent two other factors potentially limiting the diagnostic accuracy of
FibroScan [67, 68] as well as cholestasis, heart failure, ascites, and post-meal [69].
5.3.4 Liver Stiffness as Predictor of Liver Events
Patients with NAFLD and chronic liver diseases progressing to advanced fibrosis
and cirrhosis may often undergo development of liver-related events (LREs) includ-
ing HCC, hepatic decompensation (variceal bleeding, ascites, hepatic encephalopa-
thy, spontaneous bacterial peritonitis, hepatorenal syndrome), and liver-related
death: in this context, liver stiffness measurement (LSM) using TE has been used as
a surveillance strategy to evaluate the severity of the liver disease and to appraise
consequently the risk of LREs. In a recent study, Kim SU et al. [70] have analyzed
128 chronic hepatitis B (CHB) patients showing advanced (F3) liver fibrosis on LB
with a high viral load: the authors reported that LSM represents a significant predic-
tor of LREs and performs better than liver biopsy alone, especially in chronic hepa-
titis B patients undergoing antiviral therapy. However, another study has evaluated
1772 hepatitis C patients with advanced fibrosis or cirrhosis and treated with
telaprevir-based triple therapy in the context of the telaprevir Early Access Program
HEP3002: the authors reported that although FibroScan exhibited a low prediction
profile of safety and efficacy in HCV patients, it can be used in addition to other
clinical and biochemical data to support the detection of patients who will benefit
from the triple therapy [71].
In a recent multicenter study, 1039 patients with NAFLD and F3–F4 fibrosis,
baseline LSM was independently associated with occurrence of hepatic decompen-
sation (HR 1.03; 95% CI, 1.02–1.04; P < 0.001), HCC (HR, 1.03; 95% CI,
1.00–1.04; P = 0.003), and liver-related death (HR, 1.02; 95% CI, 1.02–1.03;
P = 0.005). In addition, in patients with availability of LSMs during the follow-up
period, change in LSM was independently associated with hepatic decompensation
(HR, 1.56; 95% CI, 1.05–2.51; P = 0.04), HCC (HR, 1.72; 95% CI, 1.01–3.02;
P = 0.04), overall mortality (HR, 1.73; 95% CI, 1.11–2.69; P = 0.01), and liver-
related mortality (HR, 1.96; 95% CI, 1.10–3.38; P = 0.02) [72].
Moreover, subjects with NAFLD are often characterized by insulin resistance
(IR) which correlates with severe hepatocyte inflammation and cardiovascular
diseases. Considering the prevalence of NAFLD and its association with possible
systemic consequences, Hanafy et al. [73] have analyzed 272 patients with
NAFLD and cardio-metabolic risk factors by evaluating some blood parameters
such HOMA-IR, mean platelet volume (MPV), neutrophil-lymphocyte ratio
(NLR), uric acid, ferritin, and lipid profile, and then they correlated these results
to liver stiffness measurement (LSM), controlled attenuation parameter (CAP) by
FibroScan, and carotid intima media thickness (CIMT): significant fibrosis and
cardiovascular risk in NAFLD were independently associated with AST/ALT
ratio, GGT, CIMT, uric acid, VLDL, HOMA-IR, ferritin, CAP, and LSM. By this
method, a new noninvasive tool was identified to assess the severity of NAFLD
and cardiovascular risk.
5.4 Conclusions
Due to its noninvasiveness, good accuracy, and reproducibility, TE is strongly rec-

ommended in patients with NAFLD. In this setting, TE can be used to assess fibro-
sis at baseline and to identify patients at risk of liver-related events during follow-up.
When looking at the general population, a suggested strategy could be screening
at-risk patients by easy noninvasive scores like FIB-4 and then using TE for further
stratifying the risk of fibrosis severity in patients at medium-high risk by FIB-4.
Evaluation of CAP can help to detect steatosis and to parse LSM results in the
presence of higher hepatic fat.
However, TE may not replace hepatic biopsy that is still considered the “gold
standard” to diagnose NAFLD and to stage fibrosis.
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Elastography in Liver-Transplanted
Patients 6
Cristina Rigamonti, Carla De Benedittis,
and Maria Francesca Donato
Liver transplantation (LT) is one of the most complex and fascinating surgical pro-
cedures: it represents the best curative treatment option for patients with decompen-
sated end-stage liver disease, hepatocellular carcinoma and acute liver failure. The
success of LT over the last decades has meant that there is a growing cohort of LT
recipients throughout the world at risk of complications due to graft rejection, recur-
rence of the underlying liver disease and a long-life use of immunosuppressive
drugs. The management of adult recipients of LT aims at maintaining graft and
patient health and best preventing the occurrence of complications. Causes of graft
damage after LT include immune-mediated disease (rejection and de novo autoim-
mune hepatitis), recurrent liver disease (viral, primary biliary cholangitis, autoim-
mune hepatitis, primary sclerosing cholangitis and others), drug toxicity (including
immunosuppressive drugs), alcohol and other toxins, de novo infection (including
de novo HBV and HCV), space-occupying lesion (recurrent cancer) and de novo or
recurrent non-alcoholic fatty liver disease (NAFLD) and biliary and vascular dis-
ease [1].
Liver biopsy (LB) remains the reference standard for assessing graft damage.
However, non-invasive tests for assessing liver fibrosis have gained popularity as an
adjunct and substitution to LB in the longitudinal surveillance of LT patients.
Among them, vibration-controlled transient elastography (VCTE, FibroScan®),
which measures liver stiffness (LS), has been the most validated method also in the
LT setting.
C. Rigamonti (*) · C. De Benedittis

Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy
e-mail: cristina.rigamonti@uniupo.it
M. F. Donato
C.R.C. “A.M. & A. Migliavacca” Center for Liver Disease and Division of Gastroenterology
and Hepatology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico and
University of Milan, Milan, Italy

https://doi.org/10.1007/978-3-030-74132-7_6
76 C. Rigamonti et al.
This chapter will discuss VCTE performance in assessing graft damage and its
applicability in the management of recipients after liver transplantation.
6.1 Acute Rejection
Acute cellular rejection (ACR) is a common complication of LT, characterized by a

lymphocyte-mediated immune reaction against the graft with an inflammatory
response directed to endothelial and bile epithelial cells.
The diagnosis of acute cellular rejection is based on liver histology. Nevertheless,
the presence of ACR may be suspected by increased TE values during post-transplant
follow-up. In fact, the inflammatory process that takes place in ACR may increase
liver stiffness. A pilot study on 27 LT recipients has shown that patients with moder-
ate/severe ACR had higher liver stiffness measurement (LSM) than patients with
mild ACR, thus suggesting an association between liver stiffness and severity of
rejection [2]. Similar results were achieved by Nacif et al., who observed a signifi-
cant correlation between the presence of ACR and liver stiffness assessed by VCTE
in 25 LT recipients [3].
In the study by Crespo et al. a longitudinal evaluation by VCTE demonstrated an
improvement of LSM with respect to baseline measurements in 66% of patients
with moderate/severe ACR after a successful treatment of rejection, while a pro-
gressive increase of LSM during follow-up was observed in one patient who devel-
oped an histologically proven chronic rejection [2]. Similarly, in a study on 27
recipients in the early post-LT period, liver stiffness changes predicted the develop-
ment and resolution of ACR in three patients, who presented a sharp rise in LSM
followed by a decrease after successful immunosuppression [4].
These studies, even if limited by a small sample size, highlight the ability of
VCTE to select patients to undergo LB for suspicion of rejection, since it is clear
that LSM by itself cannot replace LB for the diagnosis of ACR.
6.2 Recurrent Hepatitis C
Liver cirrhosis and hepatocellular carcinoma due to chronic hepatitis C virus (HCV)
infection have been the leading causes for LT worldwide until 2014, and recurrent
HCV infection post-LT has been a major challenge to successful LT, because of a
rapid progression to hepatic fibrosis, cirrhosis, graft failure and shortened patient
survival in the majority of HCV-re-infected LT recipients [5–7]. The first attempts
to modify the course of recurrent HCV with standard interferon (IFN)-based thera-
pies and subsequently with pegylated IFN and ribavirin yielded unsatisfactory
results in terms of successful HCV eradication after LT [8, 9]. The advent of anti-
HCV IFN-free all-oral direct antiviral agents (DAAs)-based regimens with a very
favourable safety profile and high rates of sustained virological response (SVR) of
over 95% has provided an unprecedented opportunity to cure HCV before and after
LT [10, 11]. After the introduction of DAAs in 2014, a dramatic decline was
6 Elastography in Liver-Transplanted Patients 77
observed in the number of liver transplants performed in patients with end-stage

liver disease due to HCV [12]. At the same time, the survival of LT recipients with
recurrent hepatitis C dramatically improved [12]. Historically, the management of
LT patients with recurrent hepatitis C has relied on repeated protocol liver biopsies
for assessing liver fibrosis progression and graft disease severity. As non-invasive
tests for diagnosing liver fibrosis have been introduced as a complementary tool in
the management of chronic liver diseases in the non-transplant setting [13], they
have then been validated in the setting of recurrent hepatitis C. Their diagnostic
performance has been validated with protocol LB performed during post-LT follow-
up. The first study assessing VCTE performance in liver-transplanted patients with
recurrent hepatitis C showed by cross-sectional analysis a good correlation of liver
stiffness with both histological scores of liver fibrosis and hepatic vein pressure
gradient (HVPG) (Table 6.1) [14]. In LT recipients with recurrent hepatitis C,
Rigamonti et al. replicated these results by showing a strong correlation between
VCTE results and histological scores of liver fibrosis, together with a high rate of
test applicability (95%) (i.e. the proportion of patients with a successful examina-
tion) [15].
The diagnostic performance of VCTE in diagnosing the stage of fibrosis was
good for significant fibrosis (stage ≥2 by Metavir, F ≥ 2), excellent for advanced
fibrosis (stage ≥3 by Metavir, F ≥ 3) and definite cirrhosis (stage 4 by Metavir, F4)
with VCTE having a greater negative than positive predictive power for the diagno-
sis of cirrhosis (Table 6.1) [14, 15]. Also, in patients who received living donor liver
transplantation, VCTE performance resulted excellent in diagnosing liver fibrosis
(Table 6.1) [16]. In the study by Rigamonti et al. [15], necroinflammatory activity
not only positively correlated with VCTE results, but also it turned out to be an
independent predictor of VCTE values. Perisinusoidal fibrosis, which is a determi-
nant of portal hypertension in LT patients [17], emerged as an influencer of VCTE
values at univariate analysis; steatosis did not appear to influence LS [15]. The
importance of histological activity as an influencer of LS has emerged in previous
studies in the non-transplant setting and might be due to tissue oedema accompany-
ing liver cell necrosis and swelling of liver cells as occurring in the course of the
necroinflammatory process [18, 19].
Besides being correlated with liver fibrosis in cross-sectional studies, LSM has
proven to be useful to assess histological progression after transplantation, as shown
in a prospective longitudinal study in 40 liver graft recipients with recurrent hepati-
tis C, who underwent sequential paired LB and VCTE examinations (Table 6.1)
[15]. LS changes were dynamically correlated not only with the changes in the liver
fibrosis stage but also with changes in necroinflammatory features or the occurrence
of such other concomitant complications as cellular rejection, intra- or extra-hepatic
cholestasis and de novo autoimmune hepatitis, therefore being predictive of an addi-
tional cause of graft damage [15].
With this background, on evaluating 49 untreated recipients with recurrent hepa-
titis C with yearly repeated LSM coupled with a baseline assessment and a LB after
2 years, it was demonstrated that VCTE examinations possibly enable to prolong
the time interval between protocol liver biopsies for recipients with mild/stable
78
Table 6.1 VCTE performance in LT recipients with recurrent hepatitis C

Cut-off Sensitivity, Specificity,
Author, year End-point Patient # kPa % % LR− LR+ AUROC
Carrion (2006) F≥2 124 8.7 88 81 0.15 4.6 0.90
(169 LB)
F4 124 12.5 100 87 0 7.7 0.98
(169 LB)
HVPG ≥6 mmHg 124 8.7 90 81 0.12 4.7 0.93
(129
HVPG)
Rigamonti F≥2 90 7.9 81 76 0.25 3.4 0.85
(2008) F≥3 90 11.9 82 96 0.19 19.0 0.90
F4 90 12.0 93 93 0.07 14.0 0.93
≥1 point Ishak’s score 40 ≥30% of TE baseline value 86 92 0.15 11.1 –
increase increase
Harada (2008) F≥2 56 9.9 90 91 0.10 10.0 0.92
F4 56 26.5 100 98 0 50.0 0.98
VCTE vibration-controlled transient elastography, LB liver biopsy, HVPG hepatic venous pressure gradient, F fibrosis stage by Metavir score
C. Rigamonti et al.
recurrent hepatitis C, from yearly to every other year or even longer, thus sparing
more than one third of protocol LB [20]. Furthermore, two prospective longitudinal
studies demonstrated that early repeated VCTE examinations in the first year fol-
lowing LT were able to discriminate between patients with rapidly progressive and
those with slowly progressive recurrent hepatitis C [21, 22]. The results from a
longitudinal mixed model for repeated measurements (VCTE examinations per-
formed at 3, 6, 9 and 12 months after LT) showed that the slope of LS variations was
significantly greater in “rapid” than in “slow” fibrosers: respectively, 0.42 and
0.05 kPa/month in rapid and slow fibrosers as of the study by Carrion et al. [21] and
0.40 and 0.05 kPa/month in rapid and slow fibrosers as of the study by Rigamonti
et al. [22]. Interestingly, the ≥7.9 kPa TE cut-off value at month 6 after LT could
identify 67% of rapid fibrosers [21, 22].
In another study that evaluated 173 patients who had mild recurrent hepatitis C,
as defined by absent or minimal fibrosis at LB or LSM <8.7 kPa 1 year after LT, and
were followed up for 80 months, the cumulative risk of cirrhosis was 13% and 30%
at 5 and 10 years after LT, respectively [23]. Early changes in LSM over time
resulted very helpful to identify LT recipients at risk of cirrhosis: the slope of liver
stiffness progression throughout the first 2 years after LT was significantly steeper
in patients who developed cirrhosis (0.331 kPa/month) compared to patients who
did not develop cirrhosis during follow-up (0.091 kPa/month, P = 0.038).
Interestingly, none of the patients followed up for 18 months after LT with LS
<7.8 kPa progressed to liver cirrhosis [23].
As previously stated, a successful viral eradication and, by consequence, an
increased survival [12] are nowadays achievable following the administration of
safe and highly effective DAAs in more than 95% of graft recipients with recurrent
hepatitis C; however, whether HCV eradication in such transplanted population also
determines such crucial clinical outcomes as fibrosis and/or cirrhosis regression
remains to be demonstrated. In addition, HCV LT recipients may still need hepatic
fibrosis surveillance despite HCV eradication with DAAs, since such non-viral
comorbidities as non-alcoholic fatty liver, de novo autoimmune hepatitis, allograft
rejection or other injuries may affect the liver graft.
In the non-transplant setting, several studies have shown that VCTE values
decrease after antiviral treatment in patients with chronic hepatitis C. In the pre-
DAAs era, VCTE dynamics were described in patients treated with pegylated IFN
plus ribavirin [24, 25]. More recently, some papers have shown that approximately
half of the cirrhotics who had achieved SVR after DAAs had a significant LS
decrease (>30% from baseline) at week 24 of follow-up [26–28]. In the study by
Mandorfer et al. [26], the relative change in LSM was a predictor of a HVPG
decrease ≥10% among patients with a clinically significant baseline portal hyper-
tension. However, the meaning of VCTE decrease in terms of improvement of
inflammatory activity, fibrosis regression and portal hypertension improvement,
which might be mainly related not only to regression of septal fibrosis/cirrhosis but
also to perisinusoidal fibrosis remodelling, has not been fully elucidated.
As showed in a retrospective study conducted on 30 liver-transplanted HCV
patients, who had undergone both LSM and LB before and post-DAAs treatment,
LS value decreased for ≥30% with respect to baseline in 14 patients (47%),

increased in 4 (13%) and remained stable in 12 (40%). SVR induced significant
improvement in perisinusoidal fibrosis for more than 50% of the treated recipients,
and this improvement was detected from the significant LS decrease following
DAAs [29].
In a longitudinal study, 46 LT recipients with recurrent hepatitis C and liver stiff-
ness ≥8.8 kPa before DAA treatment underwent VCTE examination 12 and
18 months after achieving SVR [30]. Over an 18-month follow-up period, 80%
showed improvement in LS (defined as a LS reduction compatible with a change in
at least one Metavir stage) and 20% did not [30]; however, liver biopsies were not
performed in this study; therefore, no conclusions could be drawn regarding the
meaning of LS decrease after SVR (i.e. regression of fibrosis or necroinflammatory
activity).
Mauro et al. [31] investigated 112 hepatitis C virus-infected LT recipients who
achieved SVR between 2001 and 2015. A LB was performed before treatment and
12 months following SVR: 67% of the cohort presented fibrosis regression (i.e. a
decrease of ≥1 stage in the Metavir score at follow-up LB) and 31% stabilization,
and only 2% saw their stage worsened. In 84 patients, TE examination was also
performed concomitantly with LB: 67% of patients showed a significant LS decrease
(defined as ≥30% decrease compared to pre-treatment evaluation). A decrease of
50% from baseline LS obtained a positive predictive value of 78% for fibrosis
regression [31]. In the 34 patients with cirrhosis, LS decreased more in those
patients with fibrosis regression. Parenthetically, post-treatment LS <10 kPa was
observed in some patients who remained with advanced fibrosis [31]. This study
emphasized the concept that the higher the liver stiffness before DAA treatment (i.e.
the more advanced the disease before treatment), the lower the probability of fibro-
sis regression after SVR.
Even if it is not fully clear yet how structural, inflammatory and haemodynamic
processes affect liver stiffness and which of such processes is mostly and earliest
affected by HCV eradication, it seems clear that LS decrease after antiviral treat-
ment is advantageous, as it carries a general meaning of liver improvement, what-
ever it is, that may in turn translate into better prognosis.
6.3 “Non-viral” Graft Disease After Transplantation
Liver stiffness is not disease-specific and simply reflects an ongoing intra-hepatic

process, which can be related to several conditions—other than fibrosis—and pro-
duces itself an increase in liver stiffness. In the non-transplant setting, VCTE was
validated in a variety of liver disease [32].
There is limited data regarding the clinical application of VCTE in patients trans-
planted for end-stage liver diseases other than hepatitis C. In these patients, histo-
logical abnormalities of the graft are commonly present in protocol liver biopsies
even in the absence of abnormal liver function tests [33]. In a prospective study
which investigated, by concurrent VCTE and protocol or on-demand LB examina-
tions, 65 liver graft recipients transplanted for non-HCV-related end-stage liver dis-
ease, LS was an accurate and independent predictor of graft damage, unrelated of
the aetiology [34]. This is not an unexpected finding since liver stiffness measured
by VCTE was previously shown to correlate not only with liver fibrosis but also
with necroinflammatory activity, cholestasis and steatosis [19, 35–37].
In 28 patients (43% of the overall series), the liver graft was impaired by multiple
aetiologic factors at both protocol (n = 19) and on-demand LB (n = 9) [34]. At ROC
curve analysis, two different VCTE cut-offs were identified able to correctly clas-
sify patients regarding the presence or absence of graft damage [34]. A higher than
7.4 kPa VCTE cut-off was found in 56% with graft damage, but in none of the 37
patients without liver graft damage, and it provided a clinical approach to confirm
the presence of liver graft damage [34]. By contrast, none of the patients with VCTE
results lower than 5.4 kPa had histological features of graft damage, providing the
best approach to exclude graft damage [34]. In the “diagnostic grey area” of VCTE
results spanning between 5.4 and 7.4 kPa, VCTE was not able to help in the diagno-
sis of graft damage [34]. However, the diagnostic performance of VCTE may be
slightly further improved by taking into the account serum levels of liver function
tests (transaminases and gamma-glutamyl transpeptidase). Indeed, if liver function
tests were increased ≥2 upper limit of normal (ULN), 50% of patients would show
graft damage, calling for a liver biopsy to confirm and define the graft disease in this
subgroup [34]. Actually, VCTE was able to detect mild graft damage, thus support-
ing the use of VCTE as a tool to guide the decision-making process for histological
evaluation of non-hepatitis C liver-transplanted patients, including patients with
normal liver function tests.
The role of longitudinal LS examination in monitoring LT patients, detecting the
presence of graft damage and selecting those requiring liver biopsy, has been
recently explored in a multicentre study which involved 162 patients (37% trans-
planted for HCV), investigated with at least three longitudinal LSMs, each at a
maximum 6-month interval [38]. In 35 patients (among them 28 with HCV), LS
increased over time (defined as a 20% LS change in three or more measurements
performed at least 3 months apart); in two patients with normal liver function tests,
the LS increase during follow-up suggested a liver graft injury, and a liver biopsy
showed severe fibrosis, and in one patient, the LSM increase reflected the occur-
rence of severe or chronic rejection, which was diagnosed at histology [38].
The use of VCTE as a guide for the selection of patients in need of histological
assessment of the graft improves the management of LT recipients: it increases the
early recognition of clinically unsuspected liver graft damage, which needs to be
further assessed by LB. In fact, the detection of histological abnormalities in the
graft may have an impact on the clinical management of the patients. VCTE detects
the presence of graft damage early, ultimately being more reliable than blood tests
in the LT setting.
6.4 Non-alcoholic Fatty Liver Disease (NAFLD)
Non-alcoholic fatty liver disease (NAFLD) is nowadays a leading cause of chronic

liver disease: it has an estimated worldwide prevalence of about 25%, which is even
higher in Central Europe (32%) [39]. NAFLD is defined by the presence at liver
histology of macrovesicular steatosis in ≥5% hepatocytes, in the absence of a sec-
ondary cause, such as alcohol or drugs. It can range across a wide spectrum of dis-
eases, from non-alcoholic fatty liver (NAFL) to non-alcoholic steatohepatitis
(NASH), fibrosis and cirrhosis [40]. NAFLD and NASH-related end-stage cirrhosis
are increasingly recognized as an indication for LT, mainly in industrialized coun-
tries. Although the gold standard for the diagnosis of NAFLD and NASH is liver
biopsy [41], several studies have investigated the potential role of non-invasive
methods in predicting liver fibrosis in patients with NAFLD.
In the non-transplant setting, VCTE is validated and widely used for assessing
the presence of fibrosis in NAFLD patients: a meta-analysis has shown that its oper-
ative characteristics are excellent for diagnosing advanced fibrosis (85% sensitivity,
82% specificity) and cirrhosis (92% sensitivity, 92% specificity) and fair for signifi-
cant fibrosis (79% sensitivity, 75% specificity) [42].
More recently, a new parameter called controlled attenuation parameter (CAP)
has been introduced for hepatic steatosis estimation [43]. CAP can be measured
concurrently with liver stiffness using the same instrument, i.e. FibroScan® (VCTE),
and allows the non-invasive measurement of liver fat content, based on the principle
that the attenuation of ultrasound signals is greater in fat than water [44]. CAP pro-
vides an immediate and standardized non-invasive measurement of hepatic steato-
sis, as shown in a meta-analysis which included data from 2735 patients [45] and in
a large study on 5323 adult patients with suspected chronic liver disease [46].
Despite good sensitivity and specificity for detecting hepatic steatosis as compared
to liver biopsy, a meta-analysis demonstrated that CAP was not an excellent test for
the detection of steatosis severity in chronic liver disease due to the low ability of
CAP to exclude the presence of steatosis in the presence of a negative test [47].
In the transplant setting, the concomitant measurement of LS and CAP is possi-
bly applicable to the assessment of hepatic steatosis and fibrosis in a donor graft and
for evaluating recurrent or de novo NAFLD [48]. With the aim of optimal graft
selection, Mancia et al. [49] performed a pilot study on 23 donors with brain death,
assessing the performance of VCTE and CAP compared to liver biopsy (as the ref-
erence standard), and found that the combination of CAP and LS could successfully
quantify steatosis and fibrosis in the preoperative selection of liver grafts from
brain-dead subjects. In the study by Hong and colleagues [50], 55 potential living
donors were evaluated by CAP and liver biopsy, with CAP showing an AUROC of
78% for detecting mild steatosis and 88% for moderate steatosis.
In 2018, Yen et al. [51] compared CAP to intraoperative LB for detecting steato-
sis in 54 living donors: a cut-off value of 257 dB/m achieved a 100% sensitivity for
hepatic steatosis, though only 58% of patients with CAP >257 dB/m had biopsy-
proven steatosis.
De novo NAFLD/NASH after LT is associated with metabolic syndrome, which

seems to have a higher incidence among LT patients than in the general population.
This can be partially explained by the use of immunosuppressive drugs, as both
corticosteroids and calcineurin inhibitors promote arterial hypertension, hyperlipi-
daemia, diabetes and weight gain. Necroinflammation related to NASH might influ-
ence graft survival because of the development of fibrosis and cirrhosis; thus, it is
important to make a prompt diagnosis of NASH in the LT setting, as well as manag-
ing risk factors for metabolic syndrome [52, 53].
LT recipients are at risk of developing hepatic graft steatosis, recurrence of
NASH after LT or de novo NAFLD occurrence [54].
Non-invasive steatosis monitoring in this setting has not been widely studied yet.
The vast majority of studies, in fact, are based on liver histology alone. One possible
limitation is that VCTE accuracy is impaired by obesity, which is obviously very
common among this type of patients.
In 2015, Karlas and colleagues [55] prospectively evaluated 204 patients by
ultrasonography and VCTE with CAP measurement and confirmed a high preva-
lence of graft steatosis, being 36% at US evaluation and rising to 44% when consid-
ering CAP measurement. They also found a high rate of graft fibrosis (31%, defined
by LS >7.9 kPa) and cirrhosis (13%, defined by LS >12 kPa); the higher the CAP,
the worse the fibrosis stage. Interestingly, these authors [55] found that the graft
steatosis was associated with neither immunosuppressive treatment regimen nor the
post-transplant interval, while it was significantly associated with BMI, diabetes
mellitus and alcoholic aetiology of cirrhosis.
The high prevalence of post-LT steatosis has also been demonstrated in the
study by Chayanupatkul et al. [56] covering 150 post-LT subjects, who underwent
CAP measurement: a 70% and 40% prevalence of any steatosis (CAP ≥222 dB/m)
and severe steatosis (CAP ≥290 dB/m) were demonstrated, respectively. Bhati
et al. [57] carried out a long-term follow-up of 90 patients liver-transplanted for
cirrhosis due to confirmed NASH or cryptogenic cirrhosis suspected to be NASH:
56 patients underwent VCTE with CAP measurement, and 34 had liver biopsy.
Post-transplant NAFLD recurrence was 88% based on LB and 87% based on CAP
(87.5%); similarly, the prevalence of advanced fibrosis was 21% in the patients
evaluated histologically and 27% in those tested by VCTE [57]. In a recent paper
evaluating 99 liver transplant recipients [58], a CAP cut-off value of 270 dB/m
showed an AUROC of 0.88 (95% CI, 0.78–0.93) for detecting any hepatic steato-
sis; however, CAP was less accurate in differentiating grades of steatosis having
overlapping cut-off values.
Due to the high prevalence of NAFLD after LT, the availability of a user-friendly,
reliable and non-invasive technique for steatosis and fibrosis assessment would be
greatly relevant. However, more data is necessary for assessing the diagnostic per-
formance of CAP in the LT setting and incorporating it into a definite diagnostic
workup of LT recipients in order to identify those with suspected NAFLD for closer
follow-up.
6.5 Elastography Outcome After Liver Transplantation
Since the stage of hepatic fibrosis significantly influences outcome, the assessment
of liver fibrosis is a cornerstone of the management of liver diseases and a key step
to the estimation of prognosis. In the non-transplant setting, non-invasive methods,
including vibration-controlled transient elastography, can ably predict patients’ sur-
vival with higher accuracy than LB staging in large cohorts of patients with chronic
hepatitis C [58]. Equally, the prognostic value of VCTE has been shown in patients
with NAFLD. In an observational cohort study of 2245 NAFLD patients followed
up for a median time of 27 months, baseline LS emerged as an independent predic-
tor of overall survival; also, the occurrence of cardiovascular events and liver com-
plications could be predicted by high LS [59].
In the LT setting, some studies have investigated the ability of liver stiffness to
predict clinical outcomes, including graft and patient survival.
Liver stiffness value at 1 year after LT has been shown to be predictive of clinical
decompensation and graft loss in 144 HCV-infected LT recipients [60]. The pres-
ence of LS ≥8.7 kPa 1 year after LT was significantly associated with all-cause-
related graft loss. Indeed, the 8.7 kPa cut-off value stratified patients in two different
categories of risk of clinical decompensation, graft loss and death: the cumulative
probabilities of clinical decompensation, graft loss and death 5 years after LT were
8%, 10% and 8% for patients with LS <8.7 kPa versus 47%, 37% and 36% for
patients with LSM ≥8.7 kPa, respectively (log-rank <0.001) [60]. In addition, LS at
1 year after LT was independently associated with graft loss and patient survival at
multivariate analysis [60].
In 173 patients with mild recurrent hepatitis C (as defined by absent or minimal
fibrosis at LB or LS <8.7 kPa 1 year after LT), after a median follow-up of 92 months,
cumulative HCV-related graft survival rates at 5 and 10 years after LT were respec-
tively 97% and 90% versus 64% and 51% in 200 patients with severe hepatitis C
recurrence (P < 0.001), this suggesting that a LS <8.7 kPa 1 year after LT might be
predictive of better graft survival over time [23].
Liver stiffness measured at 3 months after LT in 137 liver-transplanted patients
with different aetiologies of liver disease emerged as an independent risk factor of
reduced survival after LT (OR = 1.080, 95% CI 1.001–1.166, p = 0.047), along with
platelets (OR = 0.992, 95% CI 0.986–0.999, p = 0.020) and metabolic syndrome
(OR = 0.250, 95% CI 0.070–0.895, p = 0.033) [61].
In the multicentre study by Rinaldi et al. [38] on 162 patients investigated with
at least three longitudinal VCTE examinations, a stable LS over time had a very
high negative predictive value for both clinical events (including liver decompensa-
tion) and death.
Overall, these studies support the concept that the non-invasive assessment by
vibration-controlled transient elastography may help to identify recipients at risk of
poor outcome: the higher the liver stiffness during first year after LT, the poorer the
clinical outcome over time. In this setting, clinicians can use VCTE as a comple-
mentary tool for differentiating the intensity of follow-up in the clinical practice,
each patient’s clinical history remaining also crucial.
6.6 Spleen Stiffness and Liver Transplant
The measurement of spleen stiffness is a further possible application of elastogra-

phy that might be useful to assess portal hypertension dynamics after LT.
With this regard, Chin et al. [62] evaluated spleen stiffness at 2–8 weeks after
LT: spleen stiffness significantly decreased comparing pre- and post-LT, being
75.0 kPa (63.9–75.0) vs. 28.4 kPa (22.0–37.5) (P < 0.0001). In 14 patients stud-
ied at all time points, the stiffness of the spleen progressively reduced from a
median of 75.0 (62.0–75.0) kPa before LT to 41.9 (27.0–47.4) kPa at 2 weeks
after transplant and 32.9 (29.1–38.0) kPa in the subsequent weeks (4–8 weeks
after LT) (P < 0.0001) [62]. Similar encouraging results were also found by
Bayramov et al. [63], who measured spleen stiffness before LT and at 1, 3 and
6 months after LT and demonstrated a significant decrease of spleen stiffness
over time.
Although it needs further validation in larger studies, all this data is encouraging:
in the near future, spleen stiffness measurement might become the predictor of por-
tal hypertension changes or resolution after LT.
In conclusion, VTCE is a reliable tool for detecting liver graft damage, whatever
the aetiology, and its introduction in the clinical management of LT recipients may
ultimately provide added clinical benefits in terms of prediction of liver fibrosis,
sparing of unnecessary liver biopsies and early detection of graft damage with
selection of patients in need of prompt histological evaluation.
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Elastography in Autoimmune Liver
Diseases 7
Laura Cristoferi, Marco Carbone, and Pietro Invernizzi
7.1 Introduction
Surrogate markers of liver fibrosis are increasingly replacing liver biopsy (LB) in
the management of the most prevalent chronic liver diseases including viral hepati-
tis, alcohol-related liver diseases and non-alcoholic fatty liver diseases. In autoim-
mune liver diseases (AILDs), however, the validity of non-invasive tests (NITs) of
fibrosis has not been fully established and their use is, therefore, limited. The main
reason for this is the low prevalence of AILDs, mostly managed in referral centres,
and the high heterogeneity in diagnostic delay, in therapeutic management, with the
lack of curative treatment and in disease course which create a major hurdle for
biomarker discovery.
To date, vibration-controlled transient elastography (VCTE) by FibroScan®
(Echosens, Paris, France) has been the most widely used physical method of fibrosis
assessment and demonstrated to have good accuracy in discriminating patient with
advanced fibrosis and cirrhosis in AILDs [1–4].
L. Cristoferi (*)
Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of
Medicine and Surgery, University of Milano-Bicocca, Monza, MB, Italy
European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo
Hospital, Monza, Italy
Bicocca Bioinformatics Biostatistics and Bioimaging Centre - B4, School of Medicine and
Surgery, University of Milano-Bicocca, Monza, Italy
e-mail: l.cristoferi@campus.unimib.it
M. Carbone · P. Invernizzi
Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of
Medicine and Surgery, University of Milano-Bicocca, Monza, MB, Italy
European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo
Hospital, Monza, Italy

https://doi.org/10.1007/978-3-030-74132-7_7
92 L. Cristoferi et al.
VCTE is rapid, non-invasive and reproducible and is performed at the bedside by

a provider, and it acquires information from a much larger portion of the tissue
compared with LB significantly reducing the risk of sampling error. These charac-
teristics make it one of the best candidates for fibrosis staging in AILDs especially
because of their patchy distribution in the liver that could bias staging and grading
with LB that is currently the gold standard for fibrosis staging in AILDs.
In this chapter, we review the evidence on the use of VCTE in AILDs focusing
on strengths and limitations.
7.2 Primary Biliary Cholangitis
Primary biliary cholangitis (PBC) is an autoimmune liver disease characterised by

destructive cholangitis affecting the small intrahepatic bile ducts, leading to chronic
cholestasis and progressive fibrosis. Many patients eventually develop end-stage
liver disease with attendant need for liver transplantation [5].
The introduction of ursodeoxycholic acid (UDCA) has dramatically changed the
pattern and course of the disease. In fact, the response to UDCA is a major predictor
of long-term outcome. The two most important parameters in evaluating response to
UDCA are alkaline phosphatase (ALP) and serum bilirubin which have been
included in several (biochemical) criteria of response to UDCA [6].
Along with treatment response based on the liver biochemistry, fibrosis stage has
itself a prognostic value in PBC. In fact, advanced histologic stage is an independent
predictive factor for transplant-free survival, conferring a 1.5-fold increased risk for
liver transplantation or death [7, 8]. Recently, the GLOBAL PBC study group and
the UK-PBC study group demonstrated the histological assessment of fibrosis
grants’ prognostic value beyond biochemical treatment response at 1 year. This
highlighted the need to incorporate liver fibrosis stage to individual risk stratifica-
tion at diagnosis in PBC patients [9, 10]. The accurate, early identification of
patients’ fibrotic stage allows to optimise the patients’ clinical pathway; e.g. patients
with no clinically relevant fibrosis at lower risk of complication of end-stage liver
disease if adequately treated can be de-escalated in the intensity of care, e.g. dis-
charged to primary care; on the other hand, the early identification of patients with
clinically relevant fibrosis at baseline will enable to enhance their management
through earlier (second-line) treatment escalation and hepatocellular carcinoma
(HCC) surveillance [11].
Percutaneous LB is currently the reference standard for liver fibrosis staging;
however, due to its invasiveness and potential complications, it is not recom-
mended by international PBC guidelines for fibrosis staging at diagnosis [6, 12,
13]. Moreover, the patchy distribution of the disease through the liver and a sig-
nificant rate of intra- and inter-observer agreement may reduce LB diagnostic
accuracy [14].
To date, several reports have tested the usefulness of serum biomarkers to assess
liver fibrosis (i.e. serum levels of hyaluronic acid, procollagen III aminoterminal
propeptide, collagen IV and FibroTest®). However, none of them demonstrated the
7 Elastography in Autoimmune Liver Diseases 93
ability to differentiate between early and advanced fibrosis in PBC with acceptable
grade of specificity and sensitivity [15, 16]. Along with these biomarkers, the most
clinical widespread surrogate markers of fibrosis, such as platelet count, albumin
and bilirubin, prevent discrimination of fibrosis in non-advanced stages.
Non-invasive evaluation of liver fibrosis with liver stiffness measurements (LSM)
by VCTE is considered the best surrogate marker for the detection of severe fibrosis
or cirrhosis in patients with PBC, and there is an increasing interesting understand-
ing of clinically relevant cut-off values. LSM by VCTE is currently recommended
by European guidelines for disease staging at diagnosis and follow-up [6].
This recommendation is supported by a French study in PBC by Corpechot et al.
(N = 103) in which VCTE was found to be of high performance in the diagnosis of
severe liver fibrosis (≥F3 according to Metavir staging system) or cirrhosis (F4)
with sensitivity and specificity >90%. However, on the other hand, it showed rather
poor sensitivity (despite high positive predictive value (PPV) and specificity) for the
detection of mild or significant fibrosis (≥F1 and ≥F2) with only 45% of patients
with F2 at LB correctly classified and 32% and 23% under- and over-staged, respec-
tively [4]. The optimal stiffness thresholds for the diagnosis of fibrosis stage ≥F1,
≥F2, ≥F3 and =F4 were 7.1, 8.8, 10.7 and 16.9 kPa. In addition, aiming at evaluat-
ing the prognostic role of VCTE, they retrospectively tested LSM progression over
5 years of follow-up analysing a monitoring cohort (N = 150). An optimal threshold
of LSM increasing per year of 2.1 kPa and LSM >9.6 kPa at baseline have been
found to be associated with 8.4- and 5.1-fold times increased risk of adverse out-
come, respectively.
This study, while important, had some methodological flaws: the cohort was
cross-sectional with patients at different phases of the disease course with a mean
time from diagnosis of 6.7 years and only 11% of patients assessed at diagnosis and
naïve to therapy; 14% of patients had histologically proven overlap with autoim-
mune hepatitis (AIH), and 18% of patients were receiving additional corticosteroids
and/or mycophenolate mofetil; more importantly, this was a single-centre study
lacking an external validation cohort [4]. Thus, the use of cut-offs individuated in
this clinically heterogeneous cohort for disease staging at baseline, as suggested by
guidelines, is not precise. Furthermore, the presence of potential confounding fac-
tors on LSM lecture, i.e. body mass index, cholestasis or high level of transami-
nases, has not been evaluated.
Other studies evaluated the accuracy of VCTE in assessing liver fibrosis PBC
and results are summarised in Table 7.1 [4, 17–19].
Floreani et al. performed a cross-sectional single-centre study (n = 114), which
demonstrated a good performance of VCTE in discriminating advanced fibrosis
with an area under the receiver operating curve (AUROC) of 0.92 (CI 0.85–0.99)
[17]. Significant fibrosis (F ≥ 3 according to Metavir staging system) was predicted
in patients whose LSM was higher than 7.6 kPa with a PPV of 0.90 and a positive
likelihood ratio (LR+) of 11.25, and it was ruled out with a negative predictive value
(NPV) of 0.92. In this study, VCTE discriminated better intermediate stage of fibro-
sis with a cut-off of 5.9 kPa (F ≥ 2 sec. Metavir); however, the low NPV (62%)
showed a mild accuracy in identifying true negative patients. In this study, patients
Table 7.1 Comparison of most important studies on VCTE in PBC

Histological
staging Cut-off
system n (kPa) Se Sp PPV NPV LR+ LR- AUROC
Corpechot et al. [4]
≥F1 Metavir 92 7.1 0.64 1.0 1.0 0.25 64 0.36 0.80
≥F2 52 8.8 0.67 1.0 1.0 0.75 67 0.17 0.91
≥F3 30 10.7 0.90 0.93 0.84 0.96 13.14 0.11 0.95
=F4 15 16.9 0.93 0.99 0.93 0.99 82.13 0.07 0.99
Floreani et al. [17]
≥F2 Metavir 114 5.9 0.82 0.92 0.97 0.59 10.25 0.08 0.89
≥F3 7.6 0.90 0.92 0.90 0.92 11.25 0.10 0.92
=F4 11.6 0.99 0.94 0.77 1.00 16.7 0.01 0.99
Dominguez et al. [18]
≥F3 Metavir 55 14.7 0.56 1.00 1.00 0.83 56 0.44 0.86
=F4 15.6 0.88 0.98 0.98 0.98 44 0.12 0.96
Cristoferi et al. [19]
≥LS3 Ludwig 126 >11.0 0.99 0.94 91 0.08 0.89
≤LS2 ≤6.5 0.91 0.96
Se sensitivity, Sp specificity, PPV positive predictive value, NPV negative predictive value, LR+
positive likelihood ratio, AUROC area under the receiver operating curves
with overlap with AIH were excluded and VCTE was performed within 6 months
from liver biopsy.
Both studies evaluated the VCTE performance in identifying and excluding
fibrosis against the other NITs (e.g. AST to platelet index (APRI), fibrosis-4 (FIB-4)
score, hyaluronic acid (HA) levels, Mayo score and AST to ALT ratio). In the
French study, the AUROCs from LSM by VCTE were significantly greater than
those of the APRI, FIB-4, HA, AST to ALT ratio and Mayo score for the prediction
of mild (F ≥ 2) and advanced fibrosis (F ≥ 3), and, in addition, the combination
between biochemical indexes and VCTE did not improve diagnostic accuracy in a
multiple regression model. Similar results are shown by the Italian study which
demonstrated that LSM by VCTE alone outperformed both other NIT alone (i.e.
APRI, FIB-4, FibroIndex and AST/ALT ratio) and in combination with VCTE in
predicting advanced fibrosis; at multivariate logistic regression analysis, VCTE was
the only independent variable associated with advance fibrosis (odds ratio = 1.389,
1.142–1.689, 95% CI).
Despite these two important studies, there remain critical unmet needs in this
field. The first is to evaluate whether potential confounding factors such as cholesta-
sis and inflammation can influence LSM values and increase the potential number
of false positive. More importantly, considering the importance of fibrosis in the
setting of risk stratification at diagnosis, there is a need of clinically relevant cut-offs
able to correctly stage the disease at its onset in more homogeneous cohorts.
Our group tried to respond to these questions performing a diagnostic multicen-
tre study (n = 126) in which we have enrolled patients at disease onset, naïve to
therapy and with VCTE performance within 3 months from liver biopsy [19]. In our
cohort, VCTE identified patients with advanced fibrosis with AUROC of 0.89; how-
ever, despite good sensitivity and specificity of a single cut-off approach identified
at 7 kPa, NPV was 0.95 and PPV was only 0.62 with 19 patients falsely classified in
advanced stage. Thus, we explored the use of a dual cut-off approach with a lower
and a higher threshold to define areas of accurate prediction and a grey area where
VCTE may not provide reliable prediction of advanced fibrosis. LSM cut-offs
≤6.5 kPa and >11.0 kPa enabled to exclude and confirm, respectively, advanced
fibrosis (NPV = 0.94, PPV = 0.89, error rate = 5.6%). These values were externally
validated in an independent cohort PBC patients (n = 91) with NPV = 0.93,
PPV = 0.89 and error rate = 8.6%. Finally, we evaluated with a multivariable analy-
sis role of potential confounding factors influencing the LSM lecture, and we found
the only parameter affecting LSM was fibrosis stage, and no association was found
with body mass index (BMI) and liver biochemistry.
A multicentre, international effort within the Globe study group to test longitu-
dinal data of LSM and development of adverse outcome is ongoing.
7.3 Primary Sclerosing Cholangitis
Primary sclerosing cholangitis (PSC) is a chronic cholestatic autoimmune biliary

disease characterised by a chronic inflammation of intra- and/or extra-hepatic bile
ducts, leading to biliary strictures and eventually biliary cirrhosis. Usually, PSC
progresses to end-stage liver disease within 10–20 years [20]. To date, no medical
treatment has proven to effectively alter the course of disease. PSC patients are at
greatly increased risk to develop hepatobiliary carcinoma, mainly cholangiocarci-
noma, which is associated with a dismal prognosis [21]. However, for many patients,
morbidity and mortality are mainly related to fibrosis progression to liver cirrhosis
and its complications. The highly variable natural history of PSC, with possible
intercurrent clinical events (e.g. cholangitis, biliary lithiasis) that could be dissoci-
ated from the severity of underlying liver disease with consequent fluctuant clinical
symptoms and serum cholestasis marker, makes the prognostic assessment of these
patients challenging. Indeed, reliable and solid prognostic tools able to estimate
prognosis at individual level are still not available in PSC.
Limitations on the use of liver biopsy in PSC mainly relate to the patchy disease
distribution [22], which increased the interest of developing disease-specific NITs.
To date, VCTE is the most explored and easy accessible tool for non-invasive
fibrosis assessment in PSC (even if it is not recommended by the most recent guide-
lines [23, 24]). Although PSC mainly involves the large intra- and extra-hepatic bile
ducts, advanced liver fibrosis impacts on adverse outcomes.
Corpechot et al. made an important effort to define the role of VCTE in PSC stag-
ing and predicting its outcomes. In a prospective, single-centre longitudinal study
(n = 66), VCTE demonstrated to have a good accuracy in discriminating patients
with advanced fibrosis (≥F3 sec. Metavir) against liver histology with AUROC of
0.93, a sensitivity and specificity of 0.93 and 0.83, respectively, a PPV of 0.61 and
Table 7.2 Comparison of the most important studies on VCTE in PSC

Histological
staging Cut-off
system n (kPa) Se Sp PPV NPV LR+ LR− AUROC
Corpechot Metavir 66
et al. [3]
≥F1 60 7.4 0.60 0.86 0.97 0.20 4.28 0.46 0.71
≥F2 32 8.6 0.72 0.89 0.85 0.78 4.41 0.30 0.84
≥F3 15 9.6 0.93 0.83 0.61 0.98 13.14 0.08 0.93
=F4 9 14.4 1.00 0.88 0.56 1.00 82.13 0.01 0.95
Ehlken Metavir 62
et al. [25]
≥F1 57 6.6 0.65 0.60 0.95 0.13 1.63 0.75 0.63
≥F2 27 8.8 0.82 0.89 0.85 0.86 7.45 0.08 0.91
≥F3 20 9.6 0.90 0.91 0.82 0.95 10.00 0.10 0.95
=F4 16 14.4 0.69 0.97 0.92 0.90 23.00 0.41 0.98
Se sensitivity, Sp specificity, PPV positive predictive value, NPV negative predictive value, LR+
positive likelihood ratio, AUROC area under the receiver operating curves
NPV of 0.98 using a cut-off of 9.6 kPa (Table 7.2). Their results have been con-
firmed after removing patients with overlap with AIH and after internal validation
based on 100 random replications, simulating 6600 virtual patients. Furthermore,
they followed up the whole cohort (n = 162) for a median follow-up of 3.6 ± 18 years,
and they demonstrated a tenfold increased risk of adverse events (i.e. death liver
transplantation and hepatic complications) with a LSM at baseline > of 11.1 kPa
(sensitivity 67%; specificity 81%; PPV, 38%; NPV, 93%; accuracy 79%) and LSM
progression/year >1.5 kPa.
However, this study has some limitations. In fact, the small number of patients in
the intermediate stage of fibrosis (n = 23 with stage F2–F3) and the low PPV (0.61)
for the prediction of ≥F3 stage increase the probability to have false-negative
patients. Furthermore, as pointed out by Ehlken et al., approximately 25% of
patients with PSC have a high level of bilirubin at disease presentation, and the
exclusion of patients with dominant stricture could have introduced a bias in the
analysis [25]. Indeed, cholestasis is a known factor that can influence LSM value,
and the interpretation of VCTE results should be done after excluding the presence
of dominant stricture.
The French results have been confirmed by the German group (n = 62 with liver
histology), which individuated the same cut-off of 9.6 kPa able to discriminate
patients with advanced fibrosis with a specificity and sensitivity of 0.91 and 0.90,
respectively, and a NPV and PPV of 0.95 and 0.82, respectively (AUROC 0.95)
(Table 7.2). However, the small number of patients in the intermediate stage of
fibrosis (F2/F3 = 13) reduces the power of the analysis.
Recently, Cazzagon et al. demonstrated that combined use of radiological score
based on magnetic resonance cholangiopancreatography (MRCP) (Anali score
which includes intrahepatic biliary duct dilatation, portal hypertension, hepatic dys-
morphy and parenchymal enhancement heterogeneity when gadolinium is
administered) and VCTE permits easy risk stratification in PSC. In a cohort of 162
patients followed for 753 patient/year, the optimal prognostic thresholds individu-
ated by this study were 10.5 kPa for LS and 2 for the Anali score without Gd.
Hazard ratios (95% confidence interval) were 2.07 (1.06–4.06) and 3.78 (1.67–8.59),
respectively [26, 27]. The use in combination of these two thresholds allowed us to
separate patients into low-, medium- and high-risk groups with 5-year cumulative
rates of adverse outcome of 8%, 16% and 38%, respectively.
Finally, the application of Baveno VI criteria (LSM <20 kPa and PLT >150,000/
mm3) in patients with compensated cirrhosis and cholestatic liver disease (both PBC
and PSC, n = 227) has been recently explored and seems to save 30–40% of esopha-
gogastroduodenoscopies with a false-negative rate of 0% [28].
Magnetic resonance elastography (MRE) has been strongly correlated with his-
tological stage at liver biopsy and seems accurate in detecting advanced fibrosis in
patients with PSC [29]. M. Tafur et al. showed that MRE had a higher ability to
quantify liver stiffness compared to VCTE, mainly due to its capability of assessing
a broader liver area [30].
An important limitation of the above-mentioned studies is that analysis includes
mainly patients with advanced disease, such as high grades of intrahepatic biliary
stricture (Grades 3c and 4) or caudate hypertrophy. Moreover, not only both tech-
niques can only give a semi-quantitative evaluation of bile duct strictures, but also
biliary stricture severity addressed by MRCP is weakly correlated with LS values on
MRE and does not correlate with LS on VCTE. This may limit their use in the future
research on PSC.
Further studies in larger cohorts are needed to validate this result in order to
determine clinically relevant cut-offs and rate of LSM progression over time to add
to the poor arsenal of risk stratifiers in PSC a valid alternative.
7.4 Autoimmune Hepatitis
Autoimmune hepatitis (AIH) is an immune-mediated chronic liver disease charac-

terised by the presence of interface hepatitis and portal plasma cell infiltration on
histologic examination, elevated transaminase levels, circulating non-organ-specific
autoantibodies and increased levels of immunoglobulin G [31]. An acute onset of
disease is common, but most patients have a fluctuating course which led to pro-
gression to liver fibrosis and cirrhosis, HCC and end-stage liver disease [32].
AIH requires continuous treatment and care in most patients. Over 80% of
patients have a good response to immunosuppressive therapy, which usually results
in a good prognosis [33]. In 3% of AIH-treated patients, fibrosis progresses, either
due to insufficient response, intolerance or non-adherence to therapy [34]. In fact,
according to the American and European guidelines [35, 36], the assessment of liver
fibrosis and cirrhosis is essential to guide treatment strategies in patients with
AIH. Fibrosis progression may be present also in patients with normal values of
transaminases but with persistent histological activity or in patients in which histo-
logical activity may lag biochemical remission by several months. This makes
biochemical activity an imperfect biomarker to monitor the disease if consid-

ered alone.
In this setting, the use of non-invasive biomarkers of liver fibrosis may be helpful
not only for disease staging but also for the monitoring of disease progression under
treatment. Currently, although not generally recommended by current guidelines
and the potential severe complications, many experts perform follow-up liver biop-
sies to assess inflammatory activity and disease progression.
VCTE is currently the only validated non-invasive method to estimate liver fibro-
sis in AIH with a reliable accuracy and reproducibility. One of the major limitations
in the interpretation of LSM results in AIH is the presence of hepatic inflammation
that has been demonstrated to be a potential confounding factor, leading to higher
number of false-positive patients [37]. Therefore, LSM in AIH, particularly in the
acute onset on in case of relapse, may be not reliable.
The most important evidences demonstrating the accuracy of VCTE in assessing
fibrosis in AIH come from Hartl et al. [2]. In their first study, they examined a cohort
of 34 patients with AIH comparing LSM with VCTE and liver histology and found
the thresholds that best predicted fibrosis stages, defined as the highest sum of sen-
sitivity plus specificity, were 5.8 kPa (F ≥ 2), 10.5 kPa (F ≥ 3) and 16.0 kPa (F ≥ 4).
The accuracy was higher in diagnosing cirrhosis (sensitivity 0.83, specificity 1.0
with an AUROC of 0.92); however, for the discrimination of intermediate stage of
fibrosis (severe, F3 and F4 vs. non-severe, F0–F2), the VCTE showed a worse per-
formance with sensibility of 0.73 and specificity of 0.91 and an AUROC of 0.82.
These results have been validated in an external cohort of 60 patients and showed a
better performance in discriminating early from advanced fibrosis with the same
cut-off of 10.5 kPa (AUROC 0.96, sensitivity 0.89, specificity 1.00). The reason of
a better performance of the cut-offs in the validation cohort was probably due to the
higher proportion of patients biopsied at first presentation of AIH and therefore a
larger proportion of patients without (or with only a short period of) immunosup-
pression at the time of TE. In fact, assuming a role of inflammation in the LSM
values, they put together both the cohorts (n = 94), and they divided the patients in
three groups based on time from the induction with immunosuppression. In patients
treated for more than 6 months, there was a weak correlation between LSM and
inflammation, and the accuracy in assessing fibrosis was higher with respect to the
group treated for less than 6 months (Table 7.3). Furthermore, they assessed that
after this time interval, VCTE were reliable regardless of the achievement of bio-
chemical remission. These results confirm the necessity, already reported in 2008
by Romanque et al. [37], to avoid performance of VCTE in an acute setting in AIH
because inflammation could interfere with the fibrosis estimate with a greater num-
ber of false-positive patients.
The same group demonstrated the utility of VCTE in evaluating disease progres-
sion over time along with biochemical markers [1]. In patients with biochemical
remission, LSM decrease progressively over time. On the other hand, in patients
with active inflammation, despite normal LFTs, fibrosis may progress and LSM
increase over time. These results highlight the importance of repeated VCTE mea-
surements during follow-up that, associated with biochemical response, may help to
assure the lack of disease progression.
7
Table 7.3 Comparison of the most important studies on VCTE in AIH

Histological Cut-off
staging system n (kPa) Se Sp PPV NPV LR+ LR− AUROC
Hartl et al. [2] Metavir
Whole cohort 92
≥F2 52 5.8 0.90 0.72 0.83 0.84 3.2 0.14 0.87
≥F3 30 10.4 0.83 0.98 0.92 0.91 41.5 0.17 0.93
=F4 15 16.0 0.88 1.00 1.00 0.98 88.0 0.12 0.96
<3 months from 34
induction
≥F2 5.8 0.71 0.66 0.65 0.58 2.1 0.43 0.68
≥F3 10.4 0.60 0.88 0.75 0.85 5.0 0.45 0.80
=F4 16.0 0.60 0.93 0.60 0.93 8.6 0.04 0.71
6–12 months from 25
induction
Elastography in Autoimmune Liver Diseases
≥F2 5.8 0.94 0.88 0.94 0.88 7.8 0.06 0.97

≥F3 10.4 1.00 1.00 1.00 1.00 99.0 0.001 1.00
=F4 16.0 1.00 1.00 1.00 1.00 99 0.001 1.00
>4 years from 27
induction
≥F2 5.8 1.00 0.77 0.80 0.88 4.3 0.01 0.94
≥F3 10.4 0.95 0.94 0.80 0.94 15.8 0.05 0.96
=F4 16.0 1.00 1.00 1.00 1.00 99.0 0.001 1.00
Xu et al. [38] Metavir 100
≥F2 6.45 0.82 0.86 0.97 0.49 6.6 0.13 0.88
≥F3 8.75 0.90 0.84 0.84 0.81 5.0 0.11 0.88
=F4 12.50 0.87 0.90 0.71 0.96 8.4 0.14 0.91
(continued)
99
Table 7.3 (continued)
100
Histological Cut-off
staging system n (kPa) Se Sp PPV NPV LR+ LR− AUROC
Anastasiou et al. [39] Metavir 53
≥F2 10.05 0.61 0.89 0.96 0.32 5.5 0.55 0.78
≥F3 12.10 0.59 0.83 0.81 0.62 3.5 0.49 0.74
=F4 19.00 0.82 0.93 0.76 0.95 11.7 0.19 0.84
Wu et al. [40] Metavir
≥F2 329 5.80– 0.82 0.79 3.8 0.22
7.00
100 9.10– 0.70 0.98 14.6 0.30
10.05
≥F3 208 8.18– 0.80 0.85 5.2 0.23
8.75
174 10.40– 0.74 0.93 7.7 0.27
12.10
=F4 268 11.00– 0.88 0.99 7.4 0.12
12.67
147 16.00– 0.86 0.97 21.7 0.14
19.00
Se sensitivity, Sp specificity, PPV positive predictive value, NPV negative predictive value, LR+ positive likelihood ratio, AUROC area under the receiver operat-
ing curves
L. Cristoferi et al.
Other studies have been conducted aiming at defining clinically relevant cut-offs
in AIH, but the heterogeneity of cohorts (e.g. different time from immunosuppres-
sive induction) and the small sample make the results less relevant (Table 7.3)
[38, 39].
Recently, a systematic review on NITs of fibrosis in AIH has been published. All
the studies, including those already reported here, had heterogeneous cohorts of
patients with 39% of patients not treated, 26% under treatment and 35% after treat-
ment [40]. Despite this, authors demonstrated good overall diagnostic performance
of VCTE in patients with AIH for detecting significant (≥F2), advanced fibrosis
(≥F3) and cirrhosis, by evaluating ten studies and an overall cohort of 329 patients.
The cut-off points are represented in Table 7.3. On the contrary, performance of
biochemical NITs (i.e. APRI and FIB-4) showed a poor performance in detection of
advanced fibrosis and cirrhosis in AIH. To overcome the potential bias due to high
levels of transaminase, they conducted a subgroup analysis by treatment status
(patients not treated and patients after treatment) in which the good performance of
VCTE was confirmed. However, data were limited, and further studies are needed
to confirm these results in larger and more homogeneous cohorts of patients.
In this setting, a possible solution to avoid inflammation bias in assessing fibrosis
is MRE that has been demonstrated to have a good performance in fibrosis assess-
ment despite the presence of liver inflammation [41]. However, the small number of
patients studied and the limited access to this tool may limit its use in daily clinical
practice.
7.5 Conclusions
Assessing fibrosis is a key step in the prognosis and monitoring of patients with
AILDs. We have now several non-invasive methods to assess disease stage, with
VCTE by FibroScan being the most performant in all AILDs. Further studies are
needed, for each of these conditions, to explore potential confounders to confirm
VCTE reproducibility and validate the role of baseline staging and longitudinal
monitoring.
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Transient Elastography for the Diagnosis
of Liver Fibrosis and Cirrhosis in People 8
with Alcohol-Associated Liver Disease
Taisiia Turankova, Giovanni Casazza, and Chavdar S. Pavlov
8.1 Introduction
The use of alcohol resulted in about three million deaths (5.3% of all deaths) world-
wide and 132.6 million disability-adjusted life years (DALYs)—i.e., 5.1% of all
DALYs in 2016 [1]. Alcohol-associated liver disease (ALD) is a public health con-
cern, being the cause of half of all cirrhosis-related deaths (Fig. 8.1) [1].
ALD represents a spectrum of liver injury attributed to alcohol abuse. Liver
injury ranges from hepatic steatosis to more advanced forms which include alco-
holic hepatitis, alcohol-associated fibrosis, alcohol-associated cirrhosis, and liver
cancer [2, 3].
In chronic liver disease of different etiologies, fibrosis progression is a result of
an imbalanced deposition of extracellular matrix and degradation. Repeated tissue
injury represents the wound healing response to liver damaging factors, such as
viruses, fat, alcohol, etc. Fibrosis stage is one of the most important prognostic fac-
tors in ALD. The progression of fibrosis depends on the alcohol consumption and
leads to the destruction of the lobular architecture, i.e., cirrhosis. Early detection of
cirrhosis and abstinence in people with ALD minimize the risk of complications and
improve prognosis [4].
Liver biopsy is considered the reference standard for the assessment of hepatic
fibrosis stage. It can be obtained by percutaneous needle techniques, transjugular
method, ultrasound-guided fine-needle, or surgical specimens [5]. The usefulness of
obtaining liver biopsy specimen would usually depend on the liver biopsy technique
and the physician’s experience and skills. However, liver biopsy is invasive, has
T. Turankova · C. S. Pavlov (*)

Department of Therapy, I.M. Sechenov First Moscow State Medical University,
Moscow, Russian Federation
G. Casazza
Dipartimento di Scienze Biomediche e Cliniche “L. Sacco”, Università degli Studi di Milano,
Milan, Italy

https://doi.org/10.1007/978-3-030-74132-7_8
106 T. Turankova et al.
Fig. 8.1 Alcohol- All global deaths

attributable fractions for
selected causes of death,
disease type, and injury, Liver cancer 10
2016. (Adapted from [2])
Oesophagus cancer 17
Pancreatitis 26
Lip and oral cavity 26
Other pharynx 31
Cirrhosis of the liver 48
Alcohol use disorders 100
0 50 100
Attributable fraction (%)
drawbacks such as sampling error, and it is not completely free of risks and compli-
cations [6].
Several noninvasive tests (i.e., transient elastography, other ultrasound-based
elastography techniques, or magnetic resonance elastography) for assessing the
stage of liver fibrosis in people with ALD have been proposed as alternatives to the
liver biopsy, but none has been sufficiently validated yet [7].
The 2018 EASL guideline recognizes liver biopsy as the most precise diagnostic
method for staging liver fibrosis. However, there are no recommendations on what
noninvasive methods should be used in the routine clinical practice for screening
and defining liver fibrosis in people with ALD [8].
8.2 Liver Fibrosis and Staging Assessment
Fibrosis is defined by a detrimental process in progressive chronic liver disease.

Many of the chronic liver diseases are asymptomatic, presenting with almost nor-
mal laboratory tests, and progress slowly to cirrhosis over the years, making the
diagnosis of liver fibrosis difficult in routine clinical practice. Hagström et al. have
identified an increased risk of development of severe liver disease in dose-response
pattern (adjusted risk ratio (RR) for each gram/day increase of 1.02; 95% CI
1.01–1.02) associated with alcohol consumption [9]. Daily drinking, regardless of
the alcohol amount consumed, appears to increase the risk of alcoholic cirrhosis, at
least in men. The risk factor for developing alcoholic cirrhosis remains high, no
matter at what age people start their alcohol consumption [10].
Alcohol liver injury is caused by ethanol metabolites (i.e., acetaldehyde and ace-
tate) which increase redox state, steatosis, production of reactive oxygen species,
and lipid peroxidation. These in turn cause production of proteins that alter normal
liver functions, induce cell death, and/or liver inflammation. In addition, in ALD,
lipopolysaccharide derived from a breakdown in the intestinal wall determines liver
8 Transient Elastography for the Diagnosis of Liver Fibrosis and Cirrhosis in People… 107
Fig. 8.2 Histopathologic

image showing the
morphology of alcohol-
related liver disease
injury and fibrosis as a result of the induction of oxidative stress, the cytokine
release, and subsequent infiltration of immune cells [11].
Cigarette smoking, obesity, sex, and the additional presence of chronic hepatitis
B or hepatitis C virus infection are other factors which may also influence the risk
of progression to cirrhosis [12].
With the advance of chronic liver disease, excessive deposition of Type I and III
collagens is found not only in portal tracts, but also in the lobule, creating both
fibrous septa and severe alterations to sinusoidal ultrastructure [13, 14].
Liver biopsy detects and measures liver fibrosis, and the amount of fibrosis mea-
sured defines the stages of liver fibrosis. Assessment is performed during a morpho-
logical investigation of a liver tissue, using semiqualitative scores defined with
several variables. The most widely used scoring systems for assessment of fibrosis
are the Knodell Histology Activity Index (HAI) [15], the Scheuer HAI [16], the
Ishak HAI [17], and the Metavir scoring system [5]. According to these scoring
systems, the histological changes characterizing the stages of fibrosis are defined as
stage 0—no fibrosis; stage 1—perisinusoidal fibrosis; stage 2—perisinusoidal fibro-
sis with periportal fibrosis; stage 3—bridging fibrosis; and stage 4—fully developed
cirrhosis. Cirrhosis is defined as hepatic bridging fibrosis and nodular regeneration
(Fig. 8.2). At this stage of ALD, a successful treatment and abstinence from alcohol
usually would result in improvement of parenchymal architecture and regression of
fibrosis [8].
8.3 oninvasive Laboratory Tests and Machine-Based

N
Techniques for Assessment of Hepatic Fibrosis
Good alternatives to liver biopsy for assessment of fibrosis in people with ALD are
some noninvasive technologies based on laboratory tests or imaging, or elasto-
graphic techniques.
Unlike the liver biopsy procedure, these tools are less operator-dependent and
require less time for reaching the diagnosis. Some laboratory tests are FibroTest
(α2-macroglobulin, apolipoprotein A1, haptoglobin, gamma glutamyl transpepti-
dase, and total bilirubin), aspartate transaminase-platelet ratio index (APRI), and
FIB-4 (platelets, aspartate transaminase, alanine aminotransferase, and age), Hepa-
Score (α2-macroglobulin, hyaluronic acid, and gamma glutamyl transpeptidase),
ELF (hyaluronic acid, tissue inhibitor of metalloproteinase-1, and procollagen 3
peptide N-terminal), and FibroMeter (platelets, hyaluronic acid or gamma glutamyl
transpeptidase, prothrombin index, aspartate transaminase, and α2-macroglobulin).
All of these tests consist of combinations of various variables (validated and non-
validated) [18].
Ultrasound (US) is the first noninvasive imaging method for diagnosis of focal
lesions in the liver. However, although inexpensive, its accuracy in the diagnosis of
alcoholic fibrosis is still unclear due to the lack of studies with liver biopsy as a
comparator [19, 20]. Liver size, bluntness of the liver edge, coarseness of the liver
parenchyma, nodularity of the liver surface, size of the lymph nodes around the
hepatic artery, irregularity and narrowness of the inferior vena cava, portal vein
velocity, and spleen size are among the ultrasound parameters for assessing fibrosis
and cirrhosis in people with ALD. As liver fibrosis reduces tissue elasticity, mea-
surement of liver stiffness is an attractive surrogate for severity of fibrosis. In addi-
tion to ultrasound and ultrasound-based liver elastography, there are other alternative
approaches for fibrosis assessment such as Fibroscan (Echosens, Paris, France
[21]); acoustic radiation force impulse imaging (ARFI; Siemens) [22]; shear wave
elastography (SWE; Supersonic Imaging) [23], and magnetic resonance elastogra-
phy (MRE) [24]. The diagnostic test accuracy of these techniques is presented in
Table 8.1.
The use of noninvasive tests could be tailored to first tier screening of people at
risk in order to diagnose early the people with progressive liver disease and offer
targeted interventions for the prevention of decompensation [8]. Estimate of liver
fibrosis progression in a person is considered an important surrogate end point that
may facilitate treatment decisions by clarifying the vulnerability of an individual at
risk of progression to cirrhosis [8].
8.4 Transient Elastography for Fibrosis Assessment in ALD
Fibroscan is the most studied and used technique among hepatologists and gastro-
enterologists. In people with ALD, liver stiffness correlates with the degree of fibro-
sis and is measured in kPa by transient elastography [32–34]. This noninvasive
method, used in portable devices, makes it possible to test large groups of people
and improve the quality of screening.
During the transient elastography procedure, measurements are performed in the
right lobe of the liver through intercostal spaces on fasting patients lying in dorsal
decubitus with the right arm in maximal abduction.
8
Table 8.1 Study performance of machine-based techniques for the diagnosis of fibrosis and cirrhosis in patients with biopsy-proven ALD
LSM Participants Cirrhotics Fibrosis Cutoff AUROC (95%
Study type (n) (%) stage value Sensitivity Specificity LR+ LR− CI)
Nguyen-Khac et al. TE 103 32 F≥2 7.8 kPa 0.8 0.9 8.00 0.22 0.91
(2008) [25] F≥3 11 kPa 0.86 0.8 4.30 0.18 0.90
F=4 15.5 kPa 0.85 0.84 5.31 0.18 0.92
Nahon et al. (2008) TE 147 53.7 F≥3 11.6 kPa 0.87 0.89 7.91 0.15 0.4
[26] F=4 22.7 kPa 0.84 0.83 4.94 0.19 0.87
Thiele et al. (2015) SWE 199 18.1 F≥3 10.2 kPa 0.82 0.93 11.7 0.19 0.94
[27] F=4 16.4 kPa 0.94 0.91 10.4 0.07 0.95
Zhang et al. (2015) ARFI 99 9.09 F≥2 1.27 m/s 0.77 0.85 5.13 0.27 0.84
[28] F≥3 1.40 m/s 0.84 0.82 4.67 0.20 0.87
F=4 1.65 m/s 0.89 0.84 5.56 0.13 0.89
Kiani et al. (2016) ARFI 82 15.85 F≥2 1.63 m/s 0.82 0.83 4.82 0.22 0.87
[29] F≥3 1.84 m/s 0.82 0.78 3.73 0.23 0.86
F=4 1.94 m/s 0.92 0.81 4.84 0.10 0.89
Bensamoun et al. MRE 90 14.44 F≥2 2.57 kPa 0.78 0.78 3.55 0.28 0.85
(2013) [30] F≥3 3.31 kPa 0.96 0.95 19.2 0.04 0.97
F=4 4.00 kPa 1 0.92 12.5 0.00 0.98
Singh et al. (2015) MRE 697 (21 ALD) N/A F≥2 3.66 kPa 0.7 0.77 3.04 0.39 0.81
[31] F≥3 4.11 kPa 0.92 0.81 4.84 0.10 0.93
LSM liver stiffness measurement, LR likelihood ratio, AUROC area under the receiver operating characteristics, TE transient elastography, SWE shear wave
elastography, ARFI acoustic radiation force impulse imaging, MRE magnetic resonance elastography
Transient Elastography for the Diagnosis of Liver Fibrosis and Cirrhosis in People…
109
Liver stiffness values in the general population are influenced independently by

sex, body mass index, and metabolic syndrome, mean of ‘normal’ liver stiffness
values which lie between 3.3 and 7.0 kPa, using the 5th and 95th percentiles [35, 36].
Detection of fibrosis F0 or F1 is of no clinical relevance as these initial hepatic
fibrosis stages do not influence prognosis, and if the individual abstains from alco-
hol consumption, the fibrosis will reverse [37].
Results of liver stiffness measurements by transient elastography were compared
with histological staging of hepatic fibrosis by liver biopsy in publications. The
cutoff values, proposed by study authors, for diagnosis of the stages of fibrosis in
people with ALD varied. For example, the study by Nguyen-Khac et al., with 103
patients analyzed, showed that liver stiffness was correlated with fibrosis (r = 0.72,
p < 0.014) [median for F1 at 6.3 kPa, area under the ROC (receiver operating char-
acteristics) curve (AUROC) 0.84 (95% CI 0.73–0.95); F2 at 8.4 kPa, AUROC 0.91
(95% CI 0.85–0.98); F3 at 15 kPa, AUROC 0.91 (95% CI 0.82–0.97); and F4 at
47.3 kPa, 0.92 AUROC 0.91 (95% CI 0.87–0.98)] [25]. The study by Foucher et al.
reported similar results in 711 patients, among whom 12.5% were with ALD [38].
With a cutoff value of 17.6 kPa, the negative predictive value for the diagnosis of
cirrhosis was 92% and the positive predictive value was 91% [39].
The study by Cassinotto et al. analyzing a cohort of 145 patients with alcoholic
disorders showed liver stiffness median of 7.9 kPa for F1 [AUROC 0.84 (95% CI:
0.77–0.89)]; of 9.93 kPa for F2 [AUROC 0.83 (95% CI: 0.78–0.87)]; of 11.3 kPa for
F3 [AUROC 0.86 (95% CI: 0.81–0.89)]; and of 26.2 kPa for F4 [AUROC 0.90 (95%
CI: 0.86–0.93)] [39].
A study by Mueller et al., conducted in 50 people with ALD, showed that the
activity of glutamic oxaloacetic transaminase (aspartate transaminase) reduced to
<100 u/mL significantly improved the diagnostic accuracy of transient elastography
in the diagnosis of cirrhosis. The activity of steatohepatitis increased liver stiffness
in the patients, regardless of the stage of fibrosis [40]. A later study by Mueller
showed that the inflammation-adapted liver stiffness cutoff values, calculated for
ALD, improved the diagnostic accuracy and the agreement with histological fibro-
sis stages (See adapted Table 8.2) [41].
The study by Bardou-Jacquet et al. showed that transient elastography decreased
significantly after alcohol cessation over a long period of follow-up (median follow-
up of 32.5 weeks) in 85% of abstinent patients [median (range): −4.9 (−6.1 to
−1.9)], leading to a modification of the putative fibrosis stage in 28–71% of patients
according to different cutoff values [42].
Table 8.2 Cutoff values and AUROCs in patients with and without elevated aspartate aminotrans-
ferase (AST) levels both for ALD. Table with adapted results from [41]
F0 vs. F1/2 F1/2 vs. F3 F3 vs. F4
Fibrosis stage Cutoff (kPa) AUROC Cutoff (kPa) AUROC Cutoff (kPa) AUROC
All 6.1 0.744 8.1 0.684 17.1 0.864
AST <40 U/L 4.9 0.700 6.8 0.705 10.5 0.868
AST >40 U/L 6.1 0.713 8.1 0.673 16.9 0.873
To use transient elastography in clinical practice, the cutoff values need to be

confirmed both in people who continue to abuse alcohol and in abstinent people. In
2015, a Cochrane systematic review meta-analyzed available data from 14 studies
with 834 patients diagnosed with ALD (Table 8.3) [37].
Although the cutoff values for stiffness varied among the studies and were not
defined a priori, the most commonly used cutoff value for the detection of advanced
fibrosis (F3 or worse) was 9.5 and 12.5 kPa for cirrhosis (Table 8.4) [37].
The Forest plot (Fig. 8.3) summarizes diagnostic accuracy main results in terms
of sensitivity and specificity for the diagnosis of liver cirrhosis.
Table 8.3 Studies included in the review [37]

No of
included
patients with
ALD/n of Time interval
enrolled between TE and
Study Year Country patients Study design LB
Anastasiou n/a Greece 14/65 Prospective 3 days
et al. (2010) cohort study
[43]
Boursier From France, 106/390 Prospective 1 week
et al. (2009) September Morocco cohort study
[44] 2003 to
June 2007
Carl et al. From 1 UK 4/266 Retrospective n/a
(2012) [45] May 2008 cohort study
to 31 July
2011
de From France, 34/286 Prospective Within 1 week
Ledinghen September China cohort study
et al. (2012) 2009 to
[46] March
2011
Dolman From 2008 Netherlands, 20/130 Retrospective 2 months
et al. (2013) to 2011 UK study using
[47] data from a
consecutive
cohort of
participants
Kim et al. n/a Korea 45/45 Prospective With the interval
(2009) [48] cohort study of
11.2 ± 22 days
(0 to about
92 days)
Lannerstedt From 2007 Norway 16/418 Retrospective 8 participants
et al. (2013) to 2010 cohort study had TE at
[49] <2 months, and
8 had TE at
>1.9–8.6 years
(continued)

No of
included
patients with
ALD/n of Time interval
enrolled between TE and
Study Year Country patients Study design LB
Nguyen- From April France 103/160 Prospective TE and LB
Khac et al. 2005 to cohort study performed on
(2008) [25] January the same day
2007
Fernandez n/a Belgium 139 Retrospective Within 6 months
et al. (2012) cohort study
[50]
Mueller From June Germany 101/101 Prospective A mean
et al. (2010) 2007 to cohort study observation
[41] March interval of
2009 5.3 days. Range
3–10 days.
Lemoine From France 48/92 Prospective TE and LB were
et al. (2008) January cohort study performed on
[51] 2004 to the same day
September
2006
Janssens From Belgium 49/255 Prospective 1 week
et al. (2010) January cohort study
[52] 2006 to
February
2008
Nahon et al. From France 147/174 Prospective TE and LB
(2008) [26] November cohort study performed on
2005 to the same day
November
2006
Bardou- From June France 8/572 Retrospective 2 LB within
Jacquet 2005 to participants cohort study 4 weeks, and 6
et al. (2013) November with ALD LB within the
[42] 2010 had liver median of
biopsy follow-up
during 32.5 weeks
follow-up (15–85 weeks)
TE transient elastography, LB liver biopsy, ALD alcohol liver disease, UK United Kingdom of
Great Britain and Northern Ireland
Only 3 of the 14 studies were judged to be at low risk of bias. No serious con-
cerns regarding the applicability of the studies in answering the main study question
of the review were identified, i.e., the diagnostic test accuracy of transient elastog-
raphy compared with liver biopsy. Due to the small number of studies reporting data
on common cutoff values, the optimal cutoff values for the fibrosis stages could not
be identified. However, transient elastography seems to be a good diagnostic method
Table 8.4 The results of the Cochrane systematic review [37]

Cutoff
Fibrosis No. of No. of value, Summary Summary
stage studies participants kPa sensitivity specificity LR− LR+
F2 8 342 7.5 0.94 (95% CI 0.89 (95% CI 0.07 8.2
0.86–0.97) 0.76–0.95)
F3 8 564 9.5 0.92 (95% CI 0.70 (95% CI 0.11 3.1
0.89–0.96) 0.61–0.79)
F4 7 330 12.5 0.95 (95% CI 0.71 (95% CI 0.07 3.3
0.87–0.98) 0.56–0.82)
Study TP FP FN TN Cut-off for >=F2 Sensitivity (95% Cl) Specificity (95% Cl)
Boursier 2009 94 1 5 6 7.0 0.95 [0.89, 0.98] 0.86 [0.42, 1.00]
Lannerstedt 2013 14 0 0 2 7.0 1.00 [0.77, 1.00] 1.00 [0.16, 1.00]
anastasiou 2010 3 2 1 8 7.15 0.75 [0.19, 0.99] 0.80 [0.44, 0.97]
de Ledinghen 2013 32 0 1 1 7.2 0.97 [0.84, 1.00] 1.00 [0.03, 1.00]
Kim 2009 39 0 1 5 7.5 0.97 [0.87, 1.00] 1.00 [0.48, 1.00]
Dolman 2013 7 2 1 10 7.65 0.88 [0.47, 1.00] 0.83 [0.52, 0.98]
Nguyen-Khac 2008 62 2 15 24 7.8 0.81 [0.70, 0.89] 0.92 [0.75, 0.99]
Thiele 2015 69 10 14 105 9.6 0.83 [0.73, 0.90] 0.91 [0.85, 0.96]
Carl 2012 3 0 0 1 13.5 1.00 [0.29, 1.00] 1.00 [0.03, 1.00]
0 0.2 0.6 0.4 0.8 1 0 0.2 0.6 0.4 0.8 1
Mueller 2010 41 14 4 42 8.0 0.91 [0.79, 0.98] 0.75 [0.62, 0.86]
Boursier 2009 77 7 12 10 9.5 0.87 [0.78, 0.93] 1.59 [0.33, 0.82]
Kim 2009 35 2 1 7 9.5 0.97 [0.85, 1.00] 0.78 [0.40, 0.97]
Dolman 2013 4 4 1 11 9.5 0.80 [0.28, 0.99] 0.73 [0.45, 0.92]
Lannersted 2013 13 1 0 2 9.5 1.00 [0.75, 1.00] 0.67 [0.09, 0.99]
Femandez 2012 67 21 7 44 10.5 0.91 [0.81, 0.96] 0.68 [0.55, 0.79]
Nguyen-Khac 2008 46 10 7 40 11.0 0.87 [0.75, 0.95] 0.80 [0.66, 0.90]
Nahon 2008 96 4 14 33 11.6 0.87 [0.80, 0.93] 0.89 [0.75, 0.97]
de Ledinghen 2013 26 1 4 3 9.5 0.87 [0.69, 0.96] 0.75 [0.19, 0.99]
janssens 2010 23 4 9 13 17.0 0.72 [0.53, 0.86] 0.78 [0.50, 0.93]
0 0.2 0.6 0.4 0.8 1 0 0.2 0.6 0.4 0.8 1
Anastasiou 2010 3 2 1 8 7.15 0.75 [0.19, 0.99] 0.80 [0.44, 0.97]
Boutsier 2009 62 10 7 27 12.5 0.90 [0.80, 0.96] 0.73 [0.56, 0.86]
Kim 2009 29 8 0 8 12.5 1.00 [0.88, 1.00] 0.50 [0.25, 0.75]
Mueller 2010 25 15 1 60 12.5 0.96 [0.80, 1.00] 0.80 [0.69, 0.88]
Bardou-Jacquet 2013 5 2 0 1 12.5 1.00 [0.48, 1.00] 0.33 [0.01, 0.91]
de Ledinghen 2013 25 2 2 5 12.5 0.93 [0.76, 0.99] 0.71 [0.29, 0.96]
Dolman 2013 3 1 0 16 12.5 1.00 [0.29, 1.00] 0.94 [0.71, 1.00]
Lannerstedt 2013 8 4 0 4 12.5 1.00 [0.63, 1.00] 0.50 [0.16, 0.84]
Carl 2012 1 1 0 2 15.1 1.00 [0.03, 1.00] 0.67 [0.09, 0.99]
Femandez 2012 51 11 6 71 15.7 0.89 [0.78, 0.96] 0.87 [0.77, 0.93]
Nguyen-Khac 2008 28 11 5 59 19.5 0.85 [0.68, 0.95] 0.84 [0.74, 0.92]
Janssens 2010 16 7 4 22 19.6 0.80 [0.56, 0.94] 0.76 [0.56, 0.90]
Thiele 2015 35 16 1 147 19.7 0.97 [0.85, 1.00] 0.90 [0.85, 0.94]
Nahon 2008 66 12 13 56 22.7 0.84 [0.74, 0.91] 0.82 [0.71, 0.91]
Lemoine 2008 36 1 4 7 34.9 0.90 [0.76, 0.97] 0.88 [0.47, 1.00]
0 0.2 0.6 0.4 0.8 1 0 0.2 0.6 0.4 0.8 1
Fig. 8.3 Forest plot SR 2015
to rule out liver cirrhosis (F4) in people with alcoholic liver disease. Transient elas-
tography may also help in ruling out severe fibrosis (F3 or worse). Liver biopsy
investigation remains an option if the certainty to rule in or rule out the stage of
hepatic fibrosis or cirrhosis remains insufficient after a clinical follow-up or any
other noninvasive test considered useful by the clinician.
In a 2018 individual patient data meta-analysis with 1026 patients, Nguyen-Khac
et al. showed liver stiffness cutoff values of 7.0 kPa [AUROC 0.83 (95% CI
0.79–0.87) for F ≥ 1 fibrosis], of 9.0 kPa [AUROC 0.86 (95% CI 0.82–0.90) for
F ≥ 2], of 12.1 kPa [AUROC 0.90 (95% CI 0.86–0.94) for F ≥ 3], and of 18.6 kPa
[AUROC 0.91 (95% CI 0.83–0.99) for F = 4] [53]. The study concludes that liver
stiffness cutoff values are influenced by the increased AST concentrations, bilirubin
concentrations, or both.
8.5 Discussion
Fibrosis stage is one of the most important prognostic factors in alcohol-associated

liver disease and useful for patient stratification. Early staging of hepatic fibrosis in
people with alcoholic liver diseases could motivate patients and physicians in find-
ing an optimal strategy for achieving abstinence.
There are several factors that can influence the results of noninvasive methods of
liver fibrosis evaluation. It is important to remember that liver stiffness can arise not
only from fibrosis, but from edema or inflammation.
Thus, interpretation of the results in a proper clinical context is essential; for
example, acute hepatitis can yield stiffness values comparable to cirrhosis, or the
applicability of a test in obese people can be a problem. Improvement of current and
new technologies may avoid the influence of systematic bias on the diagnostic accu-
racy assessments.
The currently cutoff values proposed by Pavlov et al. [37] for the different stages
of hepatic fibrosis by transient elastography may be used in clinical practice, but
caution is needed because the reported values are only the most common cutoff
values used by the study authors.
The major issue is that there are only few studies properly designed to assess TE
in people with ALD. Most of the studies enrolled people with a mixed etiology of
the liver disease, and people with ALD are only a small proportion of the overall
number of included patients. This might be a potential source of bias. Moreover,
there are no studies that are properly designed in order to find and validate the opti-
mal cutoff value in people with alcoholic liver disease. To correctly diagnose the
stage of hepatic fibrosis in people with alcoholic liver disease using transient elas-
tography assessment, prospective studies should consider a single aetiology as the
best cutoff values for hepatic fibrosis in people with alcoholic liver disease remain
to be validated.
Hepatic fibrosis should be diagnosed with both transient elastography and liver
biopsy, and in this sequence. Transient elastography cutoff values should be pre-
specified and validated. The time interval between the two investigations should not
exceed 3 months, which is the interval, mainly required for people without cirrhosis.
Assessment of results should be properly blinded. Only studies with low risk of
bias, fulfilling the Standards for Reporting of Diagnostic Accuracy may answer the
review question.
8.6 Conclusion
In ALD patients, when chronic liver disease is suspected, liver biopsy remains the
reference standard for the diagnosing and staging of liver fibrosis. However, it is an
invasive procedure with risk of adverse events. There is a great need for reliable
high-quality comparative studies in people with alcohol-associated liver disease and

the use of noninvasive imaging techniques that can correctly assess the stage of liver
fibrosis. Most of the data available in the literature are derived from studies in which
people with ALD are only a minority among the studied population. However, even
with these methodological limitations, regarding the identification of advanced
fibrosis, transient elastography seems to be one of the most accurate and validated
modalities so far. Thus, liver stiffness measurement by transient elastography is an
appropriate for first-line investigation in primary care since it has been shown to be
cost-effective, and it is well-suited for second-line investigation in referral centers
in order to select patients who might require liver biopsy or need follow-up in the
liver clinic [54]. The cutoff values and the required parameters to diagnose liver
fibrosis by transient elastography in ALD patients should also be further validated.
Acknowledgment Authorship: All authors approved the final version of the manuscript.
Declaration of Personal Interests: TT: none known; GC: none known; CS Pavlov: none known.
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Elastography After Treatment
and During Follow-Up 9
Mirella Fraquelli, Ilaria Fanetti, and Andrea Costantino
9.1 Introduction
Liver fibrosis is the prognostic hallmark of chronic liver diseases (CLD), indepen-
dently of their etiology [1], since it significantly correlates with relevant outcomes,
such as cirrhosis development, liver-related complications, and mortality. For such
reasons, the assessment of liver fibrosis has always been considered of strategic
importance.
Until the early 2000s, liver fibrosis used to be evaluated by histological examina-
tion of the liver obtained through liver biopsy. However, liver biopsy has several
disadvantages, including poor patient compliance, sampling errors, a minor but still
consistent risk of complications, and limited usefulness for dynamic follow-up [2,
3]. Together, these drawbacks of liver biopsy have boosted the search for noninva-
sive methods of fibrosis progression assessment that could simplify the manage-
ment of patients with CLD.
Since 2004, the severity of liver fibrosis in CLD patients has been assessed
through liver stiffness measurement (LS) by vibration-controlled transient elastog-
raphy (VCTE, also commonly known as transient elastography, TE, FibroScan®)
and, thereafter, also by US elastography techniques implemented on regular ultra-
sound machines [4–9]. TE is the most frequently used technique in clinical practice:
the EASL guidelines currently recommend it for the evaluation of patients with
CLD [10].
After the evidence of the tight correlation between fibrosis regression after treat-
ment (by IFN or more recently direct-acting agents, DAA) and the improvement of
primary relevant outcomes [11–13], the longitudinal assessment of liver stiffness
after antiviral therapy has also become crucial. Mallet et al. have firstly
M. Fraquelli (*) · I. Fanetti · A. Costantino

Gastrointestinal and Endoscopy Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
e-mail: mirella.fraquelli@policlinico.mi.it

https://doi.org/10.1007/978-3-030-74132-7_9
120 M. Fraquelli et al.
demonstrated that cirrhosis regression in CHC patients significantly improved clini-

cally relevant outcomes, such as all-cause mortality [11]. In this study, in fact, 96
patients with histologically proven HCV-related cirrhosis were treated with an IFN-
based regimen and underwent at least one post-treatment biopsy. In a median fol-
low-up of 118 months (range 86–138), cirrhosis regression was observed in 18
patients (19%), who, interestingly, also showed decreased disease-related morbidity
and improved survival.
Since then, many studies investigating the use of elastographic techniques to
monitor treatment response have been published with the common aim of under-
standing how fibrosis changes during and after antiviral treatment.
However, the shared lack of histological post-treatment assessment mainly for
ethical reasons can represent a methodological flaw in most of such studies.
In addition, as already reported by Prati et al. in a previous chapter of this book,
besides hepatic fibrosis, LSM can be influenced by several confounders: interpret-
ing the results of these studies should be done with caution.
In fact, earlier studies using liver biopsy as the reference standard have demon-
strated that LS measurement is a sum of fibrosis and inflammation and that it might
be influenced by liver steatosis [14–16]. The influence of inflammation can be sup-
ported in CHC patients following HCV clearance [17–19] and by the decrease of
LSM following alcohol withdrawal [20]. It has also been suggested in CHB patients
whose liver stiffness dynamic profiles paralleled those of ALT as occurred during
ALT flares in patients with hepatitis exacerbation [21, 22]. Other possible con-
founding factors that have been described are sinusoidal pressure [20], extrahepatic
cholestasis [23], and liver congestion due to heart failure [24, 25].
Thus, post-treatment LS reduction has to be interpreted with caution, taking into
account all the available information. Also, it is still unclear at which moment to
perform LS assessment best, whether early or later during post-treatment follow-up.
9.2 Chronic HCV Infection
Over the last 20–30 years, HCV infection has been the major cause of liver fibrosis
and cirrhosis worldwide, because of its high global prevalence and the lack of any
effective treatment to achieve viral clearance in most cases. Indeed, the natural his-
tory of the HCV disease shows fibrosis progression over time, both in untreated
patients and in nonresponders [26].
More recently, thanks to the widespread application of a highly effective short-
duration treatment regimen based on direct-acting agents (DAA), most HCV
patients have been successfully treated to rapid virus elimination. Thus, fibrosis
reversal and cirrhosis regression have become the main issues of hepatologic stud-
ies, wondering how much fibrosis reversal should be expected and, in case of cir-
rhosis, if the disease would revert to a less severe form of CLD.
In the next paragraphs, we shall summarize the main results of the studies that
have assessed LS modifications in CHC patients after antiviral therapy (IFN- or
DAA-based regimens) using either liver histology as the reference standard or with-
out histological confirmation.
9 Elastography After Treatment and During Follow-Up 121
9.3 Liver Stiffness Changes Following IFN-Based Regimens
9.3.1 Studies with Histological Confirmation
Some studies, primarily performed on patients receiving IFN-based therapy with or

without ribavirin, have adopted liver histology as the reference standard and dem-
onstrated that cirrhosis reversed in a substantial proportion of patients [27–33].
D’Ambrosio et al. [28] have assessed the long-term histological benefits of SVR
in 38 HCV patients with cirrhosis who underwent paired pre- and post-treatment
liver biopsies taken 61 months after SVR. For 33 of them, post-treatment TE mea-
surement was also available at the time of the second biopsy. For these patients, TE
accuracy in assessing the stage of liver fibrosis was evaluated. In all patients, the
median area of fibrosis was significantly reduced from baseline (2.3% after treat-
ment, p < 0.0001), and cirrhosis regression was seen in 20 (61%) of the cases. For
what concerns TE accuracy, a significant correlation was found between TE and
both fibrosis stage (r = 0.56; p = 0.001) and morphometry (r = 0.56, p = 0.001) as
well as between fibrosis stage and area of fibrosis (r = 0.72, p = 0.001).
The median TE value was 9.8 kPa, lower in regressed than not regressed patients
(9.1 kPa vs. 12.9 kPa, p = 0.01). In detail, TE was <12 kPa in 5 (38%) F4 patients
and in 19 (95%) F3 patients (p = 0.0007) with 61% sensitivity and 95% specificity
in the diagnosis of F4 after treatment.
Interestingly, this study showed for the first time a low predictive power of the
viremic cutoff value of 12 kPa in the setting of cirrhotics with eradicated HCV,
probably as a consequence of liver remodeling and fibrosis reabsorption, suggesting
that liver biopsy still remains the only reliable approach for staging liver fibrosis
following SVR.
Chen et al. [32] studied a series of HCV patients who had undergone a baseline
liver biopsy before 2004 and performed, either by liver biopsy or LSM using TE, a
follow-up liver fibrosis assessment over a time length of more than 10 years. The
patients who had undergone a baseline liver biopsy but had no follow-up fibrosis
assessment were recalled to perform LS assessment. Fibrosis was categorized as
mild-moderate (METAVIR F0–F2, LS ≤9.5 kPa) or advanced (F3–F4, LS >9.5 kPa).
One hundred thirty-one patients were included in the analysis, 83% of whom
received interferon-based antiviral therapy and 40% achieving SVR. At follow-up
(the median period between fibrosis assessments being 14 years), liver fibrosis
assessment was performed by LS in 86% and liver biopsy in 14%. The results of this
study showed fibrosis progression in only 7% of patients who achieved SVR in
comparison to 30% of the patients not responding to antiviral therapy, over a decade.
Interestingly, the three participants who developed fibrosis progression despite SVR
showed additional cofactors, such as concomitant alcohol abuse and diabetes. At
multivariate analysis, SVR was independently associated with prevention from liver
fibrosis progression.
In their prospective study, Tachi et al. [34] enrolled 336 HCV patients, of whom
121 with SVR. LS measurement was performed by ARFI elastography on all
patients the same day as liver biopsy. LS significantly correlated with the histologi-
cal fibrosis score, both in viremic and SVR patients. However, in accordance with
the same fibrosis stage, LS resulted significantly lower in SVR as compared to non-
SVR subjects. In addition, the LS values were affected by necroinflammatory activ-
ity, their being higher in HCV patients with Grades 2 or 3 as compared with patients
with Grades 0 or 1. In accordance with D’Ambrosio et al. [28], in this study too, the
viremic cutoff values were not the most accurate ones for diagnosing liver cirrhosis
in SVR patients.
9.3.2 Studies Without Histological Confirmation
These studies (their characteristics are summarized in Table 9.1) have assessed the
longitudinal changes of LS determination after SVR as an indirect marker of hepatic
fibrosis [18, 19, 26, 35–43]. Overall, SVR has always been associated with the post-
treatment reduction of liver stiffness, although most of the studies are heteroge-
neous as there are differences related to different study design formats, prevalence
of cirrhosis, the different elastography techniques used, and the follow-up
time points.
Frequently, these studies are limited by a short follow-up period of around
24 weeks.
Ogawa et al. [19] studied 145 Japanese HCV patients who underwent a PEG-IFN
plus ribavirin combination therapy to assess any association between LS measured
by TE and treatment efficacy. LS values significantly decreased in SVR patients in
comparison with non-SVR patients at the end of treatment (EOT), and up to
96 weeks after EOT. Among the non-SVR patients, TE values were significantly
diminished for patients with biochemical response in comparison with those with-
out, at EOT, and up to 96 weeks after EOT.
In a French study, Vergniol et al. [35] looked at 416 treatment-naive patients, 112
of whom started treatment after enrollment. In the treatment group, the TE values
were significantly higher before and after treatment than among untreated patients
at baseline and after 1 year. However, there was no significant difference between
treated and untreated patients at the end of follow-up. TE values fell in all treated
patients, independently of their virological response, without any significant differ-
ence between treated and untreated patients at the end of follow-up. At multivariate
analysis, treatment was the only factor independently associated with TE values
reduction.
Another French study [18] involved 91 patients with CHC and significant fibro-
sis (LS >7.0 kPa) at baseline. Liver stiffness significantly decreased during therapy
(PEG-IFN and ribavirin) and continued to diminish after treatment only in patients
who achieved SVR. At multivariate analysis, only SVR was associated with long-
term liver stiffness improvement.
Wang et al. [33] reported similar results in SVR patients while showing a pro-
gressive increase in the LS values of nonresponders during follow-up.
In the paper by Calvaruso et al. [42], long-term responders to IFN-based thera-
pies revealed lower LS values than those untreated and still viremic, whereas Arima
et al. [35] observed a significant LS reduction after SVR and in relapsers. An
9
Table 9.1 Main characteristics of the studies involving CHC patients who were treated by IFN-based antiviral regimens and underwent paired liver stiffness
assessment by elastography
Time LSM
Treated after EOT
Patients Pre-Tx LSM values Post-Tx LSM values (max
Study (n) Cirrhotics Tx SVR LSM type (kPa or m/s) in SVR (kPa or m/s) in SVR available)
Ogawa et al. (2009) [19] 126 13% IFN + RBV 45% TE 10.3 ± 4.8 5.4 (median) 96 W
Vergniol et al. (2009) [35] 112 21% IFN 63% TE 10.65 ± 9.55 7.30 ± 8.45 24 W
Arima et al. (2010) [36] 145 64% IFN ± RBV 100% TE 8 (5–11.9) 5.3 (4.1–6.3) 104 W
Macías et al. (2010) [37] 143 (68% 18% IFN ± RBV 56% TE 7.7 (6.0–10.8) 6.0 (4.7–8.1) 24 W
HCV-HIV)
Wang et al. (2010) [38] 144 32% IFN + RBV 66% TE 6.1 (3.0–70.6) 5.5 (2.7–33.8) 24 W
Hezode et al. (2011) [18] 91 36% IFN + RBV 65% TE 10 (8.2–14.1) Δ −3.4 (−4.7–1.1) 24 W
Martinez et al. (2012) [39] 323 17% IFN + RBV 63% TE 9.3 ± 5.9 7.4 ± 4.4 24 W
Poynard et al. (2013) [26] 595 NA IFN ± RBV 29% TE NA NA >24 W
Osakabe et al. (2015) [40] 87 NA IFN ± RBV 47% ARFI 1.27 (1.11–1.49)a 1.05 (0.95–1.16)a 104 W
Soliman et al. (2020) [41] 150 50% IFN 90% TE F4: 21.3 (17.3–28) F4: 13.4 (10.9–19.7) 48 W
F2/3: 10.4 (9–11) F2/3: 6 (5.6–6.6)
Elastography After Treatment and During Follow-Up
CHC chronic hepatitis C viral infection, SVR sustained virological response, LSM liver stiffness measurement, Tx therapy, EOT end of treatment, NA not
available, W week
a
m/s
123
interesting aspect of the Calvaruso et al. paper is that at multivariate logistic analy-
sis, γ-GT and histological steatosis were independently associated with the persis-
tence of higher LS values, again pointing out the importance of confounders in LS
results interpretation.
9.4 Liver Stiffness Changes Following DAA Regimens
9.4.1 Studies with Histological Confirmation
Significant improvement of fibrosis noninvasive markers has been documented also

after successful treatment with DAA characterized by short-duration schedules
(12 weeks) and high sustained virological response (SVR) rates (>90%).
The main characteristics of the studies [44–46] that used liver histology as the
reference standard and performed paired liver biopsy before treatment and after
SVR are summarized in Table 9.2.
Pan et al. [44] included 84 HCV patients with advanced fibrosis or cirrhosis who
underwent DAA treatment and achieved SVR. Overall, 62% of them showed
improved liver stiffness as assessed by TE, which was consistent with the regression
of at least one stage of fibrosis. Fifteen patients with liver biopsies prior to SVR
underwent biopsy after SVR, and 13 of these patients had a concordant improve-
ment of liver stiffness. The post-SVR liver biopsies of only four patients showed
F1–F2, while 11 patients showed F3–F4; however, the morphometry of the first 11
biopsied patients revealed that ten patients had a 46% average decrease in collagen
content.
In the study by Enomoto et al. [45] among 691 patients with CHC who
achieved SVR after DAA, 51 underwent liver biopsy 41 ± 20 weeks after EOT
despite normal transaminases. Of them, 20 patients also had liver biopsy speci-
mens obtained at a median of 1.2 years before their treatment start, and the
comparison revealed a significant regression of the inflammation grade but not
of the fibrosis stage.
In their retrospective analysis of 43 patients with paired liver biopsy specimens
after SVR with DAA therapy, Huang et al. [46] observed that inflammation
improvement and fibrosis regression were achieved in 83% and 38% of patients,
respectively. Interestingly, LS measured by TE could predict post-SVR fibrosis,
and pre-SVR LS values were significantly lower in patients with fibrosis regression.
9.4.2 Studies Without Histological Confirmation
Several studies have observed a significant decrease of LS values by measurement

with different elastographic techniques after successful DAA treatment [47–81].
These studies too are heterogeneous in terms of study design formats, prevalence of
cirrhosis, and length of follow-up. The main results of these studies are summarized
in Table 9.3.
9
Table 9.2 Main characteristics of the studies involving CHC patients who were treated with DAA antiviral regimens and underwent paired liver biopsy and/
or liver stiffness assessment by transient elastography
Patients Pre-Tx LSM Post-Tx LSM Time LSM Patients
Patients with paired values (kPa) in values (kPa) after EOT (max with paired Fibrosis Δ Time
Study (n) Cirrhotics SVR TE SVR in SVR available) LB improvement paired LB
Pan et al. 84 24% 100% 28 NA 6.5a 1.2–1.9 Y 15 73% 2.3–3.9 Y
(2018) [44]
Enomoto 141 5% 100% 20 11.5 ± 6.4 7.7 ± 5.4 48 W 20 65% 41 SD
et al. (±20) W
(2018) [45]
Huang 40 35% 100% 40 9.5a 7.6a 12 W 40 83% 36 W
et al.
(2020) [46]
CHC chronic hepatitis C viral infection, SVR sustained virological response, EOT end of treatment, DAA direct-acting agents, LB liver biopsy, LSM liver stiff-
ness measurement, NA not available, W week, Y year
a
Median
125
Table 9.3 Main characteristics of the studies involving CHC patients who were mainly treated with DAA antiviral regimen and underwent liver stiffness
126
assessment by transient elastography

Treated LSM Pre-Tx LSM values Post-Tx LSM Time LSM after EOT
Study patients (n) Cirrhotics Tx SVR type (kPa) values (kPa) (max available)
Knop et al. (2016) 54 100% DAA 100% TE 32.5 (9.1–75) 21.2 (5.4–70) 24 W
[47] ARFI 2.7 (1.2–4.1) 2.4 (1.2–3.9)
Chekuri et al. (2016) 100 42% IFN (52) 100% TE 12.70 (8.3–21.1) 7.70 (5.3–11.6) 48 W
[48] DAA (48)
Pons et al. (2017) [49] 41 100% DAA 98% TE 20.8 (16.3–29.5) 14.3 (10.8–22.9) 48 W
Elsharawy et al. 337 45% DAA 92% TE 14.63 ± 10.68 11.8 ± 8.8 12 W
(2017) [50]
Dolmazashvilia et al. 304 57% DAA (152) 85% TE 16.9 (11.8–27.7) 11.9 (8.2–20.9) 24 W
(2017) [51] IFN + SOF + RBV (152)
Bachofner et al. 392 13% DAA 93% TE 14.3 (10.2–21.5) 9.1 (6.1–13.9) 40 W (143 pts)
(2017) [52]
Sporea et al. (2017) 211 100% DAA 100% TE 27.4 ± 11.9 21.3 ± 11 12 W
[53]
Tada et al. (2017) [55] 210 NA DAA 100% SWE 10.2 (7.7–14.7) 7.6 (6.3–10.3) 24 W
Tada et al. (2018) [54] 198 NA DAA 100% MRI 3.10 (2.7–4.1) 2.80 (2.4–3.7) 24 W
Hamada et al. (2018) 196 NA DAA (107) 100% SWE 8.3 (3.4 ± 36.2) 5.9 (2.7 ± 31.3) 24 W
[56] IFN (89)
Ohya et al. (2018) 302 NA DAA 96% TE NA NA 48 W
[57]
Ravaioli et al. (2018) 139 100% DAA 100% TE 18.6 (15–26) 13.8 (10.4–20.4) EOT
[58]
Noureddin et al. 101 0 DAA 100% TE 7.4 ± 1.9 6.1 ± 3.6 48 W
(2018) [59]
Omar et al. (2018) 52 POST 46% F3–F4 DAA 100% TE F2: 9 (8.8–9.25) F2: 5.5 (4.5–6.7) 72 W
[60] OLT F34: 15.35 F34: 9.2 (6.3–15.6)
(12–24.15)
Chan et al. (2018) 70 24% DAA 96% TE 8.0 (5.4, 12.4) NA 48 W
[61] IFN + DAA (4)
M. Fraquelli et al.
9
Persico et al. (2018) 749 70% DAA 98% TE 19.3 (±11.2) 14.2 (±11.7) 12 W
[62]
Facciorusso et al. 112 32% DAA (82) 100% TE 12.3 (9–17.8) 6.6 (5.3–7.4) 5 Y (62 pts)
(2018) [63] IFN (30)
Akuta et al. (2018) 217 21% 192 (88% Tx 96% TE F4: 23.9 (17.6–31.6) F4: 17.6 (12–22.3) 24 W
[64] COMPLETE) F0–3: 6.05 (4.4–7.7) F0–3: 5.1 (3.9–6.4)
Ogasawara et al. 214 52% DAA 91% TE 11.25 (2.4–51.4) 5.45 72 W
(2018) [65]
Kobayashi et al. 57 NA DAA 100% TE 8.3 (5.0–14.8) 5.4 (4.0–13.4) 48 W
(2018) [66]
Flisiak et al. (2018) 200 58% DAA 100% TE EOT: 16.6 ± 11.8 12.7 ± 9.1 48 W (120 pts)
[67]
Lee et al. (2019) [68] 270 31% DAA 93% TE 13.2 ± 12.6 10.5 12 W
Rout et al. (2019) [69] 372 26% DAA 100% TE 6.9 (5.1–12.7) 6.1 (4.8–9.4) 48 W (265 pts)
Hsu et al. (2019) [70] 388 34% DAA 98% ARFI 1.78 (1.25–2.3) 1.38 (1.14–1.8) 12 W (199 pts)
Giannini et al. (2019) 52 52% DAA 100% TE 15.2 (12.0–20.0) 9.3 (7.5–12.0) 60 W
[71]
Soliman et al. (2020) 150 50% DAA 90% TE F4: 21.8 (17.3–31.8) F4: 14.9 (11–19) 48 W
[41] F23: 10.2 (9.2–11.2) F23: 6.2 (5.6–7.1)
Kohla et al. (2020) 165 9% DAA 100% SWE 8.49 ± 0.83 5.74 ± 3.21 36 W
[72]
Kawagishi et al. 116 20% DAA 100% TE NA NA 24 W
(2020) [73]
Stasi et al. (2020) [74] 294 48% DAA 100% NA 13.4 ± 9.97 NA 96 W
CHC chronic hepatitis C viral infection, SVR sustained virological response, EOT end of treatment, DAA direct-acting agents, LSM liver stiffness measurement,
NA not available, W week, Y year
127
A finding that is common to most of the published studies is the very rapid
decrease of LS values shortly after starting DAA treatment paralleling the transami-
nases decrease: it is likely to be related to necroinflammation decrease.
For example, in the study by Pons et al. [49] concerning 41 patients treated with
DAA therapy, LS was assessed before, during, and after treatment, up to 48 weeks
using TE. LS decreased very rapidly in CLD patients during DAA treatment, with a
higher decrease observed in patients with baseline ALT values higher than twice the
upper limit of normality than in those with ALT lower than twice the upper limit
of normal.
In the paper by Kobayashi et al. [66] covering 57 patients who received DDA
therapy and achieved SVR, there is an interesting finding: ALT levels decreased
overall with significant difference among baseline, EOT, and SVR24 and thereafter
remained stable. The median LS values as measured by TE decreased significantly
at each timepoint between baseline and SVR24. Therefore, LS at SVR24 might
reflect the actual stage of liver fibrosis in patients achieving SVR after DAA.
9.5 HBV Infection
Similar to CHC patients, fibrosis represents also as the major determinant of prog-
nosis for CHB patients [82], and its longitudinal assessment during antiviral therapy
is very important for establishing treatment strategies. Indeed, HBV inhibition can
lead to fibrosis and even cirrhosis reversion leading to improved clinically relevant
outcomes [83–85].
Three studies [83–85] (see Table 9.4) with paired liver biopsy before and after
treatment documented the regression of liver fibrosis after antiviral therapy.
Dienstag et al. [83] enrolled 63 patients (17% cirrhotic) who underwent three
sets of liver biopsies: before and after 1 year on lamivudine treatment and after
2 years on further open-label treatment. At the end of the first year, 57% of the
patients showed a >2 point improvement in necroinflammatory activity; after two
additional years on lamivudine, 19% of patients continued to improve. As to fibro-
sis, bridging fibrosis improved by >1 degree in 63% of the cases, while cirrhosis
improved in 73%. Only 2% showed progression to cirrhosis and 9% showed pro-
gression to bridging fibrosis.
Chang et al. [84] followed 69 patients (7% cirrhotic) treated with entecavir ther-
apy who underwent paired liver biopsy after a median time of 6 years. At the time
of their long-term biopsy, all the patients presented with a hepatitis B virus DNA
level <300 copies/mL, and 86% had a normalized ALT level. Histological improve-
ment (≥2-point decrease in the Knodell necroinflammatory score and no worsening
of the Knodell fibrosis score) was observed in 96% of patients, and a ≥1-point
improvement in the Ishak fibrosis score was found in 88% of patients.
In a randomized controlled trial, Marcellin et al. [85] studied 585 patients who
entered a 7-year study of open-label tenofovir DF treatment, with a pre-specified
repeat liver biopsy at Week 240. Three hundred forty-eight patients (54% of the
whole study population) had their baseline and Year 5 liver biopsy results showing
9
Table 9.4 Main characteristics of the studies involving CHB patients who were treated with antiviral regimens and underwent paired liver biopsy
Patients with Δ Time LB cirrhosis LB fibrosis LB grade
Study Patients (n) Cirrhotics (%) Tx LSM paired LB paired LB reversal reversal improvement
Dienstag et al. 63 17% LMV No 63 3Y 73% NA 56%
(2003) [83]
Chang et al. 57 7% ETV ± LMV No 57 6 (3–7) Y 100% 88% 75%
(2010) [84]
Marcellin 641 28% TDF No 348 5Y 74% 51% 90%
et al. (2013)
[85]
CHB chronic hepatitis B, Tx treatment, LMV lamivudine, NUCs nucleos(t)ide analogue, ETV entecavir, ADV adefovir, CLV clevudine, IFN interferon, LB liver
biopsy, TEL telbivudine, NA not available, Y Years
129
an histological improvement in 87% of the cases; in particular, 51% had fibrosis

regression at Week 240, and out of 96 (28%) patients with cirrhosis at baseline, 74%
no longer had cirrhosis (≥1 unit decrease in score), whereas only 3 out of 252
patients without cirrhosis at baseline progressed to cirrhosis at Year 5.
In addition, in a Chinese study by Wu et al. [88], LS was sequentially performed
by TE every 26 weeks on 120 treatment-naive CHB patients receiving entecavir.
The TE results were compared to the results of paired liver biopsy performed at
baseline and at Week 78 on antiviral therapy. Interestingly, LS values presented a
rapid-to-slow decline pattern and decreased more rapidly in patients with histologi-
cal fibrosis regression than in those without fibrosis improvement at Week 78. At
multivariate analysis, the LS percent decline at Weeks 52 and 78 was an indepen-
dent predictive factor for histological fibrosis regression at Week 78 on antiviral
therapy.
Several studies (their main characteristics are summarized in Table 9.5) have
investigated the longitudinal changes in liver stiffness before, during, and after anti-
viral therapy using elastography techniques [19, 83–109] and have documented a
significant reduction of LS values after antiviral treatment as compared to basal
determination. However, the majority of these studies are limited by short periods
of observation and lack of paired histological assessment.
Several interesting results can be inferred from the studies with relatively longer
periods (≥3 years) of treatment with NUCs.
In the study by Osakabe et al. [97], LS was measured by TE in 212 CHB patients
who underwent NUC treatment. Liver biopsies were performed in 51 patients.
Changes of LS were assessed in 29 patients treated with NUCs and 52 patients
without antiviral therapy. LS measured at an interval of 512 days was significantly
reduced by antiviral therapy, from 12.9 (range 6.2–17.9) to 6.6 kPa (4.4–10.3).
Eleven out of 19 (58%) patients with baseline fibrosis stages of F3–F4 deduced
from LS had a ≥2-point reduction of the deduced stage at the last LS
measurement.
Andersen et al. [98] studied 66 patients (53 cirrhotics and 13 with advanced
fibrosis) prior to treatment. Among the patients with cirrhosis before treatment, 49%
had liver stiffness below 11.0 kPa at follow-up, suggesting cirrhosis regression.
Among the patients with advanced fibrosis (F3) prior to treatment, 77% had liver
stiffness below 8.1 kPa after treatment, suggesting improvement of fibrosis.
However, histological assessment was not available in this study.
Fung et al. [99] examined longitudinally liver stiffness changes as measured by
TE in a cohort of 426 CHB patients, 110 of whom received oral antiviral therapy.
There was a significant decline of LS at follow-up measurement compared to base-
line in treated patients with elevated ALT at baseline and subsequent normalization
after 3 years (6.1 kPa vs. 7.8 kPa, respectively) and in untreated patients who had
persistently normal ALT. Antiviral therapy ALT levels during follow-up were inde-
pendent significant factors associated with LSM decline.
A recent meta-analysis [109] identified 24 studies in adults with hepatitis B who
underwent TE before and at least 6 months after their start on NUC therapy.
9
Table 9.5 Main characteristics of the studies involving CHB patients who underwent antiviral regimens and underwent paired liver biopsy and/or paired liver
stiffness assessment by transient elastography
TE values TE values
Virological (kPa) (kPa) Δ Time
Study Patients (n) Cirrhotics (%) Tx response LB Paired LB Paired TE Pre-Tx Post-Tx paired TE
Enomoto 56 23% ETV 95% Yes 0 20 11.2 7.8 1Y
et al. (7.0–15.2) (5.1–11.9)
(2010)
[89]
Kim et al. 41 56% LMV, ADV, 96% Yes 4 41 11.7 11.8 1Y
(2010) ETV (4.1–36.3) (3.8–20.9)
[90]
Lim et al. 62 39% ETV 82% Yes 15 62 15.1 8.8 1Y
(2011) (5.6–75.0) (3.0–33.8)
[91]
Wong 71 11% CLV, ADV 70% Yes 71 71 8.8 6.6 1Y
et al. (3.1–26.3) (3.3–18.8)
(2011)
[87]
Ogawa 44 9% LMV ± ADV 86% Yes 0 22 8.2 5.3 3Y
et al. (10.5 ± 6.5) (6.8 ± 4.0)
(2011)
[19]
Zeng et al. 175 NA NUCs 54% Yes 67 175 8.9 ± 3.3 5.3 ± 1.3 2Y
(2016) IFN 34%
[92]
Sun et al. 71 72% ETV NA Yes 71 0 12.0 NA NA
(2017) (8.4, 15.2)
[93]
(continued)
131
132
TE values TE values
Jeon et al. 540 100% NA NA Yes 0 0 14.5 NA NA
(2017) (9.6–21.3)
[94]
Liang 534 NA TEL ± ADV 73% Yes 164 534 8.6 5.3 2Y
et al. (2.6–49.5) (2.7–36.8)
(2017)
[86]
Stasi et al. 50 NA NUCs 100% Yes 0 20 12.60 ± 6.31 7.28 ± 3.17 2Y
(2017)
[95]
Oliveri 87 NA NUCs, IFN NA No 0 9 12.3 ± 3.3 5.6 ± 1.1 1Y
et al.
(2008)
[96]
Andersen 66 80% NUCs NA No 0 66 53 F4 27 F4 4Y
et al.
(2011)
[98]
Osakabe 29 NA LMV, ETV NA No 0 27 12.9 4.7 3Y
et al. (6.2–17.9) (3.1–7.9)
(2011)
[97]
Fung et al. 426 NA 26% treated: NA No 0 426 6.0 5.6 3Y
(2011) LMV, ETV, (1.5–28.0) (3.0–46.4)
[99] ADV, TEL,
TDF
Kim et al. 121 52% ETV 92% No 0 121 14.3 7.3 3Y
M. Fraquelli et al.
(2013) (9.0–23.5) (5.3–11.8)

[100]
TE values TE values
9
Yan et al. 58 7% NA NA No 0 58 8.8 5.5 1Y

(2013) (3.2–47.3) (2.8–21.5)
[101]
Jang et al. 76 NA NUCs 70% No 0 76 6.5 5.3 1.5 Y
(2014) (4.7–9.2) (3.9–6.7)
[102]
Kuo et al. 233 43% ETV NA No 0 233 12.5 10.1 1.3 Y
(2014) (5.2–63.9) (4.4–67.8)
[103]
Wang 236 39% TDF 98% No 0 80 10.2 ± 6.2 7.3 ± 5.7 1Y
et al.
(2015)
[104]
Tenggara 41 41% ETV, TBV NA No 0 41 10.8 5.9 1Y
et al. (4.1–61.5) (NA)
(2017)
[105]
Chon 120 86% LMV, ETV NA No 0 NA 14.5 ± 7.2 NA NA
et al.
(2017)
[106]
Rinaldi 200 10% ETV, TDF NA No 0 189 12.4 8.22 2Y
et al. (±9.3) (±4.9)
(2018)
[107]
Wu et al. 120 54% ETV NA Yes 0 120 13.8 7.7 78 W
(2018) (9.6–20.3) (5.7–12.0)
[88]
CHB chronic hepatitis B, Tx treatment, LMV lamivudine, NUCs nucleos(t)ide analogue, ETV entecavir, ADV adefovir, CLV clevudine, IFN interferon, LB liver
biopsy, TEL telbivudine, NA not available, W week, Y year
133
Antiviral therapy was associated with a progressive decline in liver stiffness in

patients with hepatitis B; in particular, in patients with high baseline ALT and viral
load, LSM significantly declined by 2.2 kPa, 2.53 kPa, 3.73 kPa, 4.15 kPa, and
5.19 kPa at 6 months, 1 year, 2 years, 3 years, and 5 years from the start of therapy,
respectively.
Overall, TE seems to be a useful tool to monitor fibrosis changes in CHB patients
undergoing antiviral treatment with NUC. However, without histological confirma-
tion with paired liver biopsies, it is unclear whether the decrease in LS values is
associated with improvement in necroinflammation, regression of liver fibrosis, or
both. Actually, some studies have observed a significant LS reduction during NUC
treatment even in the presence of limited or no improvement of histological fibrosis
[86, 87, 91].
Finally, in CHB patients, the optimal threshold values to identify residual severe
fibrosis or cirrhosis after NUC treatment are likely to be lower than those identified
in treatment-naive patients, but such values need definition in further studies.
9.6 Conclusions
In the literature, there is consistent evidence indicating that LS values significantly

decrease during and after antiviral therapy in both CHC and HBV patients.
Some studies with paired liver biopsy, before and after antiviral treatment, have
documented a significant reduction of necroinflammatory activity and fibrosis score
in both the conditions.
On the other hand, the major limitation of most of the studies is that they were
performed without the availability of paired histological results, and thus it remains
unclear whether the reduction of TE values is closely correlated with the regression
of liver fibrosis or simply related to the improvement in necroinflammatory scores.
Another relevant issue that should to be considered is about the time at which the
determination of liver stiffness is performed. Actually, on the basis of the present
knowledge, the rapid decrease in liver stiffness after viral clearance is likely to be
related to the reduction of necroinflammation, while the true reduction of liver
fibrosis related to an architectural remodeling of the liver parenchyma is likely to
occur later on, when a further slow decrease in liver stiffness is possibly observed.
Unfortunately, the majority of the studies in the literature have follow-up periods
usually around 12 months long too short to discriminate between the two phases.
Given that the first and rapid reduction of LS is mainly attributable to the disap-
pearance of inflammation paralleling, as in some studies, the decrease in transami-
nase levels [61, 86, 87, 91], LS monitoring during antiviral treatment does not
appear clinically relevant.
Then, in the next period, there is a gradual LS reduction that is compatible with
an improvement in fibrosis. However, as the cutoff values currently used for elastog-
raphy techniques have been defined and tested on patients with active chronic hepa-
titis, it is not reliable to interpret TE evaluation in long-term HCV responders or in
patients on a NUC regimen with these same cutoff values. Indeed, liver remodeling
occurring after treatment could decrease TE ability to rule the presence of cirrhosis
out and the routine use of noninvasive tests after antiviral treatment has a high false-
negative rate. Thus, as indicated by the guidelines of many scientific societies [8–
10, 110], screening for hepatocellular carcinoma and other main complications of
liver cirrhosis should be continued despite the decrease in liver stiffness in both
CHC and CHB patients.
In addition, when considering the literature results, the possible presence of such
confounding factors as obesity, steatosis, diabetes, or concomitant alcohol abuse
should be accounted for, because the liver elasticity in such subsets of patients
might be affected and, sometimes, might worsen in spite of antiviral therapy.
In summary, according to the results in the literature, liver biopsy still remains
the only reliable approach in CHC patients to stage liver fibrosis after SVR.
In non-cirrhotic CHC patients, for whom clinical surveillance is not indicated,
routine LS measurement during treatment or after SVR does not add to their clinical
disease management.
In this setting, a periodical clinical assessment including LS measurement might
be indicated only in the presence of cofactors (such as alcohol abuse or metabolic
syndrome, diabetes, etc.) [110].
In CHC patients with severe fibrosis/cirrhosis prior to treatment, the progressive
decrease of LS observed after 6–12 months of follow-up is likely to be related to
fibrosis regression. However, LS monitoring after SVR, having a high false-nega-
tive rate, cannot be used to diagnose residual cirrhosis or to stop HCC surveillance.
On the other hand, a sudden LS increase during follow-up after SVR should
always be considered as a warning signal for the presence of cofactors or the devel-
opment of such relevant complications as HCC or clinical decompensation.
In CHB patients, a significant reduction of fibrosis or reversal of liver cirrhosis is
reported after prolonged treatment with NUCs. In this case, serial LS measurements
a few months after treatment and normalization of ALT can be useful to define a
reliable baseline value to monitor the changes in liver fibrosis.
As concerns both CHC and CHB patients with severe fibrosis or cirrhosis, the
prognostic value of LS determination (before and after antiviral treatment) to strat-
ify patients according to major clinical outcomes (survival, OLT, etc.) and the risk
of developing major complications, such as HCC, is addressed in other chapters of
this book.
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Elastography Methods to Assess Chronic
Liver Diseases: A Critical Comparison 10
Laurent Castera
10.1 Available Elastography Methods
10.1.1 Principle and Characteristics
They are two different kinds of elastography methods: ultrasound (US)- and mag-
netic resonance (MR)-based. The former uses ultrasound to detect the velocity of
the microdisplacements (shear waves) induced in the liver tissue, whereas the latter
uses the magnetic resonance scanner [1]. The shear wave’s velocity is then con-
verted into a liver stiffness measurement, expressed in kilopascals (kPa) or in meter/
second (m/s). US-based elastography methods include transient elastography (TE);
point shear wave elastography (pSWE), also known as Acoustic Radiation Force
Impulse Imaging (ARFI); and two-dimensional shear wave elastography (2D-SWE).
Transient elastography (TE) was the first commercially available elastography
system (FibroScan, Echosens, Paris, France), introduced in Europe in 2003 and
FDA approved in the United States in 2013 [2]. VCTE delivers a 50 Hz mechanical
impulse to the skin surface and then measures the velocity of the generated shear
wave (Fig. 10.1). There are several probes available, with the M probe used for
standard examinations and the XL probe introduced to increase the reliability of TE
measurements in high BMI patients [3].
pSWE/ARFI techniques, integrated in conventional ultrasound systems, use
focused US “push” pulses to deform internal tissue and generate shear waves [4].
Originally available in Siemens systems (Virtual Touch Quantification™ Acuson
2000, Siemens Healthineers, Erlangen, Germany), ARFI methods are now inte-
grated into their clinical ultrasound systems by most vendors [1]. Region of interest
(ROI) localization can be chosen under B-mode visualization. A single acoustic
L. Castera (*)
Service d’Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, INSERM
UMR 1149-CRI, Université de Paris, Clichy, France
e-mail: laurent.castera@bjn.aphp.fr

https://doi.org/10.1007/978-3-030-74132-7_10
144 L. Castera
TE MR elastography
pSWE 2D-SWE
Fig. 10.1 This figure illustrates the four elastography methods available: US elastography, includ-
ing TE (FibroScan, Echosens), pSWE/ARFI (Virtual Touch Quantification, Siemens Acuson
S2000), 2D-SWE (Aixplorer, Supersonic Imagine), and MR elastography. Region of interest
(ROI) for each method is depicted by enclosed green area. (Adapted from ref. [1])
impulse is used to induce a shear wave within a small ROI (approximately

1.0 × 0.5 cm), and the velocity of shear waves is measured in meter/second or kPa.
The technique for shear wave induction, the frequencies used, as well as the size of
ROI differ between companies and need be taken into account when interpreting the
results [5–7]. Measurement should be performed 1–3 cm below the liver capsule.
The median of ten measurements should be used for clinical interpretation. Improved
quality is obtained by pSWE estimation algorithms, which warn the user if mea-
surement is not adequate. In addition, quality criteria such as an IQR/median ≤30%
and standard deviation ≤30% have been reported to improve accuracy [6].
2D-SWE, like ARFI, is integrated in conventional ultrasonography systems,
enabling the additional performance of elastography with the same probes as
abdominal ultrasound (Fig. 10.1). Originally available clinically in Supersonic
Imagine system (Aixplorer™, Supersonic Imagine, Aix-en-Provence, France),
2D-SWE are now integrated in their systems by several vendors [1]. Multiple shear
waves are induced using acoustic impulses. The size of the ROI can be increased to
approximately 2 × 2 cm and shown as either single image or in real-time. Velocity
of stiffness can then be measured at varying locations within this ROI, and statistical
quantities such as the mean, standard deviation, minimum and maximum values of
the 2D-SWE, or Young’s modulus in kPa are calculated and displayed. The mea-
surement box should be placed at least 10 mm below the liver capsule. At least three
measurements should be obtained, and the report should include median and
IQR. The technique for shear wave induction, as well as the frequencies used, dif-
fers between companies and should be taken into account when interpreting the
results. All 2D-SWE systems have some kind of quality indicators of the shear wave
speed estimate. However, quality criteria for clinical interpretation remain poorly
evaluated [5–7].
In contrast to US elastography systems, MR elastography (MRE) quantifies
mechanical properties through “direct inversion” of the visualized “wave field” into
10 Elastography Methods to Assess Chronic Liver Diseases: A Critical Comparison 145
a map of the mechanical parameter of interest without the intermediate step of mea-
suring shear wave speed. MRE requires a special adaptation and proprietary hard-
ware and software installment (Resoundant Inc., Rochester, MN, USA) over
conventional MRI scanners and reports the shear stiffness of tissue, which is the
magnitude of the complex shear modulus, |G*|. MRE was FDA approved in 2009
and initially introduced on GE systems, but has since become available on Siemens
and Philips MR systems. Magnetic resonance elastography (MRE) enables the mea-
surement of liver stiffness with a 2D gradient echo using a 1.5 or 3 T magnetic reso-
nance systems [1].
Care must be taken when comparing results between US and MR elastography
due to the different parameters reported. An obstacle to direct comparison between
techniques is the frequency dependence of biological tissue. Higher frequency shear
waves produce higher stress and strain rates, resulting in higher stiffness measure-
ments. This can be problematic when comparing US elastography techniques, as TE
operates at 50 Hz, whereas ARFI and 2D-SWE operate at frequencies of 100–500 Hz
[8]. The frequency dependence, method of measurement, and parameter reported
(wave speed, E, or G*) should be considered when comparing elastography
techniques.
10.1.2 R
eliability, Failure Rates, and Applicability
of Elastography Methods
In the largest series to date, on more than 13,000 examinations in 7261 European
patients with chronic liver disease seen over a 5-year period, failure to obtain any
measurement was observed in 3% of cases and unreliable results (not meeting man-
ufacturer’s recommendations) in 16% [9], mostly due to patient obesity or limited
operator experience. As a result, TE applicability was 81%. The introduction of the
XL probe has improved the applicability of TE to more than 95% in patients with
NAFLD [10, 11]. Excellent interobserver reproducibility has been reported for TE,
with intraclass correlation coefficient (ICC) of 0.98 in a cohort of 200 patients with
various chronic liver diseases in whom 800 TE examinations were performed by
two operators [12]. However, reproducibility was significantly reduced in patients
with steatosis, increased BMI, and mild degrees of liver fibrosis.
The reliability of both pSWE/ARFI and 2D-SWE was compared in 79 patients
with measurements performed by three radiologists [13]. Failure rate was low for
both methods (5% for 2D-SWE and 1% for pSWE/ARFI), and intraobserver agree-
ment was significantly better for pSWE/ARFI than 2D-SWE (0.915 vs. 0.829).
Shear wave speeds measured with 2D-SWE were higher than pSWE/ARFI suggest-
ing that care should be taken when comparing methods. Scan-rescan repeatability of
2D-SWE measurements performed on the same day by the same operator has been
shown to be excellent with ICC of 0.95 and 0.93 for an expert and novice operator,
respectively [14]. However, intraobserver reproducibility between measurements
performed in the same subject on different days revealed ICC values of 0.84 and
0.65 for an expert and novice operator, respectively. There is further evidence to
146 L. Castera
suggest that operator experience has an effect on pSWE/ARFI measurements [15],

so operators are recommended to be suitably trained. With the introduction of
pSWE/ARFI and 2D-SWE into commercial US systems by many manufacturers,
interplatform variability may be an issue.
As for MRE, the failure rate is low (5.6%) in the largest series to date [16]. The
majority of these failures (71%) were attributed to iron deposition and the use of the
2D-GRE sequence. The test-retest repeatability of MRE is high [17–20], with
reported ICC of 0.95 [18]. In order to become a widely accepted method for diag-
nosis and staging of fibrosis, MRE must produce consistent results regardless of the
MR system used. Good interplatform reproducibility when using a 2D-GRE
sequence at 1.5 T has been reported, with ICC between 0.82 and 0.99 [21–23].
In summary, MRE and 2D-SWE appear to produce the highest rate of successful
measurements; however, the introduction of the XL probe has improved the appli-
cability of TE in overweight patients. Reproducibility is good to excellent among all
elastography techniques.
10.1.3 L
imitations of Liver Stiffness Measurement
with Different Methods
Though each elastography method has its own limitations, some drawbacks apply to
all techniques. For example, liver stiffness values increase after meal intake [24–
30]; therefore, elastography examinations should be performed after fasting for at
least 2 h [5], though fasting for 4–6 h prior to measurement has also been recom-
mended [8]. Similarly, cholestasis has been shown to cause increased liver stiffness
with TE [31], pSWE/ARFI [32], and MRE [33].
2D-SWE and pSWE/ARFI can be performed with one probe in all patients, inde-
pendent of body weight, as the ROI can be positioned manually at different depths
in the liver. As compared to TE, ascites is not a limitation for 2D-SWE and pSWE/
ARFI enabling their performance in decompensated liver cirrhosis for prognostic
reasons. The risk of overestimating liver stiffness values has been reported with
other confounding factors including ALT flares [34–36], congestive heart failure
[37], excessive alcohol intake [38–40], and acute viral hepatitis [34, 41]. The influ-
ence of steatosis is still a matter of debate with conflicting results, some studies
suggesting a detrimental effect [42, 43], whereas others do not [44–46].
In summary, US elastography techniques need to be performed using a standard-
ized protocol and with critically interpreted results, taking confounding factors into
account [5].
Although considered a highly accurate technique, MRE has several limitations.
The primary drawback with liver MRE is the sensitivity of 2D gradient recalled
echo (GRE) sequence to iron deposition. There is conflicting evidence on the effect
of BMI on MRE measurements: a recent study found that BMI was not a contribut-
ing factor in failure [47], but found waist circumference to be a significant factor of
failure. In contrast, a recent large retrospective study investigating the cause of
MRE failure using a 2D-GRE sequence [48] found that BMI, iron deposition,
massive ascites, and the use of 3 T were significantly associated with MRE failure.
The overall failure rate was low at 1.5 T (3.5%) though it increased to 15.3% at 3 T,
likely due to increased T2* relaxation at higher field strength.
10.1.4 R
espective Advantages and Inconveniences
of the Different Methods
Advantages and inconvenience of the different elastography methods are summa-

rized in Table 10.1. Advantages of TE are that it is a widely available point-of-care
technique, with a short procedure time (<5 min) and immediate results, that can be
performed in the outpatient clinic by a nurse after a short learning curve. Quality
criteria are well defined, based on at least ten validated measurements and an inter-
quartile range (IQR, reflects variations among measurements) of less than 30% of
the median value (IQR/LSM ≤30%). It is the most validated technique with the
highest level of evidence in most diseases. The main limitations of TE in clinical
practice are that it requires a dedicated device and that its applicability is limited
(80%) in case of obesity and limited operator experience, when using the M probe.
However, the use of XL probe in patients with BMI higher than 30 kg/m2 increases
applicability above 95%.
Advantages of pSWE/ARFI and 2D-SWE are that they can be easily imple-
mented on commercial ultrasound machines, enabling hepatocellular carcinoma
surveillance with the same machine in patients with cirrhosis, for instance. The
larger ROI used in pSWE/ARFI and 2D-SWE possibly has an advantage over TE;
however, these techniques also require more operator training and expertise. Quality
criteria for the performance and interpretation of pSWE/ARFI and 2D-SWE are not
well defined by the manufacturers.
Advantages of MRE include its ability to analyze almost the entire liver and its
applicability to patients with obesity or ascites. However, MRE has limited avail-
ability and is too costly and time-consuming to be used in routine practice and thus
more suited for research.
10.2 Performance of Elastography Techniques

for Diagnosing Cirrhosis
Early detection of compensated cirrhosis is critical in the management and surveil-

lance of patients with chronic liver disease as these patients are the most at risk of
developing complications related to portal hypertension or liver insufficiency and
hepatocellular carcinoma [49].
The diagnostic accuracy of TE for cirrhosis is based on large meta-analyses
including several thousands of patients in viral hepatitis B [50] and C [51], NAFLD
[52] and ALD [53], and considered excellent (AUROCs 0.93–0.96) with sensitivi-
ties and specificities of 84–91% and 85–89%, respectively (Table 10.2). However, a
meta-analysis based on individual data is still awaited. Actually, TE is better at
148
Table 10.1 Comparison of elastography methods for liver fibrosis staging (Adapted from ref. [10])
Confounders
Inflammation Level of
Techniques Units (range) Quality criteria Failure (%) obesity others evidence Availability Cost
TE kPa (2–75) Well-defined #3 ++ ++ Congestion High +++ $
IQR/M <30% XL XL probe Steatosis?
pSWE/ARFI m/s (0.5–4.4) Not well 2 +? +? Similar to TE? Intermediate ++ $$
defined Limited data limited data Limited data
2D-SWE kPa (2–150) Not well 13 +? +? Similar to TE? Intermediate ++ $$
defined Limited data limited data Limited data
MRE kPaa (2–11) Emerging <5 + − Congestion Low + $$$
QIBA Iron overload
consensus
statement
a
MR elastography is reported as shear modulus, while US elastography techniques are reported in Young’s modulus. Young’s modulus is three times the
shear modulus
L. Castera
Table 10.2 Diagnostic performances (meta-analyses) for cirrhosis of different elastography

methods, taking liver biopsy as reference
Studies Patients Cutoff
Etiology (N) (N) AUC (kPa) Se Sp
US elastography
TE
Li et al. [50] HBV 27 4386 0.93 9.0–16.9 86 87
Friedrich-Rust et al. CLD 50 8206 0.94 13.0 91 89
[51] (HCV)
Xiao et al. [52] NAFLD 13 1780 0.94 10.3–11.3 88 86
Nguyen-Khac et al. ALD 10 1026 0.91 18.6 84 85
[53]
pSWE/ARFI
Hu et al. [58] HBV/HCV 21 2691 0.91 2.4 m/s 86 84
2D-SWE
Hermann et al. [59] HBV 1 400 0.95 11.5 80 93
HCV 1 379 0.93 13.0 86 88
NAFLD 1 156 0.92 13.0 75 88
MR elastography
MRE
Singh et al. [61] CLD 12 697 0.92 4.7 91 81
Xiao et al. [60] HBV 9 1470 0.97 4.6 89 92
Xiao et al. [52] NAFLD 3 384 0.97 4.1–6.7 87 93
ruling out, rather than ruling in, liver cirrhosis (with negative predictive value higher
than 90%). Different cutoffs have been proposed for different causes of liver dis-
eases (HCV, HBV, NAFLD, and ALD), but no consensus has been reached. As
shown in Table 10.2, cutoffs for cirrhosis ranged from 9.0 kPa in HBV to 18.6 kPa
in ALD. This may be related to the so-called spectrum bias, depending on the
uneven distribution of different fibrosis stages in different cohorts [54, 55]. For
instance, in ALD cohorts, prevalence of cirrhosis is usually higher (40–50%) than in
HBV (10–20%). Also, cutoffs in ALD should be adjusted according to transaminase
levels and ongoing alcohol intake. In that respect, the Baveno VI consensus work-
shop recommended a diagnosis of compensated liver cirrhosis in asymptomatic
patients using TE, if liver stiffness values are repeatedly (two different days, fasting)
≥15 kPa [49]. Recently, it has been shown that in NAFLD patients, the same cutoffs
of <10 kPa and ≥15 kPa could be used to rule out and rule in compensated cirrhosis,
respectively, when using M probe in patients with BMI <30 kg/m2 and XL probe in
those with BMI >30 kg/m2 [46]. Finally, when compared head-to-head with serum
markers, TE outperforms all of them [56, 57].
pSWE/ARFI performance for diagnosing cirrhosis has been evaluated mainly in
viral hepatitis with high accuracy (AUROC 0.91) and cutoff of 2.4 m/s [58].
2D-SWE has been evaluated in a meta-analysis [59], based on individual data in
1340 patients with chronic liver diseases, reporting high accuracies (AUROCs
0.93–0.95) for cirrhosis with an optimal cutoff of 13.5 kPa.
150 L. Castera
As for MRE, evidence is based on a few hundreds of patients [52, 60, 61], but
with excellent accuracy (97%) for diagnosing cirrhosis. However, widespread use
of this method will depend on cost and availability. Finally, it should be kept in mind
that cutoffs for cirrhosis are system specific.
10.3 omparison of Elastography Methods and Other

C
Noninvasive Tests
All elastography methods have higher accuracy for diagnosing advanced fibrosis
and cirrhosis than lower fibrosis stages. When evaluating US elastography methods
alone, a meta-analysis of 13 studies including 1163 patients found that pSWE/ARFI
had similar diagnostic performance than TE for advanced fibrosis and cirrhosis
[62]. Studies comparing TE to pSWE/ARFI [63] and 2D-SWE [64, 65] have found
ARFI methods to provide similar or superior diagnostic performance to TE. In com-
parisons of all three methods, pSWE, 2D-SWE, and TE [66–68], 2D-SWE was the
slightly superior method for staging fibrosis [66] with variable reliability compared
to pSWE/ARFI [67, 68].
A few comparative studies investigating the diagnostic accuracy of MR and US
elastography methods have been published. Though MRE was generally found to be
superior to TE in diagnosing fibrosis in mixed cohorts [69–71] and NAFLD patients
[72, 73], other studies have found both techniques to perform similarly [47, 74].
Less literature on the comparison of MRE to pSWE/ARFI and 2D-SWE is avail-
able, though a meta-analysis assessing the diagnostic accuracy of pSWE/ARFI (15
studies, 2128 patients) and MRE (11 studies, 982 patients) for staging fibrosis found
that MRE is more accurate than pSWE/ARFI, particularly in diagnosing early
stages of fibrosis [75]. MRE has also been compared to 2D-SWE in a mixed etiol-
ogy cohort [76] which found comparable diagnostic accuracy for both techniques in
staging fibrosis. MRE has also been shown to outperform serum markers [69, 77–
81], morphologic features [82], and diffusion measurements [69, 83–87].
10.4 New Technical Developments
10.4.1 Controlled Attenuation Parameter (CAP)
A more recent application of TE is the controlled attenuation parameter (CAP) [88].

CAP, which is available on both M and XL probes, estimates the attenuation of the
US signal decibels per meter (dB/m) and (range from 100 to 400 dB/m) and is used
as a method to grade steatosis. A meta-analysis (19 studies including 2736 patients
with chronic liver disease), using the M probe, reported excellent accuracy for
detecting steatosis based on histopathology [89]. Recently, two large multicenter
studies using the XL probe in NAFLD patients reported high applicability (>95%)
and good performance for steatosis detection, but poor performance for quantifica-
tion [90, 91]. Although there are no consensual cutoffs, a CAP value >275 dB/m had
a positive predictive value >90% for detecting steatosis. When compared to proton
density fat fraction (PDFF) MR spectroscopy, using liver biopsy as reference, CAP
was outperformed by MRI-PDFF for grading steatosis [72, 73, 92].
In summary, CAP is a promising point-of-care technique for rapid and standard-
ized steatosis detection in patients with NAFLD. CAP needs to be compared to US
that, despite its limitations, remains the most widely used tool for first-line steatosis
assessment.
10.4.2 3D MRE
Though the acquisition of all three directions of motion is not a new development
[93], advances in inversion algorithms and the increasing availability of research 3D
MRE imaging sequences have made the technique more accessible. 3D MRE
enables the determination of additional parameters compared to 2D owing to the
acquisition of the full wave field and fewer assumptions about the material model
during inversion. These parameters, such as volumetric strain, which has been
shown to be sensitive to pressure-related changes [94] and may have applications in
the diagnosis of portal hypertension, are still being evaluated to establish clinical
benefit. The acquisition of all three motion directions also addresses the issue of
artificially increased wavelengths due to oblique 2D waves violating the planar
wave assumption [95]. In a head-to-head comparison between 3D MRE and 2D
MRE, 3D MRE at 40 Hz was superior to 2D MRE at 60 Hz with an AUROC for the
detection for advanced fibrosis of 0.98 (3D MRE) versus 0.92 (2D MRE) [96].
However, processing of 3D MRE takes a much longer time and has yet not been
applied in multicenter studies. 3D MRE appears to be an extremely promising tool
for longitudinal changes in fibrosis assessment. Further studies are needed to deter-
mine its role in fibrosis assessment in routine clinical practice. Spleen stiffness has
also been assessed with 3D MR elastography [97], with liver stiffness and spleen
stiffness significantly associated with the presence of esophageal varices.
10.4.3 Multifrequency MRE
Generally, MRE examinations are performed by imaging shear waves at a single

frequency (typically at 60 Hz). The stiffness of tissue is dependent on the fre-
quency of the imaged waves, so examinations at a frequency other than 60 Hz will
result in a different stiffness measurement. The use of multifrequency MRE,
where acquisitions acquired at multiple frequencies are performed, may lead to
the development of parameters that are independent of frequency through visco-
elastic modeling [98–100] or via analysis of the regression line of stiffness and
frequency [101]. Another application of multifrequency data is combining the
wave fields from each frequency to improve the resulting elastogram. This is
achieved by accounting for areas of low displacement and wave nodes that are
present in each wave field, but the location of which varies depending on
152 L. Castera
frequency. A downside of the acquisition of multiple frequencies is the increased

scan time, as each additional frequency incrementally increases the scan time
limiting clinical adoption, and the associated challenges with increased wave
attenuation at higher frequencies. Thus, the diagnostic benefit of multifrequency
over single-frequency MRE must be established.
10.5 Conclusions
US and MR elastography techniques have developed into accurate methods for

quantitative, noninvasive diagnosis of liver fibrosis in a wide range of etiologies.
Interpretation of results should take into account potential confounding factors of
liver stiffness measurements, pitfalls, and technical limitations. MR elastography
has equivalent, or slightly better, diagnostic accuracy to TE, pSWE/ARFI, and
2D-SWE while providing stiffness measurement over a larger area of the liver.
However, MRE requires further validation, and the higher cost and limited avail-
ability will likely limit adoption worldwide. In liver referral centers performing a
large number of MR imaging examinations, it is feasible to incorporate MRE into
the standard imaging protocols to provide a fibrosis staging tool. The weight of
published data on TE has allowed the establishment of cutoffs for staging liver
fibrosis and diagnosing cirrhosis in clinical practice for most etiologies. pSWE/
ARFI and 2D-SWE have shown similar diagnostic accuracy than TE, and it is rea-
sonable to assume that once sufficient data has been acquired to fully validate these
methods, they will also become a recommended noninvasive measurement tool for
staging of liver fibrosis. The emergence of advanced techniques like 3D MRE and
CAP may increase the accuracy of fibrosis and steatosis staging in liver disease,
although more data is needed.
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The Assessment of Portal Hypertension
11
Avik Majumdar, Giovanni Marasco, Amanda Vestito,
Massimo Pinzani, and Davide Festi
11.1 eneral Concepts on the Pathophysiology of Portal

G
Hypertension in Advanced Chronic Liver Disease
Portal hypertension (PH) and the relative clinical manifestations represent major
complications of advanced chronic liver disease (ACLD) irrespective of the aetiol-
ogy. Fundamentally, PH is caused by a progressive increase in the resistance to
portal blood flow into the liver due to substantial angio-architectural changes asso-
ciated with liver tissue fibrosis, neo-angiogenesis and increased vascular tone within
the hepatic microcirculation. Intrahepatic vasoconstriction, due to an unbalanced
predominance of vasoconstrictors, accounts for at least 25–30% of increased intra-
hepatic vascular resistance [1]. Phenotypic changes in hepatic cells, such as hepatic
stellate cells (HSCs) and liver sinusoidal endothelial cells (LSECs), are known to
play pivotal roles in causing an increased intrahepatic vascular resistance and have
been extensively studied [2, 3]. HSCs are perisinusoidal pericyte-like cells located
in the space of Disse. In response to liver injury, HSCs become activated and
undergo a phenotypical transition into myofibroblast-like cells, with an exponential
increase in the expression of pro-fibrogenic and pro-inflammatory genes [4]. In
Avik Majumdar, Giovanni Marasco, and Amanda Vestito contributed equally to this work.
A. Majumdar
AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital,
Sydney, NSW, Australia
Central Clinical School, The University of Sydney, Sydney, NSW, Australia
G. Marasco · A. Vestito · D. Festi
Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
M. Pinzani (*)
UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Centre, Royal Free
Hospital, London, UK
e-mail: m.pinzani@ucl.ac.uk

https://doi.org/10.1007/978-3-030-74132-7_11
160 A. Majumdar et al.
addition, activated HSCs become highly contractile, and their concentration around
existing sinusoids, as well as their recruitment around newly formed venous vessels,
contributes to the progressive increase in intrahepatic vascular resistance typical of
cirrhosis [5]. LSECs represent the first line of defence protecting the liver from
injury and play key homeostatic functions including the regulation of sinusoidal
vascular tone. Chronic liver tissue injury is associated with the loss of the key spe-
cialised functions of LSECs leading to “endothelial dysfunction”, which is primar-
ily characterised by the inability of regulating sinusoidal blood flow (defective
synthesis of nitric oxide and increased release of vasoconstrictors) but also by the
promotion of inflammation and fibrogenesis [6]. LSECs as well as other liver endo-
thelial cells are the main target of pro-angiogenetic growth factors with the develop-
ment of an increased number of vessels in the fibrotic septa and the surrounding
regenerative nodules [7]. As an ideal crossroad between fibrogenesis and angiogen-
esis, activated HSCs promote angiogenesis by releasing pro-angiogenic factors,
such as angiopoietin and vascular endothelial growth factor (VEGF) [8].
It is important to stress that the relationship between the cirrhotic transformation
of the liver and PH is extremely close and chronologically linear until extra-hepatic
factors become determinant in the progression of PH. Indeed, the development of
PH is progressively associated with an expansion of the splanchnic microcirculation
due also to neo-angiogenesis, with a marked increase in the total portal blood flow
reaching the liver [1, 3]. This leads to a further increase of PH, which, in turn, causes
the opening of collateral vascular circuits with portal blood escaping into the sys-
temic circulation. In a further phase of progression, the presence of arterial vasodi-
lation in the splanchnic and systemic circulations leads to the so-called hyperdynamic
circulation with an increase of cardiac output and consequent further increase in
portal blood inflow and PH [1]. These pathophysiological considerations are of key
relevance when evaluating the accuracy of non-invasive methods for the assessment
of PH such as liver and spleen stiffness as will be expanded in this chapter.
11.1.1 The Standard Assessment of Portal Hypertension
The gold standard method for evaluating the severity of portal hypertension is the
hepatic venous pressure gradient (HVPG), calculated through accessing the hepatic
vein and subtracting the free hepatic vein pressure (FHVP) from the wedged hepatic
vein pressure (WHVP) [9]. The normal HVPG is <5 mmHg, and although an HVPG
5–10 mmHg reflects an abnormal increase in portal pressure, complications only
tend to occur for HVPG >10–12 mmHg [1]. In clinical practice, an HVPG
>10 mmHg defines “clinically significant PH” (CSPH), while an HVPG >12 mmHg
outlines “clinically severe PH”. Patients with CSPH are at an increased risk of
developing gastroesophageal varices, overt clinical decompensation (ascites, vari-
ceal haemorrhage and hepatic encephalopathy), postsurgical decompensation and
hepatocellular carcinoma [1]. Although the technique of acquiring the HVPG val-
ues is relatively straightforward, specialist training is still required to achieve accu-
rate measurements.
11 The Assessment of Portal Hypertension 161
11.2 iver Elastography (Transient, US-Based)

L
as a Diagnostic and Prognostic Tool in PH
Liver elastography has evolved beyond its original purpose of staging liver fibrosis
to provide important diagnostic and prognostic information in the setting of
PH. Measurement of liver stiffness using vibration-controlled transient elastogra-
phy (VCTE) remains the most studied elastography modality in the assessment of
PH, with the role of point shear wave elastography (pSWE) and 2D-shear wave
elastography (2D-SWE) still being established [10].
11.2.1 C
linically Significant Portal Hypertension
and Liver Elastography
Liver elastography provides an indirect representation of the intrahepatic resistance

component of PH in established ACLD. There is a strong linear correlation between
VCTE and HVPG values of up to 10–12 mmHg [11, 12]. This correlation is less
robust once HVPG exceeds this threshold, supporting the concept that alterations in
portosystemic blood flow become the dominant pathophysiologic mechanism as
portal pressure increases [12]. These alterations are influenced by factors including
the hyperdynamic circulation, splanchnic vasodilatation and portosystemic shunt-
ing seen in clinically severe PH, which are not directly or indirectly quantified by
liver elastography [10]. Therefore, liver elastography in isolation can determine the
presence or absence of CSPH but cannot provide a direct approximation of
HVPG values.
VCTE has very good diagnostic accuracy in detecting if CSPH is dichotomously
present or absent. A meta-analysis of 11 studies with HVPG measurements found
the summary area under the receiver operating characteristic curve (AUC) for VCTE
to detect CSPH was 0.90. Lower cut-offs of VCTE (13.6–18 kPa) resulted in greater
sensitivity (92%) for CSPH, with higher cut-offs (21–25 kPa) yielding higher speci-
ficity (91%) [13]. Furthermore, similar cut-off values for VCTE have been shown to
stratify patients with potentially resectable hepatocellular carcinoma by the pres-
ence or absence of CSPH [14]. From these data, current consensus guidelines sup-
port a VCTE cut-off of >20–25 kPa for diagnosing CSPH [15–17].
Similar to fibrosis assessment using VCTE, the study populations in which
CSPH has been investigated have had compensated ACLD (cACLD) predominantly
due to chronic viral hepatitis, suggesting that more data in other aetiologies of liver
disease is necessary. Other non-technical limitations of VCTE in assessing CSPH
are that it cannot be used to assess the haemodynamic response to beta-blockers
[18], nor can it predict resolution or reduction of PH after sustained virological
response (SVR) in chronic hepatitis C virus (HCV) infection [19]. A recent follow-
up study of 226 patients at 96-week post-SVR found that 30% still had CSPH on
HVPG measurement despite VCTE values reducing to <13.6 kPa [20]. The diagnos-
tic accuracy of VCTE in detecting CSPH can be improved in algorithms that involve
various combinations of sonographic spleen size, spleen stiffness, laboratory values

or clinical data.
In comparison to VCTE, there are limited studies investigating the relationship
of either pSWE or 2D-SWE with HVPG. This is compounded by the fact that pSWE
and 2D-SWE modalities both have several manufacturers with proprietary technol-
ogy, making large validation studies difficult. A meta-analysis of CSPH measured
by HVPG and liver elastography using either pSWE or 2D-SWE included nine
studies (three studies using pSWE, six studies using 2D-SWE). The summary AUC
for the detection of CSPH was 0.88 for both modalities of liver elastography [21].
In the four studies that included head-to-head comparisons of VCTE and SWE for
detecting CSPH, there was no statistical difference in sensitivity or specificity; how-
ever, the values for VCTE (summary sensitivity 74% and specificity 81%) were
lower than other published meta-analysis findings for VCTE alone [13]. The authors
of the SWE meta-analysis acknowledged the limitation of combining different SWE
modalities by several manufacturers, particularly in terms of defining a consistent
cut-off value to predict CSPH. A recent individual patient meta-analysis of 328
patients that investigated 2D-SWE using Supersonic Imagine Aixplorer® found that
a liver stiffness cut-off of <14 kPa can rule out CSPH with an AUC 0.88 [22].
However, the cohort was under-represented in terms of compensated cirrhosis.
Unlike VCTE, there is currently insufficient data to support cut-offs for either
pSWE or 2D-SWE that can rule in or rule out CSPH [17]. Both pSWE and 2D-SWE
are incorporated to standard B-mode ultrasound (US) machines and hence offer
technical advantages over VCTE by allowing the operator to visualise and position
the region of interest in real time. This overcomes some of the applicability issues
experienced in obese patients undergoing VCTE and allows liver elastography to be
performed at the same time as routine US screening for hepatocellular carcinoma.
Therefore, although pSWE and 2D-SWE are both promising tools in the assessment
of PH, both require further study.
11.2.2 Gastroesophageal Varices and Liver Elastography
Unlike the detection of CSPH, liver elastography alone has limited use in the detec-
tion or risk stratification of gastroesophageal varices. The role of VCTE has been
explored extensively in this setting by focussing on the detection or exclusion of
high-risk or large varices, which are also termed varices needing treatment (VNT).
A meta-analysis of 15 studies examining VCTE alone found that the summary sen-
sitivity and specificity was 84% and 62% for detecting any varices and 78% and
76% for large varices, respectively [23]. This low diagnostic accuracy was attrib-
uted to variations in VCTE cut-offs in the included studies across various aetiolo-
gies of chronic liver disease.
In 2015, the Baveno VI consensus meeting proposed that liver stiffness measure-
ment (LSM) of <20 kPa using VCTE combined with a platelet count
>150 × 109 cells/L could safely exclude VNT and, therefore, patients meeting these
criteria could avoid regular surveillance endoscopy due to a low perceived risk of
bleeding [23]. Since then, the Baveno VI criteria have been widely studied and also
have been modified in attempts to improve clinical utility [24–26]. A meta-analysis
of 8469 participants from 30 studies found that the summary sensitivity and speci-
ficity for Baveno VI criteria for VNTs was 97% and 32%, respectively. By compari-
son, the “expanded” Baveno VI criteria (VCTE <25 kPa and platelet count
<110 × 109 cells/L) had a summary sensitivity and specificity of 90% and 51%,
respectively. In a hypothetical cohort of 1000 patients with a VNT prevalence of
20%, the use of the Baveno VI criteria would result in 262 spared endoscopies, but
six patients with VNT would be missed, compared to the expanded Baveno VI cri-
teria which would result in 428 spared endoscopies but at the cost of 20 patients
with VNT being missed [27]. A subsequent decision curve analysis of these data
favoured the latter strategy [28]. Validating pSWE and 2D-SWE for the detection or
exclusion of VNT results in the same challenges as diagnosing CSPH using these
modalities. There is a paucity of data regarding liver elastography alone using either
pSWE or 2D-SWE for the detection of varices; however, progress has been made in
terms of using these modalities for measurement of spleen stiffness [29].
Liver elastography using VCTE can detect or exclude CSPH and, when used in
combination with platelet count, can safely avoid variceal surveillance endoscopies.
These simple applications of VCTE have revolutionised hepatology clinical prac-
tice. Although pSWE and 2D-SWE are promising modalities, larger validation stud-
ies are required before defined cut-off values can be applied in the clinical setting
for CSPH or gastroesophageal varices. Both pSWE and 2D-SWE liver stiffness
measurement (LSM) can readily be combined with spleen stiffness to provide better
diagnostic accuracy and will be discussed in the next section.
11.3 The Spleen in Advanced Chronic Liver Disease
In the last decade, several authors have focused their attention on the study of
spleen-related parameters [30]. Indeed, chronic PH causes spleen congestion,
hyperplasia, angiogenesis, fibrogenesis, enlargement and hyperactivation of the
lymphoid tissue [31, 32]. Taken together, these factors may better mirror the
PH-related hyperdynamic circulation. According to this pathophysiological hypoth-
esis, spleen stiffness measurement (SSM) has been proposed [33, 34] as a non-
invasive tool (NIT) to assess the presence and degree of PH and oesophageal
varices (EV).
11.3.1 Spleen Stiffness Measurement Techniques
The evaluation of SSM has often been reported concomitantly with the evaluation
of LSM [35]. US elastography and magnetic resonance elastography are the meth-
ods most commonly used. Thereafter, the US device analyzes the feedback gener-
ated by the tissue and depending on its stiffness to the shear wave [36, 37]. To date,
no validated algorithm exists for the specific evaluation of SSM as all studies
evaluating SSM use the standardised criteria that were already present for assessing
LSM. Moreover, several factors may influence SSM feasibility: first, the spleen
anatomical location is deeper than that of the liver, and this may reduce the acoustic
window; second, feasibility is dependent on the spleen diameter and the fat thick-
ness between the US probe and the spleen [33]. For these reasons, most of the stud-
ies carried out with VCTE, which is the most common technique for evaluating
SSM, used US guidance for better targeting the spleen parenchyma [38, 39] and
pre-existing LSM feasibility and validity recommendations (M probe, patient lying
supine or prone, fasting period of at least 6 h, success rate >60%, IQR >30% and at
least ten valid measurements) [38]. Another possible limitation of SSM by VCTE is
the ceiling effect of the upper limit value of stiffness set at 75 kPa, likely due to the
fact that the VCTE probe was initially designed for the liver. Indeed, the spleen is
stiffer than the liver, and this could limit further stratification of PH for values above
75 kPa. To overcome this limit, a prospective multicentre study [39] using a novel
spleen-dedicated FibroScan® (SSM@100 Hz) concluded that SSM@100 Hz accu-
racy for ruling out large EV (AUC 0.782) was higher than that reached with the
standard LSM probe (SSM@50 Hz, AUC 0.720, p = 0.027). However, SSM by
VCTE still remains the most used technique mainly due to high inter- and intra-
observer agreement (0.89 and 0.94, respectively) [40, 41] and an acceptable failure
rate (around 15–20%) [40]. Similar to LSM, several other US modalities beyond
VCTE have been used for SSM leading to difficult comparisons of the different
thresholds obtained in each study [42]. For example, pSWE allows direct assess-
ment of spleen stiffness in a region of interest chosen by the operator, thus avoiding
the influence of ascites, obesity or narrow intercostal spaces [43, 44] and leading to
an overall feasibility of 85–100%. However, low inter-and intra-observer agreement
has been reported [45, 46]. On the other hand, the newer elastography techniques of
2D-SWE and real-time two-dimensional shear wave elastography (RT-2D-SWE)
have a similar feasibility range to pSWE but with higher intra- and inter-operator
reproducibility [47].
11.3.2 Spleen Stiffness and Fibrosis Degree Evaluation
During the natural history of chronic liver disease, structural changes driven by PH
occur in the spleen, which enlarges not merely due to congestion. The degree of
liver cirrhosis degree influences the degree of PH, which in turn influences the
spleen structural changes and its stiffness.
Since the prognosis of patients with ACLD is largely dependent on the stage of
liver fibrosis and the presence of cirrhosis, several authors have postulated that SSM
might be useful in determining liver fibrosis as surrogate of LSM or liver biopsy,
when these methods are unfeasible or with unreliable results. Recently, it was
reported that spleen stiffness was increased already in early chronic liver disease
when compared to healthy subjects [48]. Another study by Chen et al. [49] using
SSM to classify patients according to METAVIR fibrosis (METAVIR F) scores
reported AUC 0.839 (95% CI: 0.780–0.898) for METAVIR F1 vs. F2–4, AUC 0.936
(95% CI: 0.898–0.975) for F1–2 vs. F3–4 and AUC 0.932 (95% CI: 0.893–0.971)
for F1–3 vs. F4. In parallel, Leung et al. [50] defined specific SSM cut-off points for
discriminating the different liver fibrosis stages: F1 19.4 kPa, F2 19.8 kPa, F3
20.6 kPa and F4 22 kPa. Several other studies [40, 50–52] have confirmed similar
results. However, SSM thresholds for defining the presence of liver cirrhosis are still
not yet validated and suffer from wide variability (ranging from 22 to 46 kPa or
from 2.51 to 3.32 m/s) [35].
11.4 pleen Elastography as a Diagnostic and Prognostic

S
Tool in Portal Hypertension
Several attempts have been made to replace HVPG as the gold standard for assess-
ing PH in cirrhotic patients [53]. The morphological remodelling of the spleen in
patients with PH has justified the use of SSM as another surrogate parameter of PH
in cirrhosis [31, 33]. SSM is able to more accurately reflect the dynamic changes
concerning the splanchnic circulation occurring in advanced stages of cirrhosis than
LSM [54]. In 2002, Colecchia et al. [33] demonstrated a strong correlation between
SSM and HVPG values in a series of 113 consecutive HCV-related cirrhotic patients,
suggesting that the increase in SS is closely related to PH progression.
The first meta-analysis to support the possibility of using SSM for the diagnosis
of CSPH [55] found good accuracy with a summary sensitivity and specificity of
0.88 (95% CI 0.7–0.96) and 0.84 (95% CI 0.72–0.92), respectively. Other authors
have tried to assess SSM with other US elastography methods beyond VCTE. Attia
et al. [56] assessed the use of SSM by pSWE in 78 patients with compensated
ACLD (cACLD) documenting that SSM could identify an HVPG ≥10 mmHg (cut-
off 2.32 m/s) and an HVPG ≥12 mmHg (cut-off 2.53 m/s) with high accuracy (AUC
0.97 and 0.95, respectively). In a large prospective multicentre study using 2D-SWE,
Jansen and colleagues [57] proposed an algorithm to rule out and rule in CSPH,
with cut-offs of 21.7 kPa for LSM and 35.6 kPa for SSM.
11.4.1 Spleen Stiffness and Gastroesophageal Varices
Recently, the possibility of detecting the presence and the degree of EV using
SSM in cirrhotic patients was explored. Indeed, several studies have shown that
SSM was more accurate when compared to other non-invasive parameters in
identifying patients with EV and different degrees of PH [33, 34, 58]. For exam-
ple, Colecchia et al. [33] demonstrated that SSM was more accurate than LSM in
predicting the presence of EV. Similarly, Stefanescu et al. [34] confirmed these
results on the usefulness of SSM. Notably in the latter study, a comparison
between SSM performance in detecting EV with other validated non-invasive
parameters was also carried out, confirming the superiority of SSM [34]. A cut-
off value of 46.4 kPa was proposed for identifying EV. Ma et al. [59], in a recent
meta-analysis of 16 studies performed with different ultrasound-elastography
methods, confirmed that SSM was more accurate than LSM in predicting the
presence of EV. Recently, Colecchia et al. [60] reported that a combined algo-
rithm using Baveno VI criteria and SSM (cut-off 46 kPa) was able to safely spare
a greater number of unneeded endoscopies in patients with cACLD. Indeed,
when the proposed algorithm combining Baveno VI criteria and SSM was
applied, the proportion of spared endoscopies doubled and the rate of missed
VNT safely remained less than 5%. A recent retrospective study reporting a
sequential combination of the Baveno VI criteria and SSM measured by super-
sonic shear imaging (SSI) reported similar results [61].
Interestingly, SSM may be useful even when dynamically assessed, similarly
to HVPG. Two recent studies reported SSM to predict the response to non-selec-
tive beta-blockers for EV bleeding prophylaxis [62, 63]. In the latter study [63], a
SSM reduction ≥10% was able to assess haemodynamic response, in parallel
with HVPG.
11.4.2 Spleen Stiffness and Hepatic Decompensation
The presence, degree and time progression of CSPH are the main predictors of
hepatic decompensation in patients with cirrhosis [64]. SSM is an accurate surro-
gate marker of PH and, therefore, was recently proposed as a tool for predicting
hepatic decompensation and mortality in patients with cirrhosis [65]. Early recogni-
tion of patients with compensated cirrhosis at high risk for developing decompensa-
tion is necessary to allow the initiation of preventative strategies that are able to
prolong patient survival [66]. Although patients with compensated cirrhosis have a
median survival of 12 years, patients with decompensated cirrhosis have a median
survival of 2 years [67]. In a previous report, HVPG showed a greater discriminative
ability compared with serum albumin, model for end-stage liver disease (MELD)
and Child-Pugh score for decompensation. Patients with an HVPG less than
10 mmHg had a 90% probability of not developing hepatic decompensation over a
median follow-up period of 4 years [68]. In a study by Colecchia et al. [61], SSM
by TE and MELD were independently associated with the risk of hepatic decom-
pensation; patients with a SSM >54 kPa showed higher risk of developing liver-
related complications within 2 years of enrolment. In line with these results, Takuma
et al. [69] found that in a series of 393 ACLD patients, those with SSM <3.25 m/s
had a 98.8% probability of not developing hepatic decompensation. Conversely,
SSM >3.43 m/s was able to predict mortality over a median follow-up period of
44.6 months [69]. Recently, the ability of SSM in predicting hepatic decompensa-
tion was also tested [70] in a cohort of HCV patients undergoing treatment with
direct-acting antiviral agents (DAAs). In this cohort, SSM ≥54 kPa was indepen-
dently associated with decompensation, despite achievement of SVR or history of
decompensation. Interestingly, dynamic assessment of SSM identified that a SSM
reduction <10% after antiviral therapy was directly linked to the risk of decompen-
sation after SVR.
11.4.3 S
pleen Stiffness in Monitoring Outcome After
Interventional Procedure for PH
The prognostic value of SSM has been also proposed for the evaluation of tran-
sjugular intrahepatic portosystemic shunt (TIPS) function in decompensated cir-
rhotic patients [71]. TIPS is an established intervention in the treatment of
complications of PH such as bleeding from gastroesophageal varices, ascites or
hepatorenal syndrome by reducing portal pressure. Although determination of the
portosystemic pressure gradient is considered the reference standard for diagnosing
and monitoring portal hypertension, its use in monitoring TIPS is restricted to ter-
tiary centres and limited by invasiveness [72]. Among non-invasive ultrasound
imaging techniques, colour Doppler sonography is widely used for surveillance of
TIPS patency by measurement of intra-stent flow velocity [73]. However, anatomic
conditions sometimes make sonographic flow measurements inside the TIPS diffi-
cult. A decrease in SSM values after TIPS implantation is a useful additional param-
eter in monitoring proper TIPS function. Gao et al. [74] showed a statistically
significant difference in SSM values before and after TIPS implantation (p < 0.001)
using SWE. Notably, SSM significantly decreased after TIPS implantation on post-
interventional Day 1 and 28 in patients with patent stents, while LSM decreased
simultaneously without statistical significance. In line with these results, Buechter
et al. [75] showed that SSM variations after TIPS were similar to those of
HVPG. Indeed, a high degree of PH according to HVPG before TIPS implantation
was associated with a median SSM value of 67.1 kPa (standard deviation [SD]
17.3 kPa), whereas after TIPS, HVPG decreased together with SSM (44.7 kPa [SD
18.5 kPa], p < 0.05). This prompt decrease in both HVPG and SSM values is not
surprising as haemodynamic changes in the portal venous circulation occur imme-
diately after TIPS placement. These data demonstrated that SSM reflects portal
pressure excellently, even when rapid changes occur.
In conclusion, SSM evaluation is a promising tool to be used alone or in associa-
tion with other non-invasive markers, for monitoring patients with ACLD during
follow-up and for stratifying the risk of developing PH-related complications.
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Assessing Disease Severity
and Prognosis 12
Élise Vuille-Lessard, Ahmed Y. Elmahdy,
and Annalisa Berzigotti
12.1 Introduction
The natural history of advanced chronic liver disease (ACLD) can be divided in two
very different stages. The first is devoid of the typical complications of cirrhosis and
portal hypertension, usually completely asymptomatic and termed “compensated.”
Survival in this stage of the disease is good (5-year survival 90–98.5%) [1], and
mortality is usually unrelated to liver disease (except for that related to hepatocel-
lular carcinoma). This phase is followed by a “decompensated” stage characterized
by the onset of ascites, and/or variceal bleeding and/or hepatic encephalopathy,
which often recur and pose patients at high risk of further complications and death
(5-year survival depending on the type and number of decompensation and liver
function ranges 40–80% once entered in this stage) [1]. The onset of the first clinical
decompensation is driven by the presence of portal hypertension (see previous
chapter) and by additional factors such as reduction in liver function (low albumin,
increased bilirubin, and INR) and presence of obesity [2]. Several other factors can
play a role in aggravating the prognosis and accelerating the course of the disease
(e.g., alcohol consumption; genetic factors). In the era of effective antiviral thera-
pies, it has become clear as well that the removal of the main etiological agent of
liver damage can positively modify the natural history of ACLD, preventing clinical
decompensation and even reverting from a decompensated to a (re-) compensated
stage. The complexity of this changing scenario underlines how prognostic stratifi-
cation has to take into account several factors. However, it is known since years that
the severity of liver fibrosis (even beyond the presence of cirrhosis) and portal
hypertension are major factors to be considered to identify those patients at the
É. Vuille-Lessard · A. Y. Elmahdy · A. Berzigotti (*)

Hepatology, University Clinic for Visceral Surgery and Medicine (UVCM), Inselspital,
University Hospital of Bern, University of Bern, Berne, Switzerland
Department of Biomedical Research (DBMR), University of Bern, Berne, Switzerland
e-mail: annalisa.berzigotti@insel.ch

https://doi.org/10.1007/978-3-030-74132-7_12
174 É. Vuille-Lessard et al.
highest risk of clinical decompensation and death. Liver stiffness measurement

(LSM) has been robustly validated not only as a diagnostic test for assessing liver
fibrosis but also as a prognostic test. Spleen stiffness measurement (SSM) has been
more recently added to the diagnostic armamentarium of hepatologists. This chap-
ter summarizes the current evidence regarding the prognostic significance of both
tests in patients with advanced chronic liver disease.
12.2 Prediction of First Clinical Decompensation
12.2.1 Liver Stiffness
The previous chapter described how LSM correlates with HVPG and how it can
well discriminate between patients with and without CSPH. This observation justi-
fies why LSM also holds prognostic value for the development of first clinical
decompensation. Table 12.1 summarizes the most important studies reporting on
the prediction of first clinical decompensation and LSM measured by different
ultrasound elastography techniques.
Initial studies such as that of Grgurevic et al. [22] showed that patients with
decompensated cirrhosis had a higher LSM by 2D-SWE SSI than compensated
patients (35.3 kPa vs. 18.3 kPa, adjusted difference 65%, 95% CI 43–90%;
p < 0.001) [23]. A prospective, cross-sectional study showed that LSM by vibration-
controlled transient elastography (VCTE also commonly known as transient elas-
tography, TE) and by 2D-SWE SSI were significantly different in patients with
compensated, previously decompensated, and currently decompensated cirrhosis
(for TE, 15.9 kPa, 29.9 kPa, and 39.3 kPa, respectively; for 2D-SWE SSI, 15.2 kPa,
25.2 kPa, and 35.9 kPa, respectively), suggesting that LSM is a dynamic parameter
and can improve between episodes of decompensation.
Moreover, multiple long-term follow-up studies have shown that a higher base-
line LSM is associated with a higher risk of decompensation over time in patients
with compensated cirrhosis and performs similarly as the HVPG and better than
histology. This was confirmed by a recent systematic review and meta-analysis of
62 cohort studies including 43,817 patients with compensated cirrhosis [24] that
concluded to a pooled RR of 7.33 (95% CI 3.84–14.00) for decompensation in
patients with a higher baseline LSM by TE. This was in a dose-dependent fashion:
for each kPa increase in baseline LSM by TE, there was an 8% and 7% increase in
the risk of hepatic decompensation and liver-related events (LREs, a composite out-
come of HCC, hepatic decompensation, all-cause, and/or liver-related mortality),
respectively. The risk increased the most at lower ranges of baseline LSM and then
showed a slight decrease above 25 kPa, corresponding to a lesser magnitude of
effect when very high LSM values were reached. Two other meta-analyses yielded
similar results [25, 26]. In one of them [25], a 5-kPa increase in LSM was associated
with a 53% increase in the risk of developing LREs (RR 1.53; 95% CI 1.41–1.65),
with stabilization of the risk at approximately 34.5 kPa. The progression of LSM
over time in HIV/HCV-coinfected patients [27] and its lack of improvement after
12
Table 12.1 Accuracy of LSM and SSM using elastography techniques to predict complications and mortality in CLD
Median Complicationsa Overall/ Overall/liver-related
a
Method N included (% follow-up Complications AUROC (selected liver-related mortality AUROC
Study (year) used cirrhosis) Etiology (months) rate cut-offb) mortalityc rate (selected cut-off)
LSM
Robic et al. [3] TE 100 (65%) Mixed 16 41% 0.84 (21.1 kPa) N/A N/A
(2011)
Vergniol et al. [4] TE 1457 (18%) HCV 47 N/A N/A 5.3%/2.7% 0.82/N/A (N/A)
(2011)
Chon et al. [5] TE 1126 (18%) HBV 31 6% 0.82 (N/A) N/A N/A
(2012)
Kim et al. [6] TE 217 (100%) HBV 42 12% 0.77 (18 kPa) N/A N/A
(2012)
Kim et al. [7] TE 128 (86%) HBV 28 14.8% 0.72 (19 kPa) N/A N/A
(2012)
Assessing Disease Severity and Prognosis
Merchante et al. TE 239 (93%) HIV- 20 13% 0.72 (40 kPa) 6%/4.2% 0.602/0.728 (N/A)
[8] (2012) HCV
De Ledinghen TE 600 (23%) HBV 50 N/A N/A 4.8%/2.8% 0.80/N/A (20 kPa)
et al. [9] (2013)
Corpechot et al. TE 168 (14%) PSC 47 14% N/A 3.6%/3.0% N/A (18.5 kPa)
[10] (2014)
Pang et al. [11] TE 2052 (15%) Mixed 16 3.4% N/A (20 kPa) 0.8%/N/A 0.67/N/A (N/A)
(2014)
Pérez-Latorre TE 60 (53%) HCV/ 42 25% 0.85 (25 kPa; 10%/N/A N/A
et al. [12] (2014) HIV, 40 kPa)
HCV
Wang et al. [13] TE 220 (100%) Mixed 37 22.3% 0.929 (21 kPa) N/A N/A
(2014)
Kitson et al. [14] TE 95 (93%) Mixed 15 30% 0.73 (34.5 kPa) 14%/10% N/A
(2015)
175
(continued)
176
Median Complicationsa Overall/ Overall/liver-related

a
Method N included (% follow-up Complications AUROC (selected liver-related mortality AUROC
Study (year) used cirrhosis) Etiology (months) rate cut-offb) mortalityc rate (selected cut-off)
Park et al. [15] TE 151 (40%) HBV 60 11.9% N/A 2%/2% 0.70/N/A (N/A)
(2015)
Wong et al. [16] TE 1555 (32%) HBV 69 7.6% N/A 3.6%/1.7% N/A
(2015)
Dillon et al. [17] TE 259 (100%) Mixed 36 8.1% N/A (21 kPa; N/A N/A
(2018) 35 kPa)
Wu et al. [18] SSI 430 (14%) HBV 48 6.7% 0.86 (N/A) N/A N/A
(2020)
Shili-Masmoudi TE 2251 (13% with NAFLD 27 0.9% N/A 2.4%/N/A 0.797/N/A (12 kPa)
et al. [19] (2020) LSM >12 kPa)
SSM
Colecchia et al. TE 92 (100%) HCV 24 32.6% 0.85 (54 kPa) N/A N/A
[20] (2014)
Takuma et al. pSWE 393 (100%; Mixed 45 12.5% (in 0.843 (in 17%/N/A 0.824 (3.41 m/s in
[21] (2017) 71% compensated compensated compensated
compensated) patients) patients) patients; 3.53 m/s in
(3.25 m/s) decompensated
patients)
AUROC area under the receiver operating characteristic curve, HBV hepatitis B virus, HCV hepatitis C virus, HIV human immunodeficiency virus, LSM liver
stiffness measurement, N/A not applicable, NAFLD non-alcoholic fatty liver disease, NPV negative predictive value, PSC primary sclerosing cholangitis, SSM
spleen stiffness measurement, SSI supersonic imagine, pSWE point shear wave elastography, TE transient elastography
a
Includes decompensation events +/− HCC, OLT, and death depending on the study
b
Selection criteria vary (combination of best sensitivity and specificity, or PPV/NPV, or based on prior studies, or dual cut-off with prediction of no events vs.
events or “low risk” vs. “high risk” of events)
c
Included OLT in some studies
É. Vuille-Lessard et al.
12 Assessing Disease Severity and Prognosis 177
Compensated At risk of Decompensated

state decompensation state
10 20-25 35-40
LSM by TE (in kPa)
Fig. 12.1 Cut-off values of LSM by TE (in kPa) corresponding to compensated, at risk of decom-
pensation, and decompensated stages of ACLD
direct-acting antiviral (DAA) therapy in patients with compensated HCV cirrhosis

[28] were also found to have a prognostic value for decompensation, which supports
the longitudinal use of LSM.
The LSM by TE cut-off value that identifies current decompensation (including
a “pre-decompensated” stage, i.e., ascites only detectable by US) seems to be
around 35–40 kPa (Fig. 12.1) [12, 22, 23]. As for the cut-off value that predicts the
occurrence of decompensation, it seems to be similar to the one that predicts CSPH,
i.e., approximately 20–25 kPa [3, 7, 11–13, 17, 28], with overall AUC in the
0.86–0.88 range [18, 29]. LSM by 2D-SWE seems to perform as well as LSM by
TE in predicting hepatic decompensation [18], and similar cut-off values have been
proposed [23]. Data is lacking for LSM by pSWE.
Some studies have tried to identify specific cut-off values for each decompensa-
tion event, specifically variceal bleeding and ascites [22, 29–31], but no agreement
has been reached so far, probably reflecting the poor correlation of LSM with the
portal pressure in more severe PH. This issue might be partly resolved by the use of
SSM, as discussed below.
Most of the studies assessing the prognostic ability of LSM were done in patients
with viral etiologies of cirrhosis such as HCV [12, 32], HCV/HIV coinfection [8,
12, 33], and HBV [5, 6], but the association has also been found in NAFLD [19] and
PSC [10], and other study cohorts had mixed etiologies. Patients with cirrhosis and
HCV/HIV coinfection seem to have a particularly steep rise in the risk of decom-
pensation with increasing LSM [24].
LSM by MRE has also been associated with hepatic decompensation as a single
measurement [34–36] and with progression over time [37].
Since post-hepatectomy liver failure (PHLF)/clinical decompensation is the
leading cause of death after HCC resection, the prognostic ability of preoperative
LSM in this context has been a topic of interest [38]. For instance, Wu et al. observed
a significantly different LSM (by TE) in patients who did and did not develop post-
operative liver decompensation (19.1 kPa vs. 11.9 kPa; p = 0.03) [39], while Cescon
et al. proposed a cut-off value of 15.7 kPa (by TE) to identify high-risk patients [40]
and Shen et al. 11.75 kPa (by 2D-SWE) [41]. Another study, using LSM by pSWE,
reached the same conclusion, with the most performant model combining LSM
with the remnant liver volume rate [42]. On the other hand, Procopet et al. found
that LSM had a similar performance as HVPG in predicting decompensation at

3 months but could not predict adequately post-hepatectomy liver failure [43]. A
nomogram based on LSM by TE (as well as age, MELD score, and albumin), the
CCI (Comprehensive Complication Index), was recently developed by Serenari
et al. to help predicting postoperative liver failure following HCC resection (AUC
0.751) [44].
As for TE-based CAP, data is inconclusive. Our group recently showed that a
CAP >220 dB/m with M probe was associated with an increased risk of clinical
decompensation and bacterial infections independently of LSM in patients with
cACLD [45]. Two other studies however could not confirm this association [46, 47],
and a bicentric study focusing on obese patients studied with XL probe suggested
that CAP below 220 dB/m (possibly indicating a more advanced disease in NASH
by absence of steatosis) would be an additional risk factor for decompensation in
this population [48].
12.2.2 Spleen Stiffness
A high spleen stiffness has been associated with a higher risk of hepatic decompen-
sation. For instance, in a study by Meister et al., all patients who developed hepatic
decompensation (n = 12) had a baseline SSM by TE ≥39 kPa [49], while Colecchia
et al. suggested a cut-off value of 54 kPa [20]. A SSM by SSI ≥31.7 kPa has been
associated with a 2.70-fold higher risk of event occurrence in patients with compen-
sated cirrhosis over a follow-up period of 18–48 months, with borderline signifi-
cance (p = 0.056) after adjustment for age and MELD [23]. The evolution of SSM
over time can also identify patients at risk of complications [50], supporting the
longitudinal use of SSM, as it is for LSM.
As discussed in the previous chapter, SSM potentially has multiple advantages
over LSM in the assessment of PH, which reflects in its prognostic accuracy. Indeed,
SSM outperformed LSM in predicting clinical decompensation in a few studies.
Takuma et al. observed that SSM by pSWE performed better than LSM (as well as
Child-Pugh and MELD scores) in predicting hepatic decompensation in patients
with compensated cirrhosis (HR 14.5; 95% CI 5.8–36.2), with a 14.5-fold risk
increase for each SS unit increase and with an optimal cut-off value of 3.25 m/s
(NPV of 98.8% and accuracy of 68.9%) [21]. The same group showed that SSM but
not LSM (by pSWE) was independently associated with an increased risk of vari-
ceal bleeding, with a AUC of 0.857 (maximal NPV at a cut-off value of 3.48 m/s)
[51]. Wang et al. showed that a SSM by TE cut-off value of 55.2 kPa had a sensitiv-
ity of 90% in predicting variceal bleeding [29], while Buechter et al. found that a
SSM cut-off value of 42.6 kPa had a 97% NPV for this complication [31]. In another
study, SSM but not LSM (by pSWE) correlated with the presence of ascites (AUC
0.80; 95% CI 0.63–0.98) [52].
As for the ability of SSM to predict PHLF, data is inconclusive [39, 53]. However,
interestingly, SSM predicted the development of hepatic decompensation after
radiofrequency ablation in patients with HCC in a recent study [54]. However, a
study showed that survival after liver resection was lower in patients with LSM
≥16.2 kPa, while SSM was not significantly different between those who survived
and those who did not [39].
12.2.3 Combination Tests
A few studies have observed that liver and spleen elastography have a prognostic
ability to predict decompensation when combined together or with other scores or
biomarkers. In a retrospective study of 143 patients, the combination of LSM (cut-
off value, 20.8 kPa) and SSM (cut-off value, 42.6 kPa) by TE (LSSM) had a 100%
NPV (sensitivity, 100%; specificity, 55%) in identifying those who had prior esoph-
ageal variceal bleeding, better than when taken separately [31].
In a large cohort of patients with HBV- or HCV-associated cirrhosis followed for
a median of 61.2 months, achieving a “favorable Baveno VI status” (i.e., LSM
<20 kPa and PLT >150 × 109/L) after SVR was associated with the absence of PH
progression (defined as the onset of VNT- or PH-related bleeding) as well as sur-
vival [55]. A study in patients with compensated HBV cirrhosis showed that patients
with LSPS 1.1–2.5 and ≥2.5 had a higher risk of hepatic decompensation (HR 5.8;
p = 0.004 and HR 13.6; p < 0.001, respectively) compared to those with LSPS <1.1
[6], and Chon et al. found that LSPS had an AUC of 0.848 in predicting decompen-
sation in patients with chronic hepatitis C [5]. A recent study showed that combin-
ing LSM and hyaluronic acid (specifically ≥200 ng/mL at baseline) provided could
better predict complications in patients with chronic hepatitis C than LSM alone [56].
Our group has recently shown that in patients with cACLD and overweight or
obesity, LSM, LSPS, and PH risk score have an excellent diagnostic accuracy (using
XL probe) to predict the first clinical decompensation (AUC 0.848, 0.881, and
0.890, respectively) [48].
As for liver failure after HCC resection, it could also be predicted by the platelet
to spleen stiffness ratio (PSR) [57] and the liver stiffness-spleen size-to-platelet
ratio score (LSPS) [53].
12.3 Prediction of Further Clinical Decompensation
LSM and SSM correlate well with outcomes in compensated cirrhosis, but data for
decompensated cirrhosis are scarce. A study in patients with alcoholic cirrhosis and
refractory ascites did not show any association between baseline LSM (by TE and
pSWE) or SSM (by pSWE) and incidence of events or transplant-free survival,
regardless if patients were treated with TIPS insertion or with conservative therapy
[58]. This could be explained by the limited correlation of stiffness and PH in very
advanced liver disease, for both liver and spleen.
The utility of elastography in patients with decompensated cirrhosis also lies in
the assessment of the response to treatment. For instance, a change in SSM was
shown to have a good performance in predicting response to NSBB in patients with
HRV [59], and patients treated with propranolol who had a decrease in LSM had a
lower risk of undergoing liver transplantation or death irrespective of HVPG [60].
Elastography has also been proven useful to monitor patients post TIPS. Jansen
et al. showed that an increase in LSM post TIPS reflects inflammation and predicts
organ failure and mortality [61]. Multiple studies observed a significant decrease in
SSM following TIPS, by both TE [62–64] and pSWE [65, 66], proposing it as a tool
to identify TIPS dysfunction. An exception is when there is concurrent embolization
or thrombosis of competitive shunts, where SSM may increase post TIPS [67]. An
increase in SSM by VTQ after BRTO could also predict the exacerbation of EV in
a recent study [68].
LSM and SSM could also be used as prognostic markers in non-cirrhotic PH in
various contexts. For instance, LSM was shown to be able predict the development
of sinusoidal obstruction syndrome (SOS) in patients undergoing hematopoietic
stem cell transplantation (HSCT) before the occurrence of clinical signs [69]. A
study showed that patients with extrahepatic portal vein obstruction (EHPVO) who
had a history of variceal bleeding had a higher SSM by TE than those who did not
(60.4 kPa vs. 30.3 kPa, respectively) [70].
Interestingly, a case series of seven patients with BCS suggested that extremely
high (75 kPa) LSM and SSM values at diagnosis could be associated with the devel-
opment of recurrent decompensation events and need for TIPS or OLT [71]. The
authors also suggest that a lack of improvement in LSM could help differentiating
those patients who have BCS-related cirrhosis and remain at risk of decompensation
from those who recovered.
12.4 Prediction of Development of Hepatocellular Carcinoma
Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in

the world, and its incidence is increasing worldwide [72]. HCC is diagnosed mostly
at a late stage, where treatment options are still limited, which explains the overall
low 5-year survival (12%). Early diagnosis allows a curative treatment with much
higher 5-year survival rates [73], and ultrasound screening is therefore suggested in
patients at high risk of developing HCC.
Irrespective of the etiology of liver disease, the highest incidence of HCC is
observed in patients with cirrhosis. It has been reported that up to one in three
patients with cirrhosis develops HCC in a lifetime. In addition, the vast majority of
patients with HCC but no cirrhosis show significant or severe fibrosis on histology.
In compensated patients, the identification of subjects at risk of HCC is therefore
strictly related to a correct staging of liver fibrosis and in particular to the diagnosis
of advanced chronic liver disease [73].
Ultrasound elastography proved to be accurate in assessing the degree of liver
fibrosis and diagnosing cACLD and liver cirrhosis. In addition, it is noninvasive and
reproducible and can be repeated easily in the follow-up, providing dynamic data
potentially improving the prediction of risk. Based on these assumptions, liver stiff-
ness measurement by different ultrasound elastography techniques (mostly
transient elastography) has been used in studies addressing HCC development risk
in patients with chronic liver disease of different etiologies, mostly in studies from
Asia [74, 75]. Not unexpectedly, liver stiffness correlated with the risk of develop-
ing HCC in patients with HCV and HBV chronic liver disease. In the first report
about this topic, Masuzaki et al. reported this association first in 2008 in patients
with HCV [76]. In a second study [77], the same group followed up 866 patients
with chronic hepatitis C for 3 years and divided them into five groups according to
LSM values <10, 10.1–15, 15.1–20, 20.1–25, and >25 kPa. Cumulative incidence
rates at 1, 2, and 3 years differed significantly among the five groups and increased
with increasing LS values. Similar results have been obtained in studies looking at
patients with chronic hepatitis B. In the largest published so far, Jung et al. prospec-
tively followed 1130 chronic hepatitis B patients for a median of 30.7 months [78].
Of them, 57 patients developed HCC. On multivariate analysis, basal LS by TE
value >8 kPa was an independent predictor of HCC development with HRs of 3.07,
4.68, 5.55, and 6.60 and LS values of 8–13 kPa, 13–18 kPa, 18–23 kPa, and >23 kPa,
respectively. In addition, the authors dynamically evaluated the association between
changes in LS values and changes in the risk of HCC development by serial LS
measuring during follow-up. Patients with basal LS and serial LS values <13 kPa
were significantly at lower risk than patients with basal and serial LS >13 kPa
(p < 0.001). Several additional papers confirmed these results; the most relevant of
the last 5 years are summarized in Table 12.2.
Less data is available regarding patients with viral hepatitis C who have been
treated successfully and viral hepatitis B under successful viral suppression.
Hamada et al. retrospectively evaluated 196 patients who achieved SVR using LS
by 2D shear wave elastography (SWE). Among them, eight patients developed
HCC after SVR (median time 28 months, range 6–46 months). Univariate and mul-
tivariate analysis showed that LS at SVR24 was independently associated with the
development of HCC. ROC analysis identified LS ≥11 kPa as a cut-off value for
predicting the development of HCC, with a negative predictive value of 0.989 [72].
Rinaldi et al. prospectively followed 258 patients with HCV cirrhosis who
received DAAs aiming at studying the association between pre-treatment LSM by
TE and development of HCC after SVR. Baseline LSM was significantly higher in
patients who developed HCC than patients who did not (37.2 kPa vs. 23.9 kPa;
p < 0.0001). On multivariate analysis, pre-therapy LSM was an independent predic-
tor of HCC development. The best cut-off was 27.8 kPa (sensitivity 72% and speci-
ficity 65%) [79].
Since LSM decreases rapidly during and after treatment with DAAs, which has
been attributed to changes in intrahepatic inflammation, Ravaioli et al. retrospec-
tively evaluated 139 patients with HCV cirrhosis treated with DAAs to assess
whether the difference in LSM at the end of DAA treatment (EOT) vs. pre-therapy
(ΔLSM) could provide additional information on the risk of developing HCC. During
a median follow-up of 15 months (IQR 12–19), 20 patients developed HCC. The
ΔLSM was significantly lower in patients who developed HCC than patients who
did not. On multivariate analysis, ΔLSM lower than −30% (HR 5.360; 95% CI
1.561–18.405; p = 0.008) was an independent predictor of HCC development after
Table 12.2 Main studies of the last 5 years using ultrasound elastography techniques to predict HCC in CLD
182
Median
N included follow-up N who developed Selected cut-off
Study (year) Region patients Etiology (months) HCC AUROC LSM (kPa)
Kim et al. (2015) Asia 2876 HBV 48.9 52 0.532 13.0
Wang et al. (2016) Asia 278 HCV 91.2 18 0.781 12.0
Adler et al. (2016) Europe 432 Mixed 31.3 41 N/A 20.0
Bihari et al. (2016) Asia 964 HBV N/A 14 0.767 N/A
Seo et al. (2016) Asia 381 HBV 48.1 34 0.745 N/A
Jeon et al. (2017) Asia 540 HBV 54.1 81 0.598 13.0
Li et al. (2017) Asia 1200 HBV 48 156 N/A N/A
D’Ambrosio et al. Europe 404 HCV 36 24 N/A N/A
(2018)
Hamada et al. (2018) Asia 196 HCV (pre-post DAAs) 26 8 N/A 11
Ravaioli al. (2018) Europe 139 HCV (pre-post DAAs) 15 20 N/A <−30%a
Rinaldi et al. (2019) Europe 258 HCV (pre-post DAAs) 12 35 0.691 27.8
Wang et al. (2019) Asia 371 HBV 67.2 27 0.636 21.5
Degasperi et al. Europe 546 HCV (SVR) 25 28 N/A 30.0
(2019)
Izumi et al. (2019) Asia 419 HCV 30 32 0.806 8.0
Izumi et al. (2019) Asia 377 HBV 27 23 0.795 6.2
Izumi et al. (2019) Asia 258 NAFLD 30 33 0.698 5.4
Pons et al. (2019) Europe 572 HCV (SVR) 33 25 N/A N/A
Nakagomi et al. Asia 1146 HCV 78 190 N/A N/A
(2019)
Papatheodoridis et al. Europe 1427 HBV (on entecavir or 8.4 years 33 N/A 12.0
(2020) tenofovir)
AUROC area under the receiver operating characteristic curve, DAA direct-acting antiviral, HBV hepatitis B virus, HCC hepatocellular carcinoma, HCV hepa-
titis C virus, LSM liver stiffness measurement, N/A not applicable, NAFLD non-alcoholic fatty liver disease, SVR sustained virologic response
a
Change in LSM less than −30% was an independent predictor of HCC development after DAA treatment
É. Vuille-Lessard et al.
DAA treatment. It was suggested that monitoring HCV patients with LSM at EOT
and subsequently calculating the ΔLS may therefore improve the ultrasound-based
screening for HCC identification after DAA treatment [80].
A study from Beijing followed up 438 chronic hepatitis B patients with compen-
sated cirrhosis. Patients were on entecavir-based antiviral therapy, and LSM was
measured every 26 weeks for 2 years. The researchers aimed at defining the rela-
tionship between the percentage of change in LSM and liver-related events (LRE).
Sixteen patients had episodes of decompensation and 18 developed a HCC. Patients
who did not develop LRE had a median LSM of 17.8 kPa, 12.3 kPa, 10.6 kPa, and
10.2 kPa at Week 0, 26, 52, and 78, respectively, with a decrease in the first 26 weeks
of 30.9%. Patients who developed LRE had a median LSM of 20.9 kPa, 18.6 kPa,
20.4 kPa, and 20.3 kPa at Week 0, 26, 52, and 78 with a decrease in the first 26 weeks
of 11%. The percentage of change in LSM from Week 26 vs. baseline was statisti-
cally different between the two groups (p = 0.004), suggesting that not only baseline
value but improvement or worsening of liver stiffness possibly due to the existence
of comorbidities impacts the risk of HCC and might be used for risk stratifica-
tion [81].
These observations led to the creation of models integrating liver stiffness
together with other variables independently predicting HCC risk. In a study from
Japan conducted in 1808 patients with CLD, LS by pSWE (ARFI virtual touch
quantification) >1.33 m/s, FPG >110 mg/dL, sex (male), age >55 years, and alpha-
fetoprotein (AFP) >5 ng/mL were independently associated with HCC develop-
ment. Using these five parameters, the VFMAP score could be calculated (0 if
below or 1 if above the cut-off; range 0–5). Findings were a low score with 0–1
points (n = 478), intermediate score with 2–3 points (n = 673), and high score with
4–5 points (n = 172). The 3 and 5 years cumulative incidence rates of HCC were 0%
and 0.3% in the low-score group, 3.0% and 3.5% in the intermediate-score group,
and 11.7% and 14.8% in the high-score group (p < 0.001 among groups). The haz-
ard ratios for the incidence of HCC in the intermediate- and high-score groups were
17.37 (95% CI 2.35–128.40; p = 0.005) and 66.82 (95% CI 9.01–495.80; p < 0.001),
respectively, compared to the low-score group. The AUC of VFMAP scores was
0.82 (95% CI 0.76–0.87). When using a VFMAP score cut-off level of 3, the NPV
for excluding HCC development in 5 years was 98.2% [82].
In South Korea, scientists assessed the efficiency of four models in predicting
HCC in treated chronic hepatitis B patients at two different time points with a
6-month interval. CU-HCC model included age, serum albumin level, total bilirubin
level, HBV DNA level, and cirrhosis. REACH-B model included gender, age, ala-
nine aminotransferase (ALT) level, hepatitis B e antigen (HBeAg) status, and HBV
DNA level. LSM-HCC model included LSM assessed by TE, together with age,
serum albumin level, and HBV DNA level. Modified REACH-B (mREACH-B)
model included the LSM value instead of HBV DNA. All four models significantly
predicted the HCC development at the two different time points; however, the
change in their values between the two time points did not [83].
However, it remains unclear how to translate these findings into clinical practice,
and until new data become available, according to the current guidelines, all patients
with cirrhosis prior to treatment should be kept on ultrasound surveillance for HCC
every 6 months lifelong [84]. Whether ultrasound screening intervals could be
safely modified according to risk stratification remains open to future studies.
12.4.1 Prediction of HCC Recurrence After Treatment
Lee et al. retrospectively evaluated the association between preoperative LSM val-
ues and de novo HCC recurrence in 111 HCC patients who had a resection surgery.
In this study, 47 patients had de novo HCC recurrence. On multivariate analysis,
preoperative LSM was an independent predictor of HCC recurrence, and patients
with LSM >13.0 kPa had a significantly higher risk than patients with LSM
<13.0 kPa (p < 0.05) [74].
Another prospective study evaluated 133 HCC patients with available preopera-
tive LSM who had a curative resection. During a median follow-up of 25 months
(range 3–54.6), 62 had HCC recurrence. On multivariate analysis, preoperative
LSM was one of the independent predictors of recurrence (HR 1.034; 95% CI
1.007–1.061; p < 0.05). A cut-off value of 13.4 kPa was the best to discriminate the
risk of recurrence at 1, 2, and 3 years (p = 0.009) [74]. A study from Kyungpook
National University followed prospectively 138 patients with HCC who underwent
radiofrequency ablation (RFA) for a median of 21.9 months (range 3–60). LS was
assessed by pSWE (Virtual Touch ARFI) and TE before the intervention. On multi-
variate analysis, LSM by both techniques were independent predictors of HCC
recurrence. The optimal cut-off value for pSWE was 1.6 m/s, while it was 14 kPa
for TE [85].
12.5 Survival
LSM has been repeatedly shown to be a very good predictor of survival in viral
CLD such as in HBV [9], HCV [4], and HCV/HIV [33] cirrhosis, and a rise in LSM
over time has been associated with a poorer survival compared to a decrease in LSM
in patients with chronic hepatitis C [86]. Additionally, a recent cohort study showed
that baseline LSM was an independent predictor of overall survival in NAFLD
patients [19].
A recent systematic review and meta-analysis showed that for each kPa increase
in baseline LSM, there was an 8% increase in all-cause mortality and a 11% increase
in liver-related mortality [24]. Another recent meta-analysis found similar results
(RR 1.06; 95% CI 1.06–1.07 for LREs and RR 1.06; 95% CI 1.04–1.07 for all-cause
mortality) [25], while the RR was slightly higher in an earlier meta-analysis (RR
1.22; 95% CI 1.05–1.43) [26]. The meta-analysis by Shen et al. also showed that,
compared with the reference of 5 kPa, the pooled RR (95% CI) was 1.34 (0.86–2.07)
for 8.5 kPa, 3.25 (1.90–5.56) for 13.5 kPa, 7.72 (4.51–13.22) for 19.8 kPa, and
14.25 (8.22–24.73) for 37.5 kPa, respectively [24]. The plot showed a steep increase
in the risk of all-cause mortality for baseline LSM below 24.1 kPa and then turned
into a relatively stable increase. Takuma et al. showed that SSM by pSWE was also
an excellent predictor of mortality in patients with both compensated and decom-
pensated cirrhosis, with optimal cut-off values of 3.41 m/s and 3.53 m/s, respec-
tively [21]. LSM by MRE has also been associated with survival [34].
12.6 Conclusion
Liver stiffness, and to lesser extent spleen stiffness, can be considered validated
predictors of clinical decompensation and survival in patients with compensated
advanced chronic liver disease of different etiologies. Even if cut-off values vary
among the different studies, it seems evident that models including liver stiffness
and possibly spleen stiffness together with other noninvasive variables and clinical
characteristics might be already calculated to improve risk stratification in this pop-
ulation. In addition to “static” baseline measurements, “dynamic,” repeated mea-
surements over time could be used, allowing to better understand the evolution or
regression of the underlying liver disease, which relates to prognosis. The creation
of such predictive models and the subsequent calibration in the different etiologies
and settings remain an unmet need that could potentially move the field forward
allowing individualization of care.
Liver stiffness measurement has emerged as well as predictor of hepatocellular
carcinoma, likely since this parameter integrates fibrosis severity, inflammation, and
indirectly portal hypertension, which play a role in the pathogenesis of HCC. In this
field, predictive models taking into account this parameter have already been calcu-
lated and validated, but pragmatic trials comparing different surveillance strategies
according to different LSM risk categories have not been performed and would be
highly needed to assess whether imaging could be restricted to the middle-high-
risk cases.
Acknowledgement Financial Support: Élise Vuille-Lessard is supported by a Clinical Hepatology

Fellowship of the Canadian Association for the Study of the Liver (CASL-CLF 2020–2021).
Ahmed Y. Elmahdy is supported by a Swiss Government Excellence Scholarship (ESKAS
2019.0832).
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Part III
Extrahepatic Diseases: Pancreas
Pancreas: Transabdominal Ultrasound-
Based Elastography 13
Clara Benedetta Conti and Roberta Pozzi
13.1 Introduction
Nowadays, elastography is widely used in the evaluation of many tissues, from the
liver (where the liver stiffness assessment of fibrosis has even updated the routine
use of liver biopsy in patients with chronic liver diseases) to the assessment of
lymph nodes, prostate, thyroid, breasts, and spleen.
These achievements in the noninvasive evaluation of tissue stiffness have raised
the physicians’ interest about investigating the potential feasibility and clinical
applicability of pancreatic stiffness (PS). Basically, by using ultrasound-based
methods, PS can be measured through transabdominal elastography or echoendo-
scopic elastography. This chapter aims to provide a comprehensive overview of the
application of transabdominal elastography to the pancreas.
Transient elastography (FibroScan, EchoSense), largely used for the assessment
of liver stiffness, cannot be applied to the pancreas as this organ is located deep in
the abdomen and difficult to explore without proper visualization to correctly place
the probe. Therefore, the application of transabdominal elastography to the pan-
creas needs an elastographic software module incorporated in the ultrasound (US)
machine, in order to properly apply elastography to the tissue under the US B-mode
guidance. This way a physician can perfectly target the pancreas during the paren-
chymal stiffness measurement. However, this is not the only reason to perform a
complete pancreatic US examination before performing PS assessment. Indeed, the
pancreas dimensions (head, corpus), the echo pattern, and the pancreatic duct diam-
eter should also be evaluated as they provide very useful additional information. For
example, US scan can help to find signs of chronic pancreatitis, such as calcifica-
tions, duct irregularities, pseudocysts, or lesions (solid, cysts). The presence of large
C. B. Conti (*)
Gastroenterology and Digestive Endoscopy, ASST Cremona, Cremona, Italy
R. Pozzi
Internal Medicine Unit, ASST Lecco, Lecco, Italy

https://doi.org/10.1007/978-3-030-74132-7_13
194 C. B. Conti and R. Pozzi
cysts or ductal pancreatic irregularities may interfere with measurement acquisition.

Moreover, elastographic measurements require an excellent US window, not always
easy to obtain, especially in obese patients or in the presence of large-volume asci-
tes. This difficulty can be avoided just by setting the region of interest (ROI) in a
space free of liquid. Conversely, obesity may interfere with PS measurement as a
consequence of the deep location of the organ. In this case, a physician may find it
impossible to correctly position the ROI and, thus, to acquire the measurement.
Apart from these possible technical problems, measuring PS is usually a quick and
easy task to perform. The measurements should be performed with the patient in
supine position, fasting conditions (for at least 6 h). The number of measurements
to be performed is ideally five to ten, and it usually takes around 10 min [1–8]. The
patient should stop breathing in an indifferent breathing phase while each measure-
ment is made, in order not to affect the measurement value as it occurs in the inspi-
ration phase of breathing.
PS assessment has been proposed to characterize both pancreatic tumors and
benign pancreatic diseases [1]. Regarding the different techniques, in the available
studies, the methods that are commonly applied are both ultrasound strain elastogra-
phy and ultrasound shear wave elastography (SWE). The strain method is only quali-
tative and depends on color maps to display the magnitude of strain in a tissue. Thus,
it is a highly operator-dependent method. In the case of strain elastography, in fact,
quantitative analysis can be achieved by the use of the strain ratio, defined as the ratio
of the strain of a reference tissue divided by the strain of the target tissue. However,
there is no consensus yet on where to set the reference area in the pancreas. During
pancreatic cancer assessment, some investigators have set the reference area on a non-
tumorous area inside the pancreatic parenchyma, whereas others have set it on a red
area around the pancreas which was estimated as fat; but this latter consideration is
not supported by any evidence. Conversely, SWE consists in a quantitative method,
which is considered as the most informative method to assess PS. In the available lit-
erature, the PS value of the normal parenchyma at shear wave speed is about 1.4 m/s
[2] and seems to increase with age [3, 4]. However, a precise stiffness cut-off value to
define the normal pancreatic parenchyma is still missing or needs standardization.
13.2 ancreatic Stiffness Measurement in Benign

P
Pancreatic Diseases
13.2.1 Chronic Pancreatitis and Alcohol-Related Disease
In the setting of chronic pancreatitis (CP), the values of PS resulted significantly

higher compared to healthy volunteers in the study by Yashima et al. [5]. The authors
assessed the pancreatic stiffness by using Acoustic Radiation Force Impulse (ARFI)
transabdominal elastography in 46 patients (76% with alcohol-related CP, 70% with
calcifications or signs of advanced disease) and in a control group including 52
healthy volunteers (HV). The authors found stiffness values significantly higher in
patients with CP than in HV in every part of the pancreas (head, corpus, and tail),
13 Pancreas: Transabdominal Ultrasound-Based Elastography 195
although the measurements were demanding in the tail of the organ. Actually, the
feasibility of the technique resulted good in the body, fair in the head, and low in the
tail: 75%, 69%, and 42%, respectively. They determined a SWE cut-off value of
1.40 m/s for diagnosing chronic pancreatitis and reported sensitivity, specificity,
PPV, and NPV of 75%, 72%, 69%, and 78%, respectively, for diagnosing chronic
pancreatitis. Alcoholic etiology (r2 = 0.142) and a decreased BMI (r2 = 0.107) were
found to be significantly associated to high stiffness values.
Similarly, in a study by our group, 52 CP patients and 42 healthy subjects under-
went PS measurement by using point-SWE [6]. In this study, feasibility was excel-
lent (98%). PS was significantly higher in CP patients than HV (p = 0.001).
Significantly higher values in the CP group were also observed in patients with
longer disease duration (>10 years vs. ≤10 years) (p = 0.01), on chronic analgesic
drugs (p < 0.05), and with lower body weight (p < 0.05, r = −0.38). At multivariate
analysis, all the three variables resulted independently associated with the PS value.
The intraclass correlation coefficient (ICC) for PS was 0.77. These results, even if
limited and derived from small samples, showed an excellent level of feasibility of
the technique and good reproducibility. Strong correlation between clinical out-
come and PS in the CP setting is lacking, but elastography may have a future poten-
tial role in the stratification of CP patients by severity.
In this direction, in another study by using point-SWE, Kawada et al. [7] pro-
spectively investigated a cohort of 85 patients with alcoholic abuse, to identify a
possible high-risk group for pancreatic cancer. Of the 85 patients, five patients,
including obese patients, were excluded because the pancreas was not clearly visu-
alized at US, and other six patients with an already known diagnosis of pancreatic
cancer were excluded because of a markedly dilated main pancreatic duct accompa-
nied with severe atrophic pancreas. Fourteen patients were excluded because the
shear wave velocity IQR/median was higher than 40%. Thus, the analysis was lim-
ited to 60 patients: among them, 18 patients (21%) with pancreatic cancer were
identified. A 100% success rate was achieved at the head, body, and tail of the pan-
creas in 80%, 83%, and 68% of the patients, respectively. The comparison between
patients with and without cancer did not reach statistical significance, but stiffness
values were associated with a severe (>60 g ethanol/day) amount of alcohol intake
(p = 0.005). In another study by our group, PS was measured in 87 patients with
alcohol-related liver and/or pancreatic disease resulting significantly higher than
HV (p < 0.001). The feasibility of the technique was excellent, and the only variable
that significantly correlated with the PS value at multivariate analysis was the pres-
ence of liver cirrhosis (p = 0.005). Reproducibility was fair, but patients were mostly
obese or with decompensated cirrhosis [8]. The amount of alcohol intake did not
correlate with the PS value. However, differently from the population in the Kawada
study [6], all the patients told of homogeneous severe alcohol abuse. These results,
even if limited, open up to the interesting possibility to use elastography to detect
and monitor alcohol-related pancreatic damage earlier.
Figure 13.1 summarizes the main available studies focusing on the role of PS in
chronic pancreatitis and alcohol-related diseases. The values of PS in healthy volun-
teers and patients are illustrated by the histograms.
18
Chronic Pancreatitis p<0.001
16
15,4
14
Healthy
12 11,8
10
6 p=0.0.001
4,3
4 p<0.001
2,8 p=NS
2 1,68
1,23 1,28 1,25
0
Pozzi Yashima Mateen Conti
(kPa) (m/s) (m/s) (kPa)
Fig. 13.1 Main studies focusing on the role of PS in chronic pancreatitis and alcohol-related
diseases. The values of PS in healthy volunteers and patients are illustrated by the histograms
13.2.2 Acute Pancreatitis
The application of PS in acute pancreatitis is an interesting topic. However, the

few available studies offered little and conflicting data. In detail, a study that
investigated PS values in 44 acute pancreatitis and 210 HV did not find any sta-
tistically significant difference between the two groups [9]. Conversely, a study
that evaluated 166 patients divided into normal, chronic, and acute pancreatitis
group found different mean PS values: 1.28 m/s, 1.25 m/s, and 3.28 m/s for the
normal pancreas, chronic, and acute pancreatitis, respectively. The authors con-
cluded that PS may have a role in the diagnosis of acute pancreatitis, to assess the
extent of inflammation or to identify necrosis and to monitor a patient’s response
to treatment [10]. Another study [11] compared PS by using ARFI with CT scan
in 41 patients. The results appeared promising, as PS measurement showed very
high accuracy (97.1% sensitivity, 92.9% specificity) for the diagnosis of acute
pancreatitis. Again, a significant difference in PS values between patients with
acute pancreatitis and HV was found (1.27 ± 0.50 m/s vs. 1.00 ± 0.17 m/s,
p = 0.001, respectively) by Sanjeevi et al. [12]. The authors of this latter study
found a positive correlation between PS and the number of pain episodes
(p = 0.026) reported by the patients and a negative correlation with BMI
(p = 0.002). Nevertheless, these observations need validation in larger samples,
and further studies are thus necessary.
5
Acute Pancreatitis
4,5
Healthy
4
p<0.001
3,5
3,28
3
m/s 2,5
p<0,001
2,14
2
p=0.001
p=NS
1,5 1,27
1,25 1,21 1,28
1,17
1 1
0,5
0
Xie Mateen Goya Sanjeevi
Fig. 13.2 Main studies focusing on the role of PS in acute pancreatitis. The values of PS in
healthy volunteers and patients are illustrated by the histograms
acute pancreatitis. The values of PS in healthy volunteers and patients are illustrated
by the histograms.
13.2.3 Application in Surgery
A further interesting application of PS is its preoperative measurement to predict the

incidence of postoperative pancreatic juice fistula (PF) and the risk of surgical com-
plications [13]. Indeed, in the study by Harada et al. [14], PS turned out to be a good
index for estimating pancreatic fibrosis and predicting postoperative PF in 17
patients. Similarly, the shear wave velocity (SWV) of the pancreas was preopera-
tively measured by ARFI in 62 patients undergoing pancreatic resection. SWV
directly correlated with the degree of pancreatic fibrosis (p < 0.001) and inversely
with postoperative amylase concentrations and the daily output of pancreatic juice.
Multivariate analysis showed that low stiffness values were independent predictors
of postoperative PF (odds ratio 38.3; 95% CI 5.82–445; p = 0.001) [15]. Another
study found clinically relevant fistulae in eight patients, in a group of 25 patients
who had undergone pancreaticoduodenectomy or distal pancreatectomy. No statisti-
cally significant difference was found between the fistula and non-fistula groups.
Only in the sub-analysis of the group of patients who had undergone pancreatico-
duodenectomy, ARFI values were significantly lower in the patients with fistulas
than in those without [16].
13.2.4 Cystic Fibrosis and Diabetes
Regarding the application of PS in the cystic fibrosis setting, a German study [17]
investigated liver and pancreatic stiffness in 106 patients. The patients with pancre-
atic insufficiency had significantly lower pancreas ARFI values as compared to those
without. Similar results were found in a cohort of 27 CF patients who underwent PS
measurement by pSWE: significantly lower SW velocities were found in CF patients
than in HV [18]. Conversely, another study that investigated 22 CF patients found
that the mean SWV of the pancreas was significantly higher than that of the HV [19].
Regarding the potential application of PS measurement to the diabetic popula-
tion, the studies focusing on type 2 diabetes investigated the chance of predicting
the presence of microangiopathy through PS measurement. In detail, a study mea-
sured PS in 213 type 2 diabetic patients with or without known microangiopathy.
The pancreatic SWV increased significantly in patients with microangiopathy
(p < 0.01) and resulted correlated with the number of microvascular complications.
Therefore, the authors suggested that the SWV in the pancreatic body may be con-
sidered as a potential marker for diabetic microangiopathy [20]. Similar results
were found by Öztürk et al. [21], who confirmed that an increased SWV in the
pancreatic body was significantly related to the presence of microangiopathy [21].
The evaluation of type 1 diabetes, conversely, has focused on the possible PS use
as a marker of severity of the disease. However, in a pilot study, no significant PS
difference was found between patients and HV. In fact, the patients showed higher
values than HV only in the tail segment [22]. Similar results were found in a larger
study that assessed kidney and pancreatic stiffness in children with type 1 diabetes
[23]. Conversely, another study on 60 children with type 1 diabetes made use of
strain elastography. ROC analysis yielded a pathological pancreas cut-off value of
2.24 (AUC = 0.999, p < 0.001; sensitivity, 0.983; specificity, 1.00) for the strain
ratio. The strain ratio in patients was significantly higher than in HV and signifi-
cantly correlated with age and disease duration (p < 0.001) [24].
Therefore, for the purpose of evaluating such diseases as CF or type 1 diabetes in
the pediatric population, PS appears promising and useful, it being a noninvasive,
repeatable, and largely available technique. However, the results of the studies are
still scanty and conflicting to support the routine use of this method as a surrogate
marker of pancreatic damage in these settings: further studies are needed.
13.3 ancreatic Stiffness Measurement in Focal

P
Pancreatic Lesions
The application of PS in the evaluation of pancreatic lesions aims to help in the dif-
ferential diagnosis between benign and neoplastic lesions and among different types
of pancreatic cancer (PC). Few studies in literature have focused on the transab-
dominal evaluation of pancreatic masses in this setting. However, some promising
evidence is available to support the noninvasive assessment of pancreatic lesions’
stiffness and corroborate the histological diagnosis.
5 Pancreatic Cancer
4,5
p<0.05 Healthy
4
3,7
3,5
p<0.05
3
2,74
m/s 2,5
2
1,55
1,5
1,17
1
0,5
0
Park D’Onofrio
Fig. 13.3 Main studies focusing on the role of PS in predicting pancreatic cancer. The values of
PS in healthy volunteers and patients are illustrated in the histograms
predicting pancreatic cancer. The values of PS in healthy volunteers and patients are
illustrated in the histograms.
13.3.1 Evaluation of Solid Lesions
D’Onofrio et al. [25] prospectively evaluated 123 pancreatic lesions. The median
SWV for adenocarcinoma (ADK) was 2.74 m/s. In the HV group, the median SWV
value was 1.17 m/s. The difference between the PS of ADK and the normal pancreas
was statistically significant (p < 0.05). Moreover, good sensitivity (73.3%) and
specificity (83.3%) were obtained for the characterization of mucinous cystic
lesions. Another study performed ARFI elastography in 26 patients, with 27 focal
solid pancreatic lesions: eight benign (focal pancreatitis and autoimmune pancreati-
tis) and 19 malignant (16 ADK, two metastases, one neuroendocrine tumor). No
statistical difference was found in the mean SWV between benign and malignant
lesions. However, the mean SWV difference values between the lesions and back-
ground parenchyma of the malignant lesions (1.5 ± 0.8 m/s) were higher than those
of the benign lesions (0.4 ± 0.3 m/s; p = 0.011) [26]. Furthermore, a preliminary
Phase I and a prospective Phase II studies were conducted. In the Phase I study, five
patients with PC, two with endocrine tumor, five with chronic pancreatitis, and 14
with intraductal papillary mucinous neoplasm were investigated. In the Phase II
study, 53 consecutive patients were enrolled. In the Phase I study, the colorimetric
scale evaluated the normal parenchyma, which resulted homogeneously colored and
Fig. 13.4 Pancreatic stiffness measurement by point SWE in a healthy volunteer (a) and in a focal
pancreatic solid lesion (b)
PC, which resulted as a markedly hard area with soft spots inside. Conversely, neu-
roendocrine tumors appeared as uniform and soft. Chronic pancreatitis did not show
a peculiar pattern. In the Phase II study, the authors identified 77.4% of the lesions
and observed 60.0% of the cancers, 100% of the endocrine tumors, and 92.0% of
the cases of chronic pancreatitis [27].
Figure 13.4 illustrates the PS measurement by point SWE in a healthy volunteer
(a) and in a focal pancreatic solid lesion (b).
13.3.2 Evaluation of Cystic Lesions
Regarding the stiffness evaluation of cystic lesions, PS assessment seems to have a

remarkable role in their histologic characterization. Indeed, a study investigated 38
patients with pancreatic cystic focal lesions (diameter >3 cm and located at a 5.5 cm
depth). The sensitivity, specificity, positive predictive value, negative predictive
value, and accuracy for the differential diagnosis between mucinous and non-
mucinous cystic lesions were 68.8%, 77.3%, 68.8%, 77.3%, and 73.7%, respec-
tively; by the second method, the values were 37.5%, 100%, 100%, 68.8%, and
73.3% [28]. Similarly, other studies with small samples have shown encouraging
results as regards the application of PS measurement in distinguishing mucinous

from non-mucinous lesions [29–31].
In conclusion, the method seems to be good at distinguishing between solid
benign and malignant masses. Similarly, the stiffness assessment of pancreatic cys-
tic lesions seems to be promising in helping physicians to distinguish between
mucinous and non-mucinous lesions. However, further studies are required to
largely corroborate the use of the technique in these settings.
13.4 Limitations of Transabdominal PS Assessment
There are many limitations in transabdominal PS determination and its widespread

use in clinical practice. The most important are anatomical limitations related to the
deep location to the organ, as already described, in the presence of obesity or large-
volume ascites or ductal abnormalities. Regarding the clinical application of the PS
measurement to benign pathological conditions, the method remains a promising
tool, but strong, univocal, and agreed results are still lacking. Even if pancreatic
biopsy in absence of a target lesion is not routinely performed, the lack of it as the
reference standard to assess chronic, acute pancreatitis, or alcoholic pancreatic
damage still remains the main methodological limitation of the studies.
The use of PS measurement in the differential diagnosis of pancreatic lesions,
even if promising, still requires further evidence.
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Endoscopic Ultrasound Elastography
in Pancreatic Diseases 14
EUS-EG in Pancreatic Diseases
Federica Cavalcoli, Roberta Elisa Rossi, and Sara Massironi
14.1 Introduction
Elastography is an imaging modality for the evaluation of tissue stiffness, by using

ultrasound. Pathologic processes such as cancerization and fibrosis alter tissue elas-
ticity and therefore induce changes in elastographic appearance [1]. Neoplastic
lesions are known to be stiffer (or less elastic) than surrounding healthy tissue;
therefore, they could be characterized in elasticity-based imaging. Ultrasound elas-
tography has been used to differentiate malignant from benign neoplasms in several
organs, such as breast, thyroid, cervix, and liver. More recently also the pancreas has
been a field of application of this technique, due to the increasingly widespread use
of endoscopic ultrasound (EUS), in several different pancreatic diseases, including
neoplasms, and inflammatory processes, that can modify the tissue stiffness.
Endoscopic ultrasound elastography (EUS-EG) has been proposed in the evaluation
of both focal lesions and parenchymal diseases [2]. Concerning focal lesions,
EUS-EG is a promising imaging technique with a high degree of accuracy for the
differential diagnosis of solid pancreatic tumors, and the recent introduction of the
second generation EUS-EG allows not only for qualitative analysis of tissue stiff-
ness but also for the quantitative one [1, 3]. EUS-EG is classified into two catego-
ries, based on the different mechanical properties: EUS strain elastography
(EUS-SE) and EUS shear wave measurement (EUS-SWM) [4, 5]. EUS-SE evalu-
ates tissue stiffness by measuring the relative tissue distortion within a region of
F. Cavalcoli
Gastroenterology and Endoscopy Unit, Istituti Clinici Zucchi, Monza, Italy
R. E. Rossi
Gastrointestinal Surgery and Liver Transplantation Unit, Fondazione IRCCS Istituto
Nazionale dei Tumori and Department of Pathophysiology and Organ Transplant, Università
degli Studi di Milano, Milan, Italy
S. Massironi (*)
Gastroenterology Unit, San Gerardo Hospital, University of Milano – Bicocca, Monza, Italy

https://doi.org/10.1007/978-3-030-74132-7_14
206 F. Cavalcoli et al.
interest (ROI) when applying pressure, giving therefore a visual pattern that lacks
objectivity and reproducibility. Therefore, it is necessary to use strain ratio (SR) or
strain histogram (SH) analysis to have quantitative parameters [5–7]. EUS-SWM is
based on the properties of a shear wave and involves a technique to measure the
velocity of the shear wave [4, 8]. Theoretically, greater tissue elasticity corresponds
to faster shear wave propagation.
14.2 Focal Lesions
14.2.1 Pancreatic Ductal Adenocarcinoma
The diagnosis of solid pancreatic lesions is challenging. Up to 40% of such lesions

are due to pancreatic ductal adenocarcinoma (PDAC), the remaining being repre-
sented by several entities including neuroendocrine neoplasms (NENs), metastases,
focal pancreatitis, and small solid-appearing serous cystadenomas [9]. Pancreatic
cancer is characterized by a dismal prognosis, mainly because of its aggressive
behavior and the difficulty in early diagnosis [10]. Surgical resection represents the
only potential cure, but small pancreatic cancers are often lately diagnosed so that
only less than 15% of patients can undergo surgery with curative purpose. Therefore,
an accurate differential diagnosis between benign and malignant pancreatic masses
is crucial for making clinical decisions.
Available radiologic and endoscopic methods such as transabdominal
ultrasound, computerized tomography (CT), magnetic resonance imaging (MRI),
positron emission tomography (PET), or endoscopic retrograde cholangiopan-
creatography (ERCP) are all characterized by limited sensitivity for recognizing
early pancreatic tumors as they often fail in accurately differentiating malignant
from benign lesions. Endoscopic ultrasound-guided fine-needle aspiration (EUS-
FNA) has been recognized to be the most accurate technique in this setting [11].
EUS-EG has been increasingly used for the evaluation of solid pancreatic lesions
and has been largely reported as a useful supplemental method to EUS-guided FNA
[12–17], particularly in those cases where the FNA results are inconclusive. Of
note, EUS-EG has the relevant advantage of potentially causing no additional
adverse risk [10]. On qualitative elastography, the normal pancreas appears elasto-
graphically soft (homogenously green) in most cases, being this finding highly
reproducible [18–20]. Conversely, malignant pancreatic lesions are generally harder
than adjacent pancreatic tissue, due to the presence of fibrosis and marked desmo-
plasia [18]. A five-score classification was firstly reported based on the color pat-
terns of lesions (Fig. 14.1), according to Giovannini et al. [19, 21], with a sensitivity
of 100% and a specificity of 67%. In detail, a green pattern is considered to be sug-
gestive of soft homogeneous tissue, namely, normal pancreatic tissue, while blue
lesions with heterogeneity might suggest hard tissue and, therefore, PDAC. In this
scoring system, scores 3–5 were considered indicative of malignancy. A four-score
classification has also been used, which varies from homogenous green to homoge-
neous and heterogeneous blue, suggestive of a pancreatic neuroendocrine tumor and
14 Endoscopic Ultrasound Elastography in Pancreatic Diseases 207
Elastic score Elastography Pattern Condition
1
Distortion for Normal
entire low echo pancreas
area
2
No distortion on Fibrosis, chronic
low echo area pancreatitis
even for a part
3
Distortion at Small
the edge of low adenocarcinoma
echo area, even
for a part
4
No distortion for Endocrine
entire low echo tumor
area
5
No distortion on Advanced
low echo area and adenocarcinoma
surrounding
Fig. 14.1 Classification of elastography findings proposed by Giovannini et al. [19]. (Image
adapted from [21]. License: http://creativecommons.org/licenses/by-nc/4.0/)
pancreatic adenocarcinoma, respectively [22]. Based on this score, the diagnostic

sensitivity, specificity, and overall accuracy of EUS-EG for diagnosing malignancy
were reported to be 100%, 85.5%, and 94%, respectively [22]. In a recent multi-
center study [9], including 218 patients with solid pancreatic lesions ≤15 mm in
size and a definite diagnosis, on elastography, 50% of lesions were stiffer than the
surrounding pancreatic parenchyma (stiff lesions), and 50% were less stiff or of
similar stiffness (soft lesions). The high stiffness values had a sensitivity of 84% and
specificity of 67% for the diagnosis of malignancy. Furthermore, for the diagnosis
of PDAC, the sensitivity and specificity were 96% and 64%, respectively, thus high-
lighting that in patients with small solid pancreatic lesions, EUS-EG can rule out
malignancy with a high level of certainty if the lesion appears soft, although a stiff
lesion can be either benign or malignant.
On the other hand, some authors reported poor results for qualitative EUS-EG,
observing a poor accuracy in distinguishing pancreatic malignancy from chronic
pancreatitis [4, 23, 24]. Taken into account that qualitative elastography is largely
based on the subjective interpretation of the elastographic pattern, the diagnostic
accuracy is variable among different studies [4].
Quantitative EUS-EG can be based on both strain ratio (SR) and strain histogram
(SH) without differences regarding the accuracy of the two techniques for the dif-
ferentiation between benign and malignant pancreatic masses [1]. In a prospective
study including 86 consecutive patients who underwent EUS for the evaluation of
solid pancreatic masses, the SR was significantly higher among patients with pan-
creatic malignant tumors compared with those with inflammatory masses. The sen-
sitivity and specificity of SR for detecting pancreatic malignancies were 100% and
92.9%, respectively [3]. In detail, A SR higher than 6.04 was reported to be 100%
sensitive for classification of tumors as being malignant, being the specificity
improved to 100% with an SR higher than 15.41. Of note, it was also possible to
differentiate pancreatic cancers from neuroendocrine tumors with 100% sensitivity
and 88% specificity, respectively [3]. Available studies proposed a cut-off of 175 for
mean SH, with satisfactory results in terms of sensitivity (approximately 90–100%),
specificity (66–100%), and accuracy (85–90%) [18, 25–27]. However, in the study
by Schrader et al. [27], reporting excellent results in terms of both sensitivity and
specificity for malignancy detection (100%), the control group was represented by
normal control pancreatic parenchyma, instead of different consecutive pancreatic
lesions or chronic pancreatitis, which must be considered as a bias of that study
overestimating operative characteristics.
Although qualitative EUS elastography is considered to be more operator-
dependent, according to a recent meta-analysis [10], both qualitative and quantita-
tive EUS-EG have high accuracy in the detection of malignant pancreatic masses.
However, specificity was not satisfactory (approximately 60%) with both methods.
Previous studies [28–31] reported that the combination of contrast-enhanced ultra-
sound (CEUS) and EUS-EG might improve the specificity, although further studies
are needed to confirm these preliminary observations. In details, in a prospective
study [28], including 54 patients with chronic pancreatitis (n = 21) and pancreatic
adenocarcinoma (n = 33), the sensitivity, specificity, and accuracy of the combined
techniques for differentiation of hypovascular hard masses suggestive of pancreatic
carcinoma were 75.8%, 95.2%, and 83.3%, respectively.
A prompt diagnosis of pancreatic adenocarcinoma is, indeed, needed given the
poor prognosis of this type of cancer; however, it is challenging. When there is
strong clinical suspicion of pancreatic cancer, but the biopsy is inconclusive or neg-
ative, a hard focal lesion on elastography should guide clinical management by
indicating repeat EUS-FNA or direct referral to surgery. Qualitative EUS seems
more operator-dependent, even if superimposable results have been reported for
both techniques. However, accuracy is not fully satisfactory, and this is due to the
difficult differential diagnosis between pancreatic cancer and other malignancy and/
or chronic pancreatitis. The combination of EUS elastography and CEUS might be

a viable solution to improve specificity, but further studies are needed to draw more
solid conclusions.
14.2.2 Pancreatic Neuroendocrine Neoplasms
The diagnosis of pancreatic neuroendocrine neoplasms (pNENs), especially non-

functioning pNENs, represents a significant diagnostic challenge since these tumors
have a nonspecific clinical presentation and more than half of them are detected
incidentally, usually during diagnostic imaging studies or endoscopic procedures
performed for other indications [32]. Among pancreatic solid lesions, after adeno-
carcinomas and inflammatory masses, pNENs, even if rare in incidence, represent a
relatively frequent finding during the EUS examination. Ultrasound imaging using
elastography is an increasingly available technique allowing one to assess focal
lesion’s hardness [1].
At qualitative EUS-EG, NENs appear as well-defined “blue lesions” (Fig. 14.2),
indicating stiff lesions. In a study by Iglesias-Garcia et al. [3], different kind of
pancreatic solid lesions in 86 consecutive patients were analyzed (49 PDAC, 27
inflammatory masses, six pNENs, two metastatic cell lung cancers, one pancreatic
lymphoma, and one pancreatic solid pseudopapillary tumor) and compared with 20
controls. Normal pancreatic tissue showed a mean strain ratio of 1.68 (95% CI:
1.59–1.78). Inflammatory masses exhibited a strain ratio (mean 3.28) that was sig-
nificantly higher than that of the normal pancreas but lower than that of pancreatic
adenocarcinoma (mean 18.12). The highest strain ratio was found among endocrine
tumors (mean 52.34). On the other hand, in another more recent study by Ignee [9],
a b
Fig. 14.2 Qualitative diagnosis in endoscopic ultrasound strain elastography (EUS-SE). B-mode
image (left, a) of a small pancreatic lesion shows a 9 mm hypoechoic, rounded, well-defined pan-
creatic lesion. Endoscopic ultrasound strain elastography (EUS-SE) (right, b) demonstrated a
“blue lesion”; that means that the lesion is stiffer compared to surrounding pancreatic tissue, sug-
gesting a possible neuroendocrine neoplasm. Subsequent biopsy resulted in the diagnosis of a G1,
well-differentiated pancreatic neuroendocrine tumor
NENs were diagnosed in 114/218 patients (52%). A stiff lesion was seen in 36% of
patients with NETs, while 64% showed a soft lesion compared to the surrounding
pancreatic parenchyma.
In summary, qualitative and quantitative EUS-EG is useful as a complementary
tool used to differentiate between benign and malignant pancreatic lesions [3].
According to the recommendations of the European Federation of Societies for
Ultrasound in Medicine and Biology (EFSUMB), EUS elastography may be helpful
in making therapeutic decisions in cases where fine-needle biopsy performed during
EUS has no diagnostic value [33]. However, elastography alone cannot replace the
cytological assessment.
14.3 Parenchymal Diseases
The normal pancreas has been demonstrated with high reproducibility to be a homo-
geneous soft tissue at EUS-EG [19, 34], while parenchymal pancreatic diseases
may result in diffuse alterations of pancreas or mass-forming lesions.
14.3.1 Chronic Pancreatitis
Chronic pancreatitis (CP) is characterized by chronic, progressive pancreatic

inflammation and scarring and irreversible pancreatic damage leading to a perma-
nent impairment of exocrine and endocrine functions. With an estimated annual
prevalence and incidence of 52.4/100,000 and 14.0/100,000, CP is currently consid-
ered as an important healthcare problem [35]. Since the introduction of the Rosemont
classification based on morphological criteria, EUS has assumed a key role in the
diagnosis of CP [36] (Table 14.1). However, Rosemont morphological criteria pres-
ent some pitfalls in the diagnosing of non-advanced disease [18]. EUS-EG can pro-
vide additional relevant information on tissue stiffness providing an objective
evaluation of CP [37, 38].
In 2013 a prospective study on 191 patients [38] observed a significant direct
linear correlation between the mean pancreatic SR and the number of EUS criteria
for CP (r = 0.813). Overall, EUS-EG showed a diagnostic accuracy of 91.1% (cut-
off SR of 2.25). In this study, the SR was measured in the head, body, and tail of the
pancreas and compared with a soft reference area corresponding to the normal sur-
rounding gut wall; the mean value was used for analysis. Similarly, Kuwahara et al.
observed a significant correlation between the Rosemont criteria staging and mean
pancreatic elastographic values (p < 0.001), as well a significant negative correla-
tion between mean pancreatic elastographic values and the number of EUS features
(rs = −0.59, p < 0.001) [7].
More recently, Yamashita et al. reported the mean EUS-SWM to be significantly
correlated with the presence of Rosemont criteria and the number of EUS features
[39]. The authors also observed EUS-SWM values to be suggestive for chronic
pancreatitis, being significantly higher than normal control. Diagnostic operative
Table 14.1 Rosemont endoscopic ultrasound criteria (divided in major and minor) for the diag-
nosis of chronic pancreatitis
Criteria Feature Definition
Major Hyperechoic foci with Echogenic structures ≥2 mm in length and width that
A shadowing shadow
Major Lobularity with Well-circumscribed, ≥5 mm structures with enhancing rim
B honeycombing and relatively echo-poor center, contiguous ≥3 lobules
Minor Lobularity without Well-circumscribed, ≥5 mm structures with enhancing rim
honeycombing and relatively echo-poor center, noncontiguous three
lobules
Minor Hyperechoic foci Echogenic structures foci ≥2 mm in both length and width
without shadowing with no shadowing
Minor Cysts Anechoic, rounded/elliptical structures with or without
septations
Minor Stranding Hyperechoic lines of ≥3 mm in length in at least two
different directions concerning the imaged plane
Major MPD calculi Echogenic structure(s) within MPD with acoustic
A shadowing
Minor Irregular MPD contour Uneven or irregular outline and ectatic course
Minor Dilated side branches Three or more tubular anechoic structure each measuring
≥1 mm in width, budding from the MPD
Minor MPD dilation ≥3.5 mm body or >1.5 mm tail
Minor Hyperechoic MPD Echogenic, distinct structure greater than 50% of entire
margin MPD in the body and tail
characteristics for CP, with a cut-off value of 2.19, were very encouraging, with a
sensitivity of 100%, a specificity of 94%, and the overall diagnostic accuracy of 97%.
Moreover, a direct relationship was found between SR values and the probability
of both pancreatic exocrine failure [40] and endocrine insufficiency [39].
In conclusion, current data suggest EUS-EG is a promising diagnostic tool for
CP, although the optimal diagnostic cut-off value for CP has not been identified yet.
The significative correlation between SR and endocrine and exocrine insufficiency
may be of value in tailoring the medical substitutive treatment.
14.3.2 Autoimmune Pancreatitis
Autoimmune pancreatitis (AIP) is a rare condition with a hypothesized autoimmune

mechanism, accounting for up to 10% of chronic pancreatitis cases [41]. AIP is
characterized by diffuse or focal enlargement of the pancreas and diffuse irregular
narrowing of the main pancreatic duct. The main biochemical feature of AIP is an
increase of serum gamma globulin, including IgG and particularly IgG4 [41].
However, some patients present with atypical imaging with a “mass-forming” pic-
ture that requires differentiation from pancreatic cancer. In such cases, a 2-week
steroid trial may be helpful in confirming the diagnosis, because AIP shows a dra-
matic response to steroid therapy. On the other hand, it is not always easy to
a b
Fig. 14.3 Qualitative endoscopic ultrasound strain elastography in autoimmune pancreatitis:

B-mode image (left, a) shows an enlarged, heterogeneous, course, and hypoechoic pancreas.
Endoscopic ultrasound strain elastography (EUS-SE) (right, b) demonstrated the entire pancreas
as a homogenously blue tissue stiffer than the normal pancreatic gland
evaluate the treatment response over a short period, and relapse may occur [42].
Therefore, mass-forming AIP represents a clinical challenge for the physician.
Establishing a correct diagnosis of AIP can prevent the consequences of progressive
disease and unnecessary surgery [43–47].
EUS-EG has been demonstrated to be helpful for the diagnosis of AIP [48].
Typically, at elastography, AIP presents with a diffuse, homogeneous, pattern of
small spotted, mainly blue, color signals that are evenly spread over all the pancre-
atic parenchyma even in presence of mass-forming autoimmune pancreatitis [49]
(Fig. 14.3). Thus, the unique finding of a homogenous stiffness of the whole organ
has high diagnostic accuracy for AIP, as compared with PDAC in which the increase
of stiffness is limited to the lesion. More recently, Ohno et al. suggested EUS-SWM
as a method for assessment of AIP activity in patients undergoing steroid therapy
[8]. The authors observed, in a series of six AIP patients on steroid therapy, a signifi-
cant decrease of mean share wave elastography (3.32 m/s before steroid treatment
vs. 2.46 m/s after steroid treatment, p = 0.023), suggesting EUS-SWM as an objec-
tive method for disease activity evaluation. Moreover, a recent study investigating
the usefulness of EUS-EG combined with strain ratio (SR) in the estimation of the
short-term treatment effect of AIP showed a high diagnostic capability of SR in
identifying the steroid response at 2 weeks [48], even if the exact cut-off point varies
between the reports.
14.4 Conclusion
EUS-EG allows the assessment of pancreatic tissue stiffness, and it has been dem-
onstrated to be able to rule out malignancy with a high level of certainty in small
pancreatic lesions when displayed as soft homogenous tissue. In the case of a small
lesion with a very hard pattern, a pNEN should be hypothesized. In larger pancreatic
lesions (>30 mm), the results are less convincing, mainly due to the heterogenicity
of the lesions but also because of concomitant changes of the surrounding pancre-
atic parenchyma [9].
To date, elastography still presents some limitations in the differential diagnosis
between focal pancreatitis and PDAC since chronic focal pancreatitis can also be
stiffer than the otherwise healthy pancreatic parenchyma. Finally, strain elastogra-
phy is also useful in the diagnosing of parenchymal diffuse such as chronic pancre-
atitis and autoimmune pancreatitis in which the entire organ shows stiffer tissue
properties. The current role of EUS-SWM remains to be clarified.
In conclusion, EUS-EG represents a useful tool compared to EUS alone, provid-
ing relevant information on tissue stiffness for characterization of both focal lesion
and parenchymal disease. In the study of focal lesions, EUS-EG may have a key
role in cases in which EUS-FNA results inconclusive. Concerning parenchymal dis-
ease, EUS-EG provides a quantitative analysis of tissue stiffness allowing an objec-
tive evaluation of pancreatic disease at diagnosis and during follow-up.Conflict of
Interest StatementNo conflicting interests (including but not limited to commercial,
personal, political, intellectual, or religious interests) to declare.
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Part IV
Extrahepatic Diseases: Bowel
Application of Elastography in Patients
with Inflammatory Bowel Diseases 15
Federica Branchi and Mirella Fraquelli
15.1 Introduction
Inflammatory bowel diseases are chronic inflammatory conditions that affect the
gastrointestinal tract and are often associated with extra-intestinal conditions.
Among them, Crohn’s disease can involve every segment of the gastrointestinal
tract, the small bowel being frequently affected [1]. According to the Montreal clas-
sification, Crohn’s disease can manifest with a predominantly inflammatory, fistu-
lizing, or stricturing pattern [2].
Among the most common complications affecting patients with Crohn’s disease,
intestinal fibrotic strictures are responsible for significant morbidity and need for
surgical intervention [1]. The link between chronic inflammation and intestinal
fibrogenesis in Crohn’s disease is still far from being clearly understood, although
recent data shows that bowel wall fibrosis results from extracellular matrix deposi-
tion and mesenchymal cell activation, which are both observed after release of pro-
inflammatory mediators in the tissue [3, 4] (Fig. 15.1). This pathogenetic mechanism
explains why Crohn’s disease behavior may vary over time, from an initial inflam-
matory phenotype to the development of stricturing complications as chronic
inflammation progressively damages and alters the structure of the bowel wall [5, 6].
The ability to discriminate between inflammatory and fibrotic strictures takes on
a relevant meaning when it comes to the clinical management of patients with
Supplementary Information The online version of this chapter (https://doi.

org/10.1007/978-3-030-74132-7_15) contains supplementary material, which is available to
authorized users.
F. Branchi
Medical Department, Division of Gastroenterology, Infectious Diseases and Rheumatology,
Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany
M. Fraquelli (*)

https://doi.org/10.1007/978-3-030-74132-7_15
220 F. Branchi and M. Fraquelli
Fig. 15.1 Inflammation

and fibrogenesis in
inflammatory bowel
diseases. The inflammatory
process triggered by a Th
immune response
(involving APC, Th1 and
macrophages) causes the
activation of fibroblasts
and the endothelial cells,
which increases the
production of inflammatory
cytokines and the
deposition of extracellular
matrix, thus leading to the
development of fibrosis. Th
T helper lymphocytes,
APC antigen-presenting
cells, TNF tumor necrosis
factor, IL interleukin,
TIMPs tissue inhibitors of
metalloproteinases, MMPs
matrix metallopeptidases
Crohn’s disease: inflammatory tissue will be likely to respond to currently available

medical therapies and may also act as a disease modifier and prevent the develop-
ment of fibrotic strictures [7, 8]. On the other hand, patients who have already devel-
oped fibrotic strictures will need endoscopic dilation or (in up to 60% of cases) will
eventually require surgery [6, 8, 9].
Noninvasive imaging techniques have been widely used to discriminate between
inflammatory and fibrotic tissue in bowel wall segments affected by inflammatory
bowel diseases, including computed tomography [10], magnetic resonance imaging
[11], and ultrasound with or without contrast enhancement [12, 13]. Elastography is
the latest technique that has been studied as a mean of predicting intestinal fibrosis
in the setting of inflammatory bowel diseases [14–16].
Thanks to its wide availability and applicability as an additional tool in ultra-
sound devices, elastography has shown its potential in the setting of Crohn’s dis-
ease, where identifying inflammatory and fibrotic bowel segments and tracing their
modifications over time are crucial for the correct management of these patients [17].
15.2 lastography in Inflammatory Bowel Diseases: First

E
Data from Animal Models and Surgical Series
Both strain elastography, acoustic radiation force impulse (ARFI) imaging, and
shear wave elastography have been evaluated in the setting of inflammatory bowel
diseases (see Table 15.1 for a summary of the technical characteristics of these dif-
ferent technologies) (Fig. 15.2).
15 Application of Elastography in Patients with Inflammatory Bowel Diseases 221
With strain elastography, the compression exerted on a tissue with the ultra-
sound transducer generates a strain transmitted to the tissue along the transducer’s
axis, which can be calculated and then converted to an elastic modulus profile [18].
Harder/stiffer tissues have low compliance to stress thus low strain. The quantitative
imaging of strain and elastic modulus distributions in soft tissues displayed along
with real-time ultrasound images is called strain imaging or ultrasound elasticity
imaging (UEI).
The first data on the potential application of strain elastography in gastrointesti-
nal disorders were shown in an animal model of left-sided colitis and fibrosis: six
rats treated with intra-rectal 2,4,6-trinitrobenzenesulfonic acid (TNBS) and five
controls were evaluated with both strain measurement in vivo, with a transducer
connected to a deformation device, and direct elastometry ex vivo, by means of a
specific elastometer [14]. The association between the degree of chronic inflamma-
tion/fibrosis in a tissue and its stiffness was confirmed by the significant difference
observed between the strain values of affected and healthy colon segments, as well
as between the correspondent Young’s modulus computed with direct elastometry.
The good correlation between Young’s modulus and strain suggested a good accu-
racy of the indirect assessment of tissue stiffness with strain elastography [14]. In
this first study, the ability of strain elastography to discriminate between an inflam-
matory and a fibrotic process was not addressed; however, a second study by the
Table 15.1 Elastography techniques studied in the setting of inflammatory bowel diseases
Technique Excitation method Clinical applications proposed
Strain elastography or Physical characteristic Crohn’s disease
UEI measured: Strain • Discrimination between inflammation
Excitation method: and fibrosis
Manual compression • Assessment of fibrotic strictures
Ulcerative colitis
• Evaluation of disease activity
(preliminary data)
ARFI imaging Physical characteristic Crohn’s disease
measured: Strain • Assessment of fibrotic strictures
Excitation method:
Acoustic radiation force
impulse
Shear wave Physical characteristic Crohn’s disease
elastography measured: Shear wave • Evaluation of inflammatory activity
speed • Assessment of fibrotic strictures
– Point shear wave Ulcerative colitis
speed measurement • Evaluation of disease activity
– Shear wave speed (preliminary data)
imaging (real time)
Excitation method:
Acoustic radiation force
impulse
UEI ultrasound elasticity imaging, ARFI acoustic radiation force impulse
Fig. 15.2 Strain elastography in Crohn’s disease: A thickened terminal ileum with focal altera-
tions of the multi-layered pattern is shown with ultrasound (left) and strain elastography (right). In
the lower half of the picture, strain values of the ileal wall and a control area (the surrounding
mesenteric tissue) expressed as percentage are plotted over time for the calculation of the mean
strain ratio
same group suggested that this technique could discriminate between inflammatory
and fibrotic tissue based on the preliminary data from animal models [15].
In the same study, the first small group of patients with stricturing Crohn’s
disease tested with strain elastography underwent strain measurement of the
affected bowel segment before surgery and the direct measurement of bowel wall
stiffness after surgical resection [15]. The analysis showed a significant correla-
tion between strain elastography and bowel wall stiffness, thus providing the first
data on the ability of strain elastography to distinguish between healthy bowel and
fibrotic tissue.
Strain elastography was evaluated in another preliminary study on resected sur-
gical specimens (16 Crohn’s disease bowel segments, 18 adenocarcinomas, and
four adenomas) [19]. The tissue stiffness was expressed with different methods,
including a visual analog scale (VAS) and the strain ratio, which is the ratio between
the mean strain of reference surrounding tissue and the mean strain of the lesion/
affected tissue. A significant difference in stiffness was observed between adenoma
versus adenocarcinoma and Crohn’s disease, while the differentiation between ade-
nocarcinoma and Crohn’s disease by means of strain elastography results was not
possible, probably because of the relevant fibrosis degree in both lesions [19]. The
reproducibility of strain elastography was assessed for the first time with two inde-
pendent operators showing a good correlation for the VAS evaluation of tissue stiff-
ness (Pearson’s r = 0.55, p = 0.002), while the separate intra-observer strain ratio
measurements showed moderate-to-good correlation (Spearman’s rho 0.47–0.82).
Acoustic radiation force impulse (ARFI) uses ultrasound beam pulses to deform
a chosen tissue area [20]. With shear wave elastography, a technique that uses ARFI
technology, the deformation induced by the mechanical excitation of the tissue is
measured as velocity of an induced shear wave and expressed as point shear wave
speed measurement or shear wave speed imaging [20].
The first data from an animal model of colitis showed that the shear wave speed
measurement was significantly higher in case of fibrosis than that of acute inflam-
mation (0% and 30%, p = 0.047 and p = 0.02, respectively) [21]. With an AUROC
of 0.971 for differentiating fibrotic from inflamed bowel, the shear wave velocity
ratio (mean velocity/applied strain) emerged as a potential tool to be applied in the
clinical setting [21]. Similarly, promising results were shown in a series of 17 human
resected bowel specimens, where the application of shear wave elastography
allowed to discriminate between tissue with high and low degree of fibrosis, but not
between different degrees of inflammation [22].
15.3 lastography and Crohn’s Disease: Assessing

E
Fibrotic Strictures
15.3.1 Strain Elastography
The potential ability of elastography to indirectly identify fibrotic tissue has

prompted further investigation in the clinical setting of Crohn’s disease, where the
discrimination between inflammatory activity and fibrosis has major relevance
especially when it comes to stricturing disease.
After the first preliminary studies, new data on the performances of strain elas-
tography emerged (Table 15.2). Strain elastography was performed in ten patients
with Crohn’s disease elected for surgery and compared with results of direct tensi-
ometry after surgery and histology [16]. As in previous studies, the strain measure-
ment was performed with the aid of a press guide function in order to allow for the
same amount of compression and to obtain values of the strain without the need to
sample surrounding tissue to obtain a ratio. Bowel segments affected by Crohn’s
disease showed a significantly lower strain than those unaffected (mean ± standard
deviation, 43.0 ± 25.9 versus 169.0 ± 27.9, p < 0.001). The comparison with histol-
ogy showed a correlation between strain and collagen deposits or muscular fibers as
Table 15.2 Clinical studies addressing the role of strain elastography in Crohn’s disease
Subjects Comparison Elastography performance
Stidham Seven CD patients Direct mechanical It discriminates between stenotic
(2011) [15] with stricturing measurement and unaffected bowel
disease Histology
Havre (2014) Human intestinal Histology It discriminates between adenoma
[19] surgical specimens and adenocarcinoma/CD, not
16 CD between adenocarcinoma and CD
18 adenocarcinomas
Four adenomas
Baumgart Ten CD patients Direct mechanical It discriminates between
(2015) [16] elected for surgery measurement unaffected and affected bowel; it
Histology correlates with higher fibrosis and
muscular hypertrophy
Fraquelli 23 CD patients Histology It discriminates between
(2015) [23] elected for surgery inflammation and fibrosis and
20 CD controls identifies severe fibrosis
Sconfienza 16 CD patients MRI It potentially discriminates
(2016) [24] between fibrosis and inflammation
Serra (2017) 26 CD patients Histology It does not seem to discriminate
[26] elected for surgery between fibrosis and inflammation
Quaia (2018) 20 CD patients Histology (17 Potentially discriminates between
[25] biopsy, three fibrosis and inflammation
surgery)
Ding (2019) 25 CD patients Histology (biopsy) Seem not to discriminate between
[30] fibrosis and inflammation
CD Crohn’s disease, US ultrasound, MRI magnetic resonance imaging
signs of fibrosis, although the role of inflammatory tissue changes in determining

strain values was not fully explored [16].
The performance of strain elastography in predicting bowel fibrosis and discrim-
inating between inflammation and fibrosis in vivo was addressed in another study,
where strain elastography was performed on 23 Crohn’s patients with ileal or ileo-
colonic disease, elected for surgical resection, and on 20 uncomplicated Crohn’s
disease patients serving as controls [23]. Tissue strain was assessed by means of
both a semi-quantitative visual color scale and the strain ratio, as previously
described [19], using the mesenchymal tissue surrounding the affected bowel wall
as the reference. The results were compared to histology after resection, and a sig-
nificant correlation between the strain ratio values and the severity of fibrosis at both
semi-quantitative and quantitative histological image analysis was showed. The
strain ratio was proven to have excellent discriminatory ability for severe bowel
fibrosis (AUROC: 0.917; 95% CI 0.788–1.000), and for the first time, the issue of
tissue inflammation as a possible confounder was explored, at multivariate analysis
showing no influence of the histological degree of inflammation on strain ratio
results [23]. Further data on the ability of strain elastography to distinguish between
inflamed and fibrotic tissue was provided in a later study, which tested 16 patients
with Crohn’s disease of the terminal ileum, using magnetic resonance enterography
as the reference standard for the detection of inflammation or fibrosis [24].
Elastography results, evaluated by two independent operators (with good inter-
observer agreement) and expressed as a semi-quantitative score with higher scores
corresponding to harder tissue, were significantly lower in patients with inflamma-
tory than fibrotic strictures identified at magnetic resonance (p = 0.003) [24].
Moreover, a pilot study aimed at assessing the diagnostic performance of ultrasound
techniques showed that the diagnostic performance of conventional ultrasound in
discriminating inflammatory from fibrotic strictures was implemented by adding
strain assessment and contrast enhancement ultrasound [25]. The data on the perfor-
mance of strain elastography alone were not brilliant as compared to histology
(accuracy 30–35%), but a visual classification of bowel wall appearance at real-time
strain elastography was used to evaluate bowel wall stiffness instead of strain
ratio [25].
Interestingly, a study questioned the previously promising observations on the
potentiality of strain elastography [26]: 26 symptomatic Crohn’s disease patients
were evaluated with ultrasound, contrast-enhanced ultrasound, and strain elastog-
raphy before surgery. The authors found no significant correlation between fibro-
sis at histology and mean strain ratio, attributing a possible confounding role to
the presence of inflammation [26]. It is important to point out, though, that the
mean strain ratio was obtained by selecting as a reference not the tissue surround-
ing the affected area but a dark red area in the deepest portion of the elastogram,
representing the bottom of the color scale [26]. The “strain” represents the tissue
deformation under a given pressure and has to be expressed as strain ratio during
real-time elastography since the manual pressure applied by the operator cannot
be measured—the ratio is calculated between two areas that receive roughly the
same amount of stress and thus varies according to the specific stiffness of the
tissue sampled as a region of interest (ROI). The use of an optical artifact like the
bottom of the scale area as the reference tissue may have influenced the results
since in that case the applied pressure of the operator has no influence on the value
of the strain.
15.3.2 A
coustic Radiation Force Impulse: Shear
Wave Elastography
The application of shear wave technology in the setting of Crohn’s disease has been
investigated in various studies (a summary is provided in Table 15.3).
The first clinical study on the subject enrolled 105 patients, 15 of whom under-
went surgical resection during follow-up [27]. Point shear wave speed measure-
ments for the evaluation of bowel wall stiffness were performed, and the results
were compared between patients who underwent surgery and those who did not, as
well as to the histological analysis of fibrosis, inflammation, and muscle hypertro-
phy. Interesting results were shown: first of all, the mean shear wave velocity was
higher in patients who underwent surgery (2.8 ± 0.7 m/s vs. 2.2 ± 0.8 m/s, p < 0.01),
Table 15.3 Clinical studies investigating shear wave elastography techniques in Crohn’s disease
Subjects Technique Comparison Elastography performance
Dillman 17 human Point SW speed Histology It discriminates between
(2014) [22] intestinal surgical measurement inflammation and fibrosis
specimens (from and SW speed
subjects with imaging
known or
suspected IBD)
Lu (2017) 105 CD patients Point SW speed Histology It correlates with
[27] (15 elected for measurement muscular hypertrophy of
surgery) the bowel wall
Chen 35 CD patients SW speed Histology It detects intestinal
(2018) [28] with strictures imaging fibrosis; it potentially
elected for surgery discriminates between
fibrosis and inflammation
Goertz 77 retrospective Point SW speed Clinical It potentially identifies
(2018) [36] 21 prospective CD measurement data inflammatory activity
patients
Ding 25 CD patients Point SW speed Histology Point SW speed
(2019) [30] measurement (+ (biopsies) measurement
ARFI imaging discriminates between
and strain fibrosis and inflammation
elastography)
IBD inflammatory bowel diseases, CD Crohn’s disease, SW shear wave
confirming the previous observations linking higher wall stiffness with the presence
of a chronic/fibrotic process. A moderate correlation was found between shear wave
velocity and muscular hypertrophy (r = 0.59, p = 0.02), but not with fibrosis.
However, strictured bowel segments showed more muscular hypertrophy than fibro-
sis (p < 0.001). All in all, this study suggested that the dominant cause of bowel wall
stiffness in chronic Crohn’s strictures may not be fibrosis but muscle hypertrophy as
a marker of chronic inflammation and that this feature could be detected by shear
wave elastography.
A successive study on 35 Crohn’s patients was able to refocus the attention on
the role of elastographic techniques (in this case, real-time shear wave elastography
or shear wave speed imaging) in assessing the presence of fibrosis [28]. Shear wave
elastography was performed on the stenotic bowel wall of 35 Crohn’s disease
patients with ileal or ileocolonic strictures within a week before surgical resection.
The results were compared to the degree of fibrosis and inflammation at histology,
showing significantly different mean shear wave values (expressed in kPa) between
severe, moderate, and mild fibrosis (23.0 ± 6.3 kPa vs. 7.4 ± 3.8 kPa vs. 14.4 ± 2.1 kPa,
respectively, with p = 0.008), while no difference was observed between different
degrees of inflammation. The authors established a 22.5 kPa for severe fibrosis,
showing a sensitivity of 69.6% and specificity of 91.7% for shear-wave elastogra-
phy in diagnosing severe fibrosis (AUROC 0.822). Although the 22.5 kPa cut-off
value seems quite arbitrarily established, the study has shown promising results on
the performance of shear wave elastography in identifying fibrotic strictures.
Another study performed shear wave velocity measurements on various seg-

ments of the intestinal tract of Crohn’s patients in order to establish a possible cor-
relation with inflammatory activity: not surprisingly, considering previous data
contradicting this hypothesis, no significant correlation was found [29].
15.3.3 Comparison Between Elastographic Techniques
A comparison between the different elastographic techniques, including ARFI imaging,

has been attempted in a recent study on 25 patients with Crohn’s stenosis [30]. Between
the semi-quantitative evaluation of strain elastography and ARFI imaging and point
shear wave elastography, only the last technique seemed to achieve a satisfactory perfor-
mance for the detection of fibrotic strictures, with a sensitivity of 75% and a specificity
of 100% with a 2.73 m/s cut-off. However, both strain elastography and ARFI results
were assessed by means of a semi-quantitative color scale, which—in the case of strain
elastography—already proved less accurate than the strain ratio [23].
To date, some systematic reviews have shown that elastographic techniques seem
to correlate with the presence of fibrosis in Crohn’s disease; however, the heteroge-
neity of these studies as regards techniques as well as methods prevents from formu-
lating conclusive statements on the accuracy of elastography [31, 32].
15.4 lastography as a Predictor of Therapy Outcome

E
in Crohn’s Disease?
Considering the overall promising data available on the ability of elastography to pre-
dict the presence of fibrosis in Crohn’s disease strictures, efforts have been made to
establish whether elastography results could predict the response to anti-inflammatory
therapy. Since inflammatory processes tend to respond to medical treatment, while
fibrotic strictures usually require endoscopic dilation or surgery, the noninvasive
assessment of the degree of fibrosis may possibly help identify which patients will
benefit from treatment and which ones should be evaluated for surgery. In a recent
study, 30 consecutive patients with ileal/ileocolonic Crohn’s disease were evaluated
by ultrasound and strain elastography before and after the beginning of anti-TNF
treatment [17]. The bowel wall stiffness was assessed by calculating the strain ratio,
with a ratio ≥2 as cut-off value for severe ileal fibrosis [23]. The bowel wall thickness
measured by standard ultrasound was used to define transmural healing (cut-off:
3 mm) at 14 and 52 weeks after starting the treatment. In patients with a strain ratio
≥2 at baseline, subsequent surgery was performed more frequently (p = 0.003).
Noteworthy, a significant inverse correlation between the strain ratio values at base-
line and the reduction in bowel wall thickness following therapy was observed, while
the patients who achieved transmural healing had a significantly lower baseline strain
ratio (p < 0.05). All in all, evaluation by strain elastography, its accurately identifying
severe fibrosis, seems to be able to predict therapeutic outcomes for Crohn’s patients,
although further studies are needed to confirm these promising results.
15.5 Other Applications of Elastography
15.5.1 Pediatric Crohn’s Disease
Strain elastography in the setting of pediatric Crohn’s disease may help widening
the range of noninvasive methods in this group of patients. A specifically designed
study examined 48 bowel segments of 14 pediatric Crohn’s patients [33]. The devel-
opment of a visual classification of bowel wall appearance at strain elastography
(remission bowel, inflammatory wall, and fibrotic wall) and its correlation with
clinical and imaging features was attempted. The results suggested a possible cor-
relation between different visual patterns and signs of disease activity or complica-
tions. However, no comparison to histology or other reference standards was made,
and, therefore, these preliminary results still require validation [33].
15.5.2 Ulcerative Colitis
Elastography has been tested as a potential diagnostic tool in another inflammatory

bowel disease, ulcerative colitis. Preliminary data is available from murine [34] and
human models [35, 36]. A single-center, retrospective, and prospective study con-
ducted on 37 patients with ulcerative colitis compared real-time tissue elastography
with endoscopic findings and disease activity [35]. Elastographic findings showed a
significant correlation with endoscopic activity at colonoscopy, with individuals in
the active phase of the disease more likely to show “abnormal” elastographic find-
ings. However, no conclusive data can be drawn, at present, regarding the associa-
tion between elastography results and disease activity.
A further study compared bowel wall stiffness measured by ARFI in ulcerative
colitis patients and healthy volunteers, showing that ARFI elastography of the
colonic bowel wall and the terminal ileum is feasible, but the results were scattered
with high standard deviation [36]. According to the authors’ experience, ARFI shear
wave velocities appear to be slightly higher in patients with ulcerative colitis than in
healthy volunteers, particularly in the sigmoid and transverse colon [36]. All in all,
interesting preliminary data suggests that a role of elastographic techniques can be
hypothesized in the management of patients with ulcerative colitis, but further larger
prospective studies are needed before drawing any conclusions.
15.6 Summary
Elastography is an extremely promising technology that may develop to play a

major role in the field of inflammatory diseases, particularly Crohn’s disease. Its
overall simplicity and availability allow to expect the validation of the available data
on its accuracy with larger studies, as well as the broadening of its application in the
near future. The current European recommendations for gastrointestinal ultrasound
already state that elastography “can be used to evaluate the stiffness of a patient’s
pathological thickened bowel” [37].
Strain elastography has shown very promising results as a discriminator between
fibrotic and inflammatory strictures and may acquire a role as a predictor of response
to treatment. Contradictory results questioning its accuracy and reproducibility in
this setting may derive from methodological differences in the small studies avail-
able. In particular, the measurement of the strain ratio, thanks to an easily available
software, has been proven more reliable than visual or semi-quantitative color
scales, as well as more accurately correlated with the degree of tissue fibrosis.
On the other hand, shear wave elastography may indeed prove a simpler and
more reproducible technique in comparison to strain elastography with strain ratio
calculation. However, there is still little and dispersed data pointing to the correla-
tion between shear wave elastography results and both fibrosis and inflammation,
still generating inconclusive inferences.
For all techniques, clear-cut quantitative cut-offs may be difficult to obtain but
are needed to improve the clinical applicability of these techniques, as well as their
ability to orient clinical decision-making. For the strain ratio measurement, a cut-off
of 2 for the identification of severe fibrosis has shown good discriminatory ability
and good performance [17]. A recent study on shear wave elastography proposes a
cut-off of 22.5 kPa for the identification of severe fibrosis which shows good accu-
racy but certainly needs validation in bigger prospective studies before being intro-
duced in routine clinical practice [28].
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Part V
Spleen Involvement in Liver
and Non-Liver Diseases
Liver and Spleen Stiffness in Vascular
Liver Disease 16
Federico Ravaioli, Elton Dajti, Luigina V. Alemanni,
and Antonio Colecchia
16.1 Introduction
Vascular liver disease related to portal hypertension is an exciting and not com-
pletely studied issue that includes the most common manifestations of non-cirrhotic
portal hypertension, acute non-cirrhotic portal vein thrombosis (NCPVT), extrahe-
patic portal vein obstruction (EHPVO), and idiopathic non-cirrhotic portal hyper-
tension (INCPH).
These entities though diverse and undergoing to periodic update not infrequently
are present in hepatological departments, and very often their recognition is a diag-
nostic challenge because the shared clinical manifestations are due to portal hyper-
tension (ascites, esophageal varices, splenomegaly, etc.). Their correct diagnosis
involves different expertise, as hepatologists, radiologists, hematologists, and
experts in coagulation; thus, often a multidisciplinary approach should be neces-
sary. Firstly, the presence of liver cirrhosis should be ruled out through non-invasive
tools useful for fibrosis staging and portal hypertension to avoid misclassifications.
Imaging techniques like color duplex ultrasound or MRI/CT scan are considered as
modality of choice for these diseases; however, in the long term, there could be
some difficulty in differentiating between portal vein thrombosis due to cirrhosis
or EHPVO.
Correct diagnosis is critical, as the evaluation, prognosis, and treatment can be
different. In the last decade, a new non-invasive tool, elastographic ultrasound, born
to assess fibrosis staging, and in time also portal hypertension, has deeply modified
the clinical diagnosis and management of liver diseases. In fact, international
F. Ravaioli · E. Dajti · L. V. Alemanni

Department of Medical and Surgical Sciences (DIMEC), S. Orsola-Malpighi Hospital,
University of Bologna, Bologna, Italy
A. Colecchia (*)
Gastroenterology Unit, Borgo Trento, University Hospital, Verona, Italy
e-mail: antonio.colecchia@aovr.veneto.it

https://doi.org/10.1007/978-3-030-74132-7_16
236 F. Ravaioli et al.
guidelines included elastographic ultrasound in almost all diagnostic flow chart and
clinical decision-making.
In this chapter, we describe the role of the measurement of liver and spleen stiff-
ness in the different vascular liver conditions. In diseases such as pre-hepatic portal
hypertension, the simultaneous elastographic assessment of the liver and the spleen
stiffness represents the unique approach to reach quickly and non-invasively a diag-
nosis. Likewise, in Budd-Chiari syndrome, it could help the hepatologists making
the best clinical decision since during follow-up it can identify the timing for inter-
ventional treatments or liver transplantation. In others, as hepatic veno-occlusive
disease, liver stiffness measurement can allow a pre-clinical diagnosis, anticipating
the treatment and leading to a reduction of the overall mortality.
16.2 art I: Liver and Spleen Stiffness in Patients

P
with Budd-Chiari Syndrome
The Budd-Chiari syndrome (BCS) is a rare vascular disease of the liver, defined as
the obstruction of hepatic venous outflow that can be located from the small hepatic
venules up to the entrance of inferior vena cava (IVC) into the right atrium [1]. In
Western countries, thrombosis of the hepatic veins is the most frequent site of
obstruction, whereas in Asian countries, IVC thrombosis is the more predominant
form [2]. The most common clinical presentation is that of hepatic decompensation,
with ascites, hepatomegaly, and abdominal pain being the most frequent signs and
symptoms [3]. However, one must bear in mind that its manifestation can be highly
variable, ranging from asymptomatic to fulminant disease. Of consequence, the
prognosis of BCS patients is also variable, and, despite significant advances in the
medical management of these patients, still, 49–64% require endovascular and/or
surgical derivative treatments, 12–17% liver transplantation (LT), and 20–22% die
[4, 5]. Therefore, the availability of accurate prognostic models able to stratify the
risk of complications and to identify the patients with a more severe course of the
disease would be of tremendous help for the clinician. To date, this represents an
unmet clinical need for patients with BCS. Standard prognostic scores used in hepa-
tology, such as model for end-stage liver disease (MELD), are suboptimal in these
patients because liver function might be preserved despite complications due to
severe portal hypertension [6]. Many authors have tried to develop and validate
specific scores for BCS [5, 7, 8]; these models present moderate overall accuracy in
predicting clinical outcomes such as the need for invasive therapies (c-
statistic = 0.697–0.797) or LT (c-statistic 0.619–0.693) [4] and are suboptimal for
individual patients in day-to-day clinical practice [1].
Liver stiffness measurement (LSM) has been extensively validated as a useful
diagnostic and prognostic tool in hepatology, especially in the context of viral hepa-
titis [9]. Its values correlate well with the degree of fibrosis [10] and indirectly with
that of portal hypertension [11, 12]. However, LSM may also reflect other condi-
tions, such as cholestasis, inflammation, and congestion [13]. While these compo-
nents might interfere with the accuracy of LSM incorrectly identifying the fibrosis
16 Liver and Spleen Stiffness in Vascular Liver Disease 237
stage in patients with chronic liver disease, the fact that LSM reflects hepatic con-
gestion [14, 15] is precisely the reason why LSM can help in assessing the degree
of the outflow obstruction and the severity of the disease in patients with BCS. Spleen
stiffness, on the other hand, is a more recently described non-invasive test that is to
be considered a direct surrogate of portal hypertension [16]. Therefore, it correlates
better with the hepatic venous pressure gradient (HVPG) [16], is more accurate for
the diagnosis of clinically significant hypertension [17, 18] or esophageal varices
[19, 20], and generally reflects better the degree of portal hypertension despite its
cause (i.e., pre-, post-, or intrasinusoidal) [11].
Despite these premises, data on elastosonography in BCS is still minimal
(Table 16.1). The most extensive series focuses on LSM values in the setting of
severe BCS requiring endovascular interventional procedures (i.e., TIPS placement
or angioplasty) and its changes after treatment [21, 24, 27]. For the first time,
Mukund et al. reported high LSM values (range 20.5–75 kPa, mean 62.8 kPa), as
evaluated by transient elastography (TE), in 25 BCS patients before endovascular
procedures; these values were reduced significantly at 24 h after treatment (mean
26.3 kPa, p < 0.001) and then again slightly after 3 months (21 kPa, p = 0.003), sug-
gesting for the first time that LSM was predominantly determined by hepatic con-
gestion in BCS patients. Similar findings were reported later by Wang et al. [27],
who assess LSM by two-dimensional shear wave elastography in 32 patients with
BCS before and after angioplasty. The authors found that LSM progressively and
significantly decreased at +2 days and +3 months, but no significant changes were
found between the measurements at +3 months vs. +6 months after angioplasty.
Noteworthy, the authors reported a significant correlation between hepatic venous
pressure and LSM before angioplasty (r = 0.701, p < 0.001), but not between LSM
and fibrosis stage at liver specimen (not even after the intervention). Xu et al.
recently confirmed these results [24] in 23 BCS patients undergoing magnetic reso-
nance elastography (MRE) before and after endovascular treatment, as the authors
found a significant correlation between changes in LSM and those in pressure gradi-
ent before and after treatment (r = 0.651, p = 0.009). Importantly, given the hetero-
geneity of BCS, the authors evaluated LSM in three liver regions (right posterior,
right anterior, and left medial) and found no significant difference among the differ-
ent evaluations, with an excellent intra- and inter-observer agreement for LSM
determination by MRE in all three segments.
Long-term data on LSM after endovascular treatments are very scarce. We
recently reported two cases in which LSM was low (<10 kPa) [12] at 1 and 10 years
after TIPS placement, in patients who indeed had responded well to TIPS and had
remained compensated throughout this period [23]. Oppositely, a sudden increase in
LSM during follow-up was associated with a recurrence of BCS [25, 27] or TIPS
obstruction [23], suggesting that LSM could play a role in the non-invasive assess-
ment of response to endovascular treatments, alongside with routine Doppler
ultrasound.
As mentioned above, BCS is very heterogeneous, and not all patients present
severe cases requiring endovascular derivative therapies. In fact, in many patients,
medical management of ascites and/or varices, as well as anticoagulation with
Table 16.1 Main papers reporting liver and/or spleen stiffness in patients with Budd-Chiari
syndrome
N. of Inclusion Elastometry
Nr. Citation patients criteria technique Main result
1. Mukund 25 TIPS, PTA TE Progressive LSM reduction
et al. [21] after 24 h and after
3 months after treatment
No difference in ΔLSM
across fibrosis stages
(Metavir >2 vs. ≤2)
No correlation between
ΔLSM and Δ in pressure
gradient
2. Wang et al. 32 PTA 2D-SWE Progressive LSM reduction
[22] after 2 days and 3 months,
but not at 6 months
LSM correlates with
hepatic venous pressure,
but not with fibrosis stage
ΔLSM significantly lower
in patients with fibrosis
stage >2
3. Dajti et al. 7 Mixed TE The first description of
[23] SSM in BCS patients
LSM reduces <10 kPa a
long time after TIPS
4. Xu et al. 23 Endovascular MRE LSM was reduced after
[24] treatment endovascular treatment
Changes in LSM correlate
with changes in portal
pressure
5. Nakatsuka 2 PTA TE LSM can monitor response
et al. [25] to PTA and can detect early
restenosis
6. Mancuso 3 Medical TE Reduction in LSM
et al. [26] therapy corresponded with a
compensated state of the
disease after
anticoagulation
2D-SWE two-dimensional shear wave elastography, PTA percutaneous transluminal angioplasty,
LSM liver stiffness measurement, MRE magnetic resonance elastography, SSM spleen stiffness
measurement, TE transient elastography, TIPS transjugular intrahepatic portosystemic shunt
eventual etiological therapy, might be sufficient, as suggested by a stepwise approach

to BCS treatment according to the last European guidelines [1]. However, no prog-
nostic tools are available today to identify which patients could safely undergo only
medical therapy and which could benefit from early endovascular intervention. In
this view, although data on LSM and BCS patients undergoing only medical therapy
are limited, it can be hypothesized that elastography could play a role in stratifica-
tion of venous outflow obstruction degree, disease severity assessment, and response
to medical therapy. We previously reported that LSM decreased after anticoagula-

tion in two young patients [23]. More recently, Mancuso et al. [26] showed that
lower, or at least stable, LSM values after anticoagulation correlated with stable
liver disease in two patients. In contrast, an increase in LSM despite medical ther-
apy in one patient was associated with the development of refractory ascites and
referral for liver transplantation. Both works suggest the role of elastosonography
also in the assessment of the response to medical therapy.
Last but not least, only one paper by our group reported SSM measurement in
patients with BCS [23]. In our experience, LSM and SSM values are incredibly high
(both up to 75 kPa) in patients with severe BCS; these findings are very unusual for
cirrhotic patients. Therefore near-upper-limit LSM and SSM values might help to
direct the diagnosis towards BCS in patients manifesting as decompensated cirrho-
sis. Moreover, SSM decreases slower than LSM after TIPS placement. For instance,
in one young female undergoing TIPS placement, LSM and SSM were both 75 kPa.
At 1 year after TIPS, LSM, but not SSM value, was significantly reduced (LSM and
SSM, respectively, 8 kPa and 65.2 kPa); the following year LSM was 11.2 kPa, and
SSM had decreased to 23.8 kPa. This pragmatic case suggests that LSM reflects the
immediate resolution of the outflow obstruction and hepatic congestion after TIPS,
but SSM reflects the long-term structural changes due to portal hypertension and
eventually its improvement. Finally, our data suggest that SSM reflected better than
LSM the progression of the disease in patients undergoing solely medical therapy
for BCS.
In conclusion, there is increasing evidence that elastosonography techniques can
provide insights on the outcomes of interventional therapy in patients with BCS and
could be used as surveillance tools to assess its benefits longitudinally over time and
transplantation-free survival in these patients. The reported results were consistent
among the different elastography techniques. The combination of LSM and SSM,
both at diagnosis and after medical therapy, should be further evaluated in order to
identify BCS with a better prognosis than do not require interventional treatments
or liver transplantation.
16.3 art II: Liver and Spleen Stiffness in Patients

P
Non-cirrhotic Portal Hypertension
The most common manifestations of non-cirrhotic portal hypertension that will be

discussed in this chapter are acute non-cirrhotic portal vein thrombosis (NCPVT),
extrahepatic portal vein obstruction (EHPVO), and idiopathic non-cirrhotic portal
hypertension (INCPH). The nomenclature of these conditions is ambiguous in cur-
rent literature, but, according to the last European guidelines [1], acute PVT is the
recent formation of a thrombus within the portal vein and/or intrahepatic branches,
in the absence of cirrhosis or malignancy. After the acute thrombus formation, if no
recanalization occurs, the portal venous lumen is obliterated, and numerous porto-
portal collaterals develop through a process caused cavernomatous transformation,
defining thus EHPVO. Idiopathic non-cirrhotic portal hypertension, on the other
hand, is often defined also as hepatoportal sclerosis, non-cirrhotic portal fibrosis,

and incomplete septal cirrhosis of nodular regenerative hyperplasia (NRH). The
diagnosis of idiopathic non-cirrhotic portal hypertension can be made only if known
causes of non-cirrhotic portal hypertension, such as infiltrative diseases, sarcoid-
osis, congenital hepatic fibrosis, cystic fibrosis, etc., can be excluded. More recently,
the term porto-sinusoidal vascular disease was proposed for this condition by a
group of experts [28], with a focus on the histopathological findings in these
patients. In this paper, new diagnostic criteria were proposed, aiming to promote
earlier diagnosis of this condition, before overt clinical manifestations such as vari-
ceal bleeding or ascites develop.
Since all these conditions require that cirrhosis is ruled out, non-invasive surro-
gates of fibrosis staging and portal hypertension can be very helpful to raise suspi-
cion and diagnose these forms of PH. The main studies reporting LSM and/or SSM
in non-cirrhotic portal hypertension are summarized in Table 16.2.
One of the most important papers on the role of elastography in patients with
EHPVO is that of Sharma et al. [35], who described that LSM values are slightly
higher than those seen in healthy controls (mean 6.7 kPa vs. 4.6 kPa, respectively)
but lower than those of cirrhotic patients (median 44.2 kPa). SSM values, on the
other hand, were higher than those seen in controls (51.7 kPa vs. 16 kPa, respec-
tively) and could accurately distinguish between patients with and without a history
of variceal bleeding at multivariate analysis. In this view, the most common findings
in patients with EHPVO are normal [54] or slightly elevated LSM values [35], high
SSM, and therefore high SSM/LSM ratio [35, 52, 55]. The SSM values could reflect
the degree of obstruction and severity of PH directly, as higher values were associ-
ated with the grade of varices [52, 56], and history of bleeding [35], although these
results were not always confirmed [43]. The prognostic role of LSM, on the other
hand, is not clear. Although less common than in INCPH (see below), LSM in
patients with EHPVO can be high (>10 kPa) and overlap with those seen in patients
with advanced chronic liver disease (ACLD). Whether these values express a certain
degree of fibrosis or intrahepatic thrombosis due to chronic obstruction [35, 57] or
reflect a “misdiagnosed” INCPH complicated later on by PVT, it is not known [58].
The facts that up to 30% of INCPH are complicated by PVT during follow-up [59]
and that the two conditions share many etiological and risk factors [1] make it very
difficult to establish which condition came first.
The interpretation of elastography values in patients with INCPH is more com-
plicated. Since the very first papers reporting LSM in patients with human immuno-
deficiency virus (HIV) that had developed PH in the absence of known causes of
liver disease, it was shown that LSM was high and overlapped with cirrhotic values
in 30–60% of the cases [60–62]. In a large cohort of patients with NRH [63], the
range of LSM values was 2.5–16.8 kPa; 17 (63%) and 11 (41%) patients had values
>7.1 kPa and 10 kPa, compatible with significant fibrosis and ACLD, respectively.
Moreover, LSM did not correlate with fibrosis stage at liver biopsy, nor with the
presence of varices, ascites, or splenomegaly. Seijo et al. [64] measured both LSM
and HVPG in 30 patients with biopsy-proven INCPH, 24 patients with NCPVT, and
39 patients with liver cirrhosis. The authors reported that LSM was significantly
Table 16.2 Main papers reporting liver and/or spleen stiffness in patients with non-cirrhotic portal hypertension
Elastometry LSM or SSM value Comment on diagnosis or
Nr. Citation N. of patients Etiology technique (median, range) results
1. Chang et al. [29] 5 INCPH in HIV TE LSM: 8.9 kPa Diagnosis with liver biopsy
(6.8–14.9 kPa)
2. Panos et al. [30] 5 INCPH in HIV TE LSM: 11.8 kPa (9.9–21.1) Liver biopsy, high LSM
3/5 pts >10 kPa (>10 kPa) in patients without
cirrhosis
3. Cesari et al. [31] 11 INCPH in HIV TE LSM: 8.1 kPa Signs of portal hypertension at
(2.5–11 kPa) imaging/endoscopy, 5/11 liver
3/11 pts >10 kPa biopsy
4. Laharie et al. [32] 27/30 INCPH TE LSM: 7.9 kPa Liver biopsy in patients with
(3.5–16.8 kPa) NRH
11/27 pts >10 kPa
5. Scourfield et al. 11/17 INCPH in HIV TE LSM: 6/11 >9.6 kPa, of Liver biopsy in HIV patients
[33] whom 4/6 >21 kPa without liver disease
6. Jackson et al. [34] 4/5 INCPH in HIV TE LSM: 11 kPa Radiological or endoscopic
(6.3–13.3 kPa) signs of PH, 4/5 liver biopsy
16 Liver and Spleen Stiffness in Vascular Liver Disease
3/4 >10 kPa

7. Sharma et al. [35] 65 NCPVT TE LSM: 6.7 kPa Higher SSM in patients with
(3.4–14.6 kPa) previous variceal bleeding
SSM: 51.7 kPa
(11.7–75 kPa)
8. Seijo et al. [36] 30/39 INCPH TE LSM: 8.4 ± 3.6 kPa Signs of PH and absence of
14/30 pts >7.8 kPa, 2/30 cirrhosis at liver biopsy
>13.6 kPa
24/39 NCPVT TE LSM: 6.4 ± 2.2 kPa PVT and absence of cirrhosis at
liver biopsy
(continued)
241
242

9. Furuichi et al. [37] 17 INCPH pSWE, ARFI LSM: 1.56 m/s Liver biopsy in all patients
(0.98–2.37 m/s)
SSM: 3.88 m/s SSM/LSM ratio: AUROC
(2.69–4.79 m/s) 0.933
10. Logan et al. [38] 2/81 INCPH in HIV TE LSM: 8 and 10 kPa Abnormal TE, ultrasound or
liver enzymes => liver biopsy,
2 confirmed INCPH
11. Scherpbier et al. 7 INCPH in HIV TE LSM: 8.3 kPa
[39] (5.6–9.5 kPa)
12. Madhusudhan et al. 50 NCPVT 2D-SWE LSM: 5.96 kPa No difference with LSM in
[40] (4.27–8.63 kPa) healthy controls
13. Sood et al. [41] 19 INCPH, children TE LSM: 10.6 kPa Clinical, imaging, and
(7.6–13.5 kPa) endoscopic findings
14. Sharma et al. [42] 20 INCPH TE LSM: 6.8 kPa Liver biopsy, HVPG
(2.9–11.9 kPa)
15. Madhusudhan et al. 21 NCPVT 2D-SWE SSM: 46.04 ± 8 kPa SSM did not correlate with
[43] portal pressure (intra-operative)
or esophageal varices
16. Chougule et al. 66 INCPH TE LSM: 9.2 kPa Liver biopsy; no correlation
[44] (4.4–26.3 kPa) with periportal fibrosis
17. Vuppalanchi et al. 22 INCPH TE LSM: range 4.4–22 kPa A high rate of patients with
[45] 11/22 pts >10 kPa LSM >10 kPa (cACLD) in
13 NCPVT TE LSM: range 3.6–18.8 kPa patients with NCPVT and
4/13 pts >10 kPa INCPH
8 Other NCPH TE LSM: 7.4–67.8 kPa
6/8 pts >10 kPa
F. Ravaioli et al.
18. Madhusudhan et al. 52 NCPVT 2D-SWE SSM: 44.92 kPa Poor AUROC for HRV
[46] (25.3–75.6 kPa) diagnosis*
Almost all had varices, LRV
vs. HRV
19. Sutton et al. [47] 15/67 NCPVT, children TE LSM: 19.4 kPa vs. 8.7 kPa SSM was accurate to predict
(no EV) varices
SSM: 62.8 kPa vs.
13.2 kPa (no EV)
20. Cunningham et al. 44 NCPH, mixed TE LSM: 8.7 kPa LSM not useful for HRV
[48] (6.7–11.5 kPa) diagnosis
22. Navin et al. [49] 41 NCPH, mixed MRE LSM: 3.4 ± 1 kPa (56% LSM 4.7 kPa AUROC 0.99 for
>3 kPa, F2) NCPH diagnosis (vs. cirrhosis)
SSM: 8.2 ± 4.9
23. Ahmad et al. [50] 11 INCPH in HIV pSWE LSM: 6.8 kPa (5–12 kPa) SSM is more accurate that
SSM: 76.3 kPa LSM
(18–197 kPa)
24. Cannella et al. [51] 37 INCPH MRE LSM: 3.56 ± 1.10 kPa Liver biopsy as the reference
25. Yuldashev et al. 34 NCPVT 2D-SWE SSM: 47.23 SSM correlated with EV grade,
[52] (16.3–104.5 kPa) decreased after surgical shunt

26. Gupta et al. [53] 53 NCPVT pSWE LSM: 1.2 m/s (1–1.9 m/s) LSM higher in INCPH vs.
63 INCPH LSM: 1.5 m/s NCPVT
(0.9–2.8 m/s)
2D-SWE two-dimensional shear wave elastography, EV esophageal varices, HIV human immunodeficiency virus, INCPH idiopathic non-cirrhotic portal hyper-
tension, LSM liver stiffness measurement, MRE magnetic resonance elastography, NCPVT non-cirrhotic portal vein thrombosis, NCPH non-cirrhotic portal
hypertension, SWE point shear wave elastography, SSM spleen stiffness measurement, TE transient elastography
SEARCH STRING: ((“non-cirrhotic” OR “noncirrhotic” OR “idiopathic”) AND (“portal hypertension” OR “portal vein thrombosis”) OR “portal vein obstruc-
tion” OR “nodular regenerative hyperplasia”) AND (“liver stiffness” OR “spleen stiffness” OR “elastography” OR “elastometry”)
243
higher in patients with INCPH than in patients with NCPVT (8.4 ± 3.6 kPa vs.
6.4 ± 2.2 kPa) but much lower than the one seen in cirrhotic patients. Moreover, no
correlation was found between LSM, HVPG, and variceal bleeding. These results
were later confirmed also by other authors [44, 65].
Similar to what reported for EHPVO, spleen stiffness, a direct surrogate of PH,
is high in patients with INCPH, and once again, the combination of LSM and SSM
can be extremely helpful in distinguishing between cirrhosis and INCPH. In a
famous study by Furuichi et al. [66], both LSM and SSM were measured in patients
with INCPH and control groups of patients with liver cirrhosis, chronic hepatitis,
and healthy subjects. The SSM/LSM ratio was elevated in INCPH patients, and with
a cut-off of 1.71, the AUROC of the ratio was excellent (0.933), higher than that of
LSM or SSM alone. Similar findings were recently reported also by Ahmad et al.
[50] and Navin et al. [67], measuring LSM and SSM with point shear wave elastog-
raphy and MRE, respectively.
In conclusion, LSM should be routinely evaluated in patients with suspected
non-cirrhotic portal hypertension, as low values can rule out cirrhosis and help to
establish the diagnosis. In patients with NCPVT, slightly high LSM values
(7.1–10 kPa) could suggest hepatic involvement or INCPH and therefore might be
used to select patients that should undergo liver biopsy. Moreover, since an overlap
with LSM values in cirrhotic patients, especially for INCPH, has been consistently
reported in the literature, LSM alone is not reliable to exclude a pre-sinusoidal cause
of PH. In this view, the combination of LSM and SSM has shown promising results
in improving the accuracy of the non-invasive diagnosis of NCPH. Further studies
are required to evaluate the prognostic role of LSM and SSM, in terms of risk strati-
fication and prediction of variceal bleeding, need for TIPS, and transplantation.
Finally, we believe that the evaluation of both liver and spleen stiffness, alongside
with a careful examination of patient history, exclusion of other causes of liver dis-
ease, evaluation of risk factors, and histopathologic findings, should help the clini-
cian to suspect and make an early diagnosis of non-cirrhotic portal hypertension, or
porto-sinusoidal disease, even before dreadful complications such as variceal bleed-
ing occur.
16.4 art III: Liver Stiffness in Patients with Sinusoidal

P
Obstruction Syndrome (SOS/VOD)
Sinusoidal obstruction syndrome, also known as hepatic veno-occlusive disease

(hereafter as SOS/VOD), is a clinical syndrome occurring after high-dose chemo-
therapy and hematopoietic stem cell transplantation (HSCT) [68] and, less com-
monly, after ingestion of toxic alkaloids (toxic injury) [69] and after high doses of
radiotherapy [70] or liver transplantation [71]. According to SOS/VOD pathogene-
sis, the syndrome has been classified as a (sinusoidal) portal hypertension [72, 73].
Indeed, hepatotoxic agents (HSCT, alkaloids, radiotherapy, etc.) exerting their
action on sinusoidal endothelial cells lead to a loss of integrity of the sinusoidal
wall, detachment of endothelium, and embolization of the hepatic acinus. These
events result in an obstacle to the outflow of liver blood, with sinusoidal obstruction
and consequent congestion and increase in portal pressures, thus generating the
status of portal hypertension (PH) [74, 75]. Although this condition is rather rare in
other clinical contexts, after HSCT the syndrome has a clinically relevant incidence
(from 5% to >30% in high-risk populations) with a high mortality rate in severe
forms (>80%) [76]. To date, the diagnostic systems of SOS/VOD are based on the
combination of clinical and biochemical scores [77]; the definitive and confirmatory
diagnosis would remain determined by liver biopsy and/or measurement of the
hepatic venous pressure gradient (HVPG) [78]. In the last 10 years, as more detailed
in the Chap. 11 of this book, many efforts have been taken in place to determine the
role of LSM for the assessment of PH degree and PH-related conditions concluding
that LSM is a very accurate surrogate of PH measure [11, 72, 79]. Since a timely
SOS/VOD diagnosis is of critical importance, due to improving the survival rate and
given the availability of therapeutic options with favorable outcome, the clinical
research has been recently focused on this “niche” condition investigating the role
of LSM (Table 16.3) [68, 77, 92].
Recently, data from the animal model have published showing the elevation of
LSM in SOS/VOD murine models [93–95]. Park et al. have achieved the first proof
of concept on the elastography usefulness in SOS/VOD assessment. The authors
induced SOS/VOD with different severity stages in rat models, by monocrotaline
gavage or by intraperitoneal injection of 5-fluorouracil, leucovorin, and oxaliplatin.
Liver shear wave velocity (SWV), assessed by ARFI imaging in the median lobe,
was higher in the SOS/VOD rat models than the matched control group [94]. This
year J. Shin et al. have achieved similar results determining the effectiveness of
supersonic shear wave imaging (SSI) and dual-energy computed tomography
(DECT) for diagnosing hepatic SOS using a rabbit model. Indeed, SSI and DECT
were significantly increased in the livers of a rabbit SOS model [95].
The first cases reported of modification in LSM in patients with SOS/VOD date
back to 2011 when a Madrid group reported increased shear wave velocity, assessed
by ARFI, in two patients who developed VOD/SOS after HSCT [96]. Later on,
Auberger et al. suggested that a pre-transplant LSM cut-off of 8 kPa could predict
and differentiate patients that developed liver toxicity (defined as increased biliru-
bin values) after HSCT [81].
Thanks to Karlas and colleagues, an extensive commitment to study the role of
ultrasound elastography in post-HSCT complications has been done [97]. In 2014,
the authors prospectively enrolled 59 patients; among them, major complications
occurred in seven patients (grade 4 Common Terminology Criteria (CTC) for
adverse events): four with acute GvHD and/or severe liver toxicity, two with VOD/
SOS development, and one case of transplant rejection. The authors showed that
baseline liver and spleen size, liver perfusion, TE, and right lobe LSM (R-ARFI) did
not differ significantly between patients with and without severe liver complica-
tions. The only baseline left lobe LSM (L-ARFI) values were significantly increased
in the group with complications. In general, these authors found a slight increase in
LSM values in almost all patients throughout the post-HSCT period, probably due
to edema and hepatic inflammation caused by the high number of drugs
Table 16.3 Main papers reporting liver stiffness in patients with sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD)
246
Author (year) Study type Methods Cohort size Main findings Further commentary Human or animal
Fontanilla Case series Point shear wave Two adult Increased shear wave Comprehensive Human
et al. (2011) elastography patients with velocities at diagnosis diagnostic workup
[80] (pSWE), serial SOS normalized after successful including contrast-
measurements treatment enhanced and Doppler
ultrasound
Auberger et al. Single-center LSM assessed with 67 post-HCT Maximal total serum Human
(2013) [81] analysis with transient bilirubin after HCT was
pre-transplant elastography (TE) significantly higher in
non-invasive patients with pre-transplant
transient LS values >8.0 kPa than
elastography with values <8.0 kPa
Karlas et al. A monocentric LSM assessed with 59 before and Baseline l-ARFI was TE and r-ARFI baseline Human
(2014) [82] prospective transient after HCT significantly elevated in assessments not
study with elastography (TE) patients who subsequently significantly different
systematic and right and left developed severe between patients with
follow-up liver lobe ARFI complications and and without severe
examinations at (r-ARFI; 1-ARFI) continued to be elevated complications during
2–3 weeks, post-HCT post-HCT follow-up
4–8 weeks, and Transient elastography
12–20 weeks showed increasing LS in
after SCT patients with complications
Colecchia Interim analysis LSM assessed with 22 pediatric A sudden increase of LSM Human
et al. (2017) of a transient patients; 4 was a note in SOS patients
[83] monocentric elastography (TE) patients before the appearance of
prospective prior HCT and on developed SOS SOS
study with Days +7 to 10, +17
systematic to 20, and +27 to 30
follow-up for
30 days after
allogeneic
F. Ravaioli et al.
So Hyun Park An animal Liver shear wave Rat SOS models The liver SWV was Rat
et al. (2018) case-control velocity (SWV) of various significantly elevated in the
[84] study, evaluate measured with severities were SOS models compared with
on Days 2, 4, 7, acoustic radiation created by that of the matched control
10 the liver force impulse (ARFI) monocrotaline rats
shear wave elastography gavage (N = 40)
velocity or by
intraperitoneal
injection of
5-fluorouracil,
leucovorin and
oxaliplatin
(FOLFOX)
(N = 16)
Reddivalla A monocentric 2D shear wave 25 pediatric SOS patients had a marked LSM changes occurred Human
et al. (2018) prospective elastography (SWE) patients; 5 increase of LSM between before further
[85] study with was performed at patients Day 10 and 20 after SCT observations in imaging
systematic three predefined time developed SOS and laboratory tests
follow-up for points
24 days after
allogeneic SCT
Hao Han et al. The animal Liver shear wave 70 rats were Liver SWV in the low- and The liver SWV values Rat
(2019) [86] case-control velocity (SWV) by randomly high-dose groups were had significant
study evaluates virtual touch tissue divided into a elevated; the portal vein correlations with the
on Days 3 and 5 imaging control group velocity (PVV) of these histologic score and
liver SWV in quantification (n = 10), a groups was decreased PVV
the low- and low-dose compared with the control
high-dose monocrotaline group
groups group (n = 30),
and a high-dose
monocrotaline
group (n = 30).
247
(continued)
248
Karlas et al. A monocentric LSM assessed with Total Patients with confirmed No specific stratification Human
(2019) [87] prospective TE and pSWE cohort = 106; 9 SOS and/or severe other between liver GvHD,
study with including spleen developed SOS hepatic complications had drug-induced liver
systematic pSWE. Evaluation elevated LSM compared to injury, and SOS
follow-up for before allogeneic those without confirmed
3 months SCT and at the onset liver event
of hepatic symptoms
Colecchia A monocentric LSM assessed with Total A sudden increase of LSM LSM increase was only Human
A. Ravaioli F. prospective transient cohort = 78 was observed in all SOS observed in SOS cases,
et al. (2019) study with elastography (TE) patient; 4 patients 2–12 days prior to but not in other types of
[88] systematic prior HCT and on developed SOS the onset of clinical hepatobiliary
follow-up for Days +9/10, +15/17, symptoms complications
24 days after and +23/24
allogeneic SCT
Lazzari et al. Case report TE and 2D-SWE at Adult patient Maximum LSM values Normalized LSM values Human
(2019) [89] SOS diagnosis, serial were measured at SOS within 100 days after
LSM during diagnosis SCT
treatment
Zama et al. Case series Serial measurements Three pediatric SOS was associated with a LSM normalized within Human
(2019) [90] with TE and patients significant increase in LSM. 2 weeks after successful
2D-SWE treatment
Jaeseung Shin Animal Liver stiffness was Nine New Significant stiffness Compared to Day 0, Rabbit
et al. (2020) case-control measured using Zealand white changes measured by SSI liver stiffness and
[91] study supersonic shear rabbits, three in were observed starting on perfusion parameters
wave imaging (SSI) the control Day 10, with no apparent were higher on Day
and dual-energy group morphologic change even 20 in the SOS group
computed with contrast-enhanced CT
tomography (DECT) throughout the test days
on Days 0, 3, 10,
and 20
F. Ravaioli et al.
administered in this context. On the other hand, in just five patients who developed
severe hepatic complications, LSM by TE was significantly higher in comparison
with the whole population cohort [97]. Later on, in 2019, the same research group,
enlarging the previous cohort and prospectively enrolled 106 consecutive patients
undergoing allogeneic HSCT, evaluated the impact of LSM, assessed both by TE
and pSWE, on liver event-free survival and all-cause mortality at 1 year. They
observed 33 life-threatening events (14 died), including 16 liver complications (9
SOS/VOD) at 100 days. The hazard ratios for liver-related complications at 100 days
were 3.2 (95% CI: 1.8–14.6, p = 0.0022) and 4.4 (95% CI: 1.6–11.9, p = 0.0042) for
elevated TE values (n = 11) and pSWE values (n = 31), respectively. Results were
analogous for all-cause mortality at 1 year. The authors concluded that TE and
pSWE are promising for predicting the risk of free survival from hepatic events and
all-cause mortality to 1 year [87].
Our research group has worked intensely on the role of LSM change, assessed by
different elastographic techniques in SOS/VOD development after HSCT [88, 98].
Our first observation was investigating the predictive role of LSM changes, assessed
by TE, in SOS/VOD development after HSCT in a cohort of 22 pediatric patients
[98]. Five of those developed SOS/VOD after HSCT. LSMs were carried out at
baseline (before HSCT) and subsequently at the bedside at Days 7–10, 17–20, and
27–30 after HSCT. Even though none significant differences were observed at base-
line LSM between patients that developed SOS/VOD and those that did not, in
patients that developed SOS/VOD, LSM values increased markedly compared to
the previous measurement. This LSM increment was observed from 3 to 6 days
before clinical VOD/SOS diagnosis based on Seattle/Baltimore criteria. Based on
these preliminary results, a national multicenter, multi-elastographic technique,
prospective study in Italy (“ElastoVOD Study” ClinicalTrials.gov: NCT03426358,
ongoing) was set up, aimed at confirming the prognostic role of LSM. With similar
results, later on, Reddivalla et al. [99] evaluated SWV by 2D-SWE in 25 pediatrics
patients at baseline and Days +5 and +14 after HSCT. The incidence of SOS/VOD
clinical diagnosis was 5 out of 25 (20%), observing no differences in pre-conditioning
SWV between VOD/SOS and the control group. Analogously, a significant increase
in SWV velocity was observed in patients that developed SOS/VOD, and the SWV
increase generally preceded a clinical and US-based VOD/SOS diagnosis by 9 and
11 days. D. Zama et al. [100] reported the role of LSM in the management of three
pediatric patients after the diagnosis of VOD/SOS. The authors showed that after a
specific SOS/VOD treatment (i.e., defibrotide), liver stiffness values showed a pro-
gressive reduction pattern in all three patients, with normalization after 2 weeks
leading to a speculative conclusion of being able to monitor the therapeutic response
with subsequent LSM assessments.
From the perspective of adult patients’ cohort, we recently published the first
monocentric study on 78 adult patients undergoing HSCT. We confirmed what we
observed in little patients that LSM increases, here also assessed by TE, occurred
from +2 to +12 days before clinical SOS/VOD appearance and gradually decreased
following successful SOS/VOD specific treatment. Moreover, for the first time, we
observed that LSM values did not significantly increase in patients experiencing
hepatobiliary complications other than VOD/SOS [100].
These results need to be further validated by extensive prospective studies to
define the most suitable application of LSM in clinical practice. Currently, based on
quite a large number of patients in real-life HSCT practice, and suggests that LSM
by all the elastography techniques available could be considered a promising method
to perform an early, pre-clinical diagnosis and predict SOS/VOD after HSCT. Besides,
it could be further used to assess treatment response in adult patients undergoing
HSCT and developing SOS/VOD. Since the elastographic techniques are non-
invasive, bedside method, very well tolerated by patients and easily reproducible,
the LSM will find a great space as non-invasive evaluations of SOS/VOD diagnosis.
LSM could be helping the clinician to a more prompt and accurate clinical diagnosis
of SOS/VOD in the HSCT context and to differentiate this condition to the other
liver-related HSCT complications [92].
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Liver and Spleen Stiffness
in Hematological Diseases 17
Mariangela Giunta and Mirella Fraquelli
Elastographic techniques are non-invasive user-friendly tests to measure the tissue

stiffness of parenchymal organs. In hepatology the main initial target of elasto-
graphic measurements has been the liver, using transient elastography (TE,
FibroScan®). Liver stiffness (LS) is now a widely accepted and validated method to
predict the severity and prognosis of chronic liver diseases [1–3], it being an accu-
rate marker of hepatic fibrosis.
Because of the strict relationship between the severity of chronic liver diseases
and splenic modifications with a progressive splenomegaly related to congestion,
hypertrophy, and hyperplasia of the spleen parenchyma, spleen stiffness (SS) too
was subsequently investigated in these patients, it becoming particularly attractive
as compared to liver stiffness, especially in more advanced phases of hepatic
involvement. In fact, spleen modifications appear to better represent the dynamic
changes occurring in the advanced stages of liver cirrhosis and to provide useful
diagnostic information towards the assessment and staging of portal hypertension.
The spleen is also frequently involved in hematological disorders, where the
degree of splenomegaly is often related to disease prognosis. Following the favor-
able results obtained in hepatology, some researchers and physicians have been
more recently investigating how liver elasticity and spleen elasticity change in
patients affected by hematological disorders.
According to the literature to date, elastography comes with two main potential
and promising uses in patients affected by hematological diseases:
M. Giunta (*)
Division of Endoscopy, IEO, European Institute of Oncology IRCCS, Milan, Italy
e-mail: mariangela.giunta@ieo.it
M. Fraquelli
Gastroenterology and Endoscopy Division, Fondazione IRCCS Ca’ Granda Ospedale
Maggiore Policlinico, Milan, Italy

https://doi.org/10.1007/978-3-030-74132-7_17
258 M. Giunta and M. Fraquelli
1. Liver stiffness measurement to assess the severity of liver damage, in hemato-

logical diseases characterized by secondary hepatic involvement, mainly in beta-
thalassemia patients and in patients affected by sickle cell disease, presenting
with liver injury correlated to hepatic fibrosis and/or siderosis, due to iron over-
load and sometimes concomitant viral hepatitis (especially HCV infection).
2. Spleen stiffness measurement to assess the severity of the hematological disease
itself, in the case of diseases occurring with splenomegaly without hepatic
involvement, mainly in myeloproliferative disorders. Studies conducted in these
set of patients have investigated the relationship between the splenic stiffness
and some prominent parameters of hematological disease severity, such as bone
marrow fibrosis or some prognostic scoring systems.
The present chapter aimed to offer a comprehensive review of the current knowl-
edge and of the available results achieved on this topic.
17.1 Liver Elastography in Hematological Diseases
Beta-thalassemia (in its forms major and intermedia) is the most common genetic
disorder worldwide, with a remarkable impact and burden on a patient’s health
especially in the Mediterranean region. Even if the survival of beta-thalassemia
major (TM) and intermedia (TI) patients has significantly improved over the past
few decades, as better treatment and follow-up have been made available, complica-
tions are still common and affect patients’ quality of life. In particular, iron overload
is the major concern for these patients as it happens through regular blood transfu-
sions and increased intestinal iron absorption. It affects particularly the liver, heart,
and endocrine organs and continues to be the main contributor to severe morbidity
and early mortality for these patients.
Inappropriate therapy or no iron chelation therapy (ICT) causes life-threatening

morbidities and early death. In addition, adult patients with TM and TI represent a
population with a high prevalence of hepatitis C due to transfusions of HCV-infected
blood units prior to the introduction of HCV screening [4–9].
The potential use of liver elastography as a non-invasive test of liver damage in
TM and IT patients has been extensively investigated. The first goal with these
patients is to assess the liver fibrosis stage. Actually, liver biopsy is still considered
the reference standard for the evaluation of hepatic fibrosis [10]. However, the use
of non-invasive tools such as liver elastography is very attractive, since patients
affected by MT and IT (especially those with concomitant HCV infection) are at
higher risk of liver biopsy-related complications, as compared to other chronically
HCV-infected patients, and because they need continuous revaluation during their
follow-up.
A further important goal in these patients is to quantify the amount of iron over-
load. The reference standard to determine hepatic iron content is the tissue determi-
nation of liver iron concentration (LIC) in a liver specimen. However, more recently
17 Liver and Spleen Stiffness in Hematological Diseases 259
T2* magnetic resonance imaging (MRI) of the liver has been taken as the standard
non-invasive technique in use to quantify and monitor the degree of hepatic iron
overload.
To improve on the non-invasive management of thalassemia patients, some stud-
ies have aimed at assessing the diagnostic accuracy of LS, for both predicting the
degree of liver fibrosis (mainly to help the decision on antiviral treatment in HCV-
infected patients and to define the prognosis and the appropriate conditioning regi-
men in patients that are candidates for hematopoietic stem cell transplantation) and
assessing the amount of iron overload, in order to tailor iron chelation therapy.
Several studies have demonstrated that TE is a reliable tool for assessing liver
fibrosis in thalassemia patients (Table 17.1).
In fact, the relationship between liver stiffness and liver fibrosis is significant and
reliable. In a study performed by our group [11], 14 out of 115 adult patients with
beta-thalassemia major (n = 59) or intermedia (n = 56) underwent liver biopsy. The
histological stage of liver fibrosis was significantly related to TE results (r = 0.73,
p = 0.003), whereas the histological score did not correlate with LIC values. A TE
cut-off value of 12 kPa diagnosed cirrhosis with 100% sensitivity (95% CI 23–100)
and 92% specificity (95% CI 62–99), LR+ 12 and LR− 0.1, respectively. Despite
the small size of the histological data set, which is the main limit of this study, the
result achieved suggests that LS is, as measured by TE, a reliable tool for assessing
liver fibrosis in patients with thalassemia. Also, in the prospective study by Di
Marco et al. [12] who dealt with 56 consecutive transfusion-dependent thalassemic
patients undergoing liver biopsy and TE, LS was found highly accurate in identify-
ing patients with cirrhosis (F4 vs. F1–F3), whereas it performed less well at lower
stages of fibrosis. The AUROC for prediction of cirrhosis was 0.997 (95% CI
92.5–100). At a cut-off value of 13 kPa, the sensitivity of LS for cirrhosis was 100%
(95% CI 69.0–100) and specificity 95.3% (95% CI 84.2–99.3). The positive and
negative predictive values for the diagnosis of cirrhosis were respectively 83.3%
and 100%. In another study by Poustchi et al. [13], 76 patients with beta-thalassemia
and chronic hepatitis C underwent liver TE, liver biopsy, and T2* MRI, and the
results showed that, regardless of liver iron concentration (LIC), TE alone or in
combination with Fibrosis 4 test (FIB-4) or the aspartate aminotransferase to plate-
let ratio index (APRI) shows moderate to high accuracy for the evaluation of liver
fibrosis: the area under the receiver operating characteristic curve (AUROC) for
predicting cirrhosis was 80% (95% CI 59–100), and using a cut-off value of 11 kPa,
LS showed 78% sensitivity and 88.1% specificity in diagnosing cirrhosis. Also, a
study involving 83 pediatric transplantation candidates affected by MT (no one with
concomitant viral hepatitis) [14] supports these results: all the patients were inves-
tigated by liver TE and liver biopsy, and the results revealed that TE increases pro-
portionally to the Metavir fibrosis stages (p < 0.001) and necroinflammatory grade
(p < 0.001) and the TE score also correlated to liver iron content measure by liver
biopsy (p < 0.001).
One study in the literature has investigated the possibility to use a different elas-
tographic technique, which is real-time elastography (RTE) [15], for assessing liver
fibrosis in 50 patients affected by TM (n = 37) and TI (n = 13) with iron overload
Table 17.1 Summary of findings from the studies assessing the role of electrographic techniques in staging hepatic fibrosis in thalassemia patients
260
Technique Liver Variables associated to

Study Population (n) Fibrosis stage (cut-off, kPa) biopsy Sens Spec LR+ LR− LS
[12] 56 F=4 TE 13 56 100 95 20 0.001 Stage of fibrosis
(p = 0.002), AST
(p = 0.006)
[11] 59 TM F≥3 TE 10.3 14 60 89 5.4 0.4 ALT (p = 0.01), GGT
F=4 TE 12.0 100 92 12 0.1 (p = 0.001), bilirubin
levels (p = 0.01), and
HCV-RNA positivity
(p = 0.03)
56 TI ALT (p = 0.007), GGT
(p = 0.01), bilirubin
levels (p = 0.04),
previous
cholecystectomy
(p = 0.011), and
splenectomy
(p = 0.018)
[13] 76 TM F=4 TE 11 76 78 88.1 6.5 0.2 NA
[14] 83 F≥1 TE 3.2 83 87.5 46.2 1.6 0.3 Stage of fibrosis
(p = 0.023),
necroinflammatory
grade (p = 0.029)
Sens sensitivity, Spec specificity, LR+ positive likelihood ratio, LR− negative likelihood ratio, LS liver stiffness, TM thalassemia major, TI thalassemia interme-
dia, LB liver biopsy
M. Giunta and M. Fraquelli
documented by MRI. The results showed that RTE values significantly correlate
with TE values (r = 0.645, p < 0.0001), the diagnostic accuracy of RTE in the range
of F ≥ 2 represented by AUROC was 0.798 (95% CI 0.674–0.890), and the diagnos-
tic accuracy of RTE for F ≥ 3 was 0.909 (95% CI 0.806–0.968). No studies have
confirmed the correlation of RTE measurements and histological data, but, on con-
sideration of the consistent results which support the accuracy of TE, it is reason-
able to think that LS values too, as measured using other electrographic techniques,
could be reliable for assessing liver fibrosis.
On the other hand, conflicting results have been reported regarding the relation-
ship of LS and the amount of iron overload (Table 17.2). Most studies were unable
to show any significant correlation between LS and LIC obtained by T2* MRI, sug-
gesting that liver elastography may not be sensitive enough to detect subtle changes
in hepatic parenchymal stiffness associated with liver iron deposition [11, 12, 16,
17]. In the study by Fraquelli et al. [11] on 115 patients affected by thalassemia
major (n = 59) and thalassemia intermedia (n = 56), who underwent T2* MRI and
liver TE, both groups showed no correlation between LIC, measured by T2* MRI,
and TE results (r = −0.14257 and r = 0.09). At multivariate analysis the variables
independently associated with TE values were ALT, GGT, and bilirubin levels in
both groups and, in patients with TM, HCV-RNA positivity but not LIC measured
by T2* MRI.
Similar results were obtained by Ferraioli et al. [17] in their study involving 119
patients with TM and 183 healthy controls and by Ou et al. [16], whose study
observed no significant correlation between TE reading and LIC values, based on
T2* MRI (pooled estimate of correlation was −0.06). In the study by Di Marco
et al. [12], involving 56 consecutive transfusion-dependent thalassemic patients (45
adults and 11 children) assessed by TE, atomic absorption spectrometry, and liver
biopsy, LS increased proportionally to the METAVIR stage, with a highly signifi-
cant relationship with fibrosis (r = 0.70; p < 0.001), independently of LIC values
Table 17.2 Correlation between liver stiffness and iron overload (mainly LIC measured by T2*
MRI) in patients affected by thalassemia major (TM) or thalassemia intermedia (TI)
Patients
Authors Year (n) Correlation coefficient (r) p
Di Marco 2010 56 0.01 0.932
et al.
Fraquelli 2010 59 TM −0.14 0.876
et al. 56 TI 0.09
Hamidieh 2014 83 0.42 <0.001
et al.
Ferraioli 2016 119 −0.04 0.7
et al.
Pipaliya 2017 154 0.85 <0.001
et al.
Al-Khabori 2019 94 LIC was higher in patients with significant LSM 0.02
et al. (median LIC: 7.2 g/g dw) than in patients without
significant LSM (median LIC: 5.4 g/g dw)
(r = 0.01; p = 0.932). It is interesting to note that in all those studies, where no cor-
relation between LS and LIC was found, the proportion of HCV-infected viremic
patients was high, ranging between 35% and 49%. Liver stiffness in thalassemic
patients could be influenced by different factors. Probably, HCV infection and iron
overload interact reciprocally in the progression of liver fibrosis, and the possible
presence of cardiac insufficiency can act as a further confounding factor, as increased
venous pressure levels [18] can also decrease liver parenchyma elasticity. To sup-
port this hypothesis, in other studies conducted on different series of thalassemic
patients without or with very low percentage of HCV-RNA positivity [19–21], liver
stiffness values were significantly related to LIC values. For example, Al-Khabori
et al. studied 94 patients with TM who underwent hepatic 2D shear wave elastogra-
phy and T2* MRI. In this study the authors found higher LIC values in patients with
LS values within the range of significant fibrosis (p = 0.0225). The study by Maira
et al. [22] on 99 transfusion-dependent thalassemia patients found a significant
reduction in LS (6.6 ± 3.2 kPa, p = 0.017) and hepatic siderosis measured by LIC
(3.65 ± 3.45 mg/g dw, p = 0.001) after 4 years on chelation therapy. However, in this
study as well, in a subset of HCV-RNA-positive patients on anti-HCV treatment,
there was no correlation with LIC despite the improvement in LS: the authors spec-
ulated that this circumstance could be due to the increased transfusion requirement
during HCV treatment. In another study [23], conducted on 154 pediatric thalas-
semia patients undergoing TE and T2* MRI, LS measurements correlated with T2*
MRI values (r = 0.85; p < 0.001), and TE results were useful to stratify patients
according to the degree (severe, moderate, and mild) of iron overload with AUROC
values of 94.8%, 84.5%, and 84.7%, respectively, using LS cut-off values of
13.5 kPa, 7.8 kPa, and 5.5 kPa. In another pediatric study [14] with no cases of HCV
coinfection, TE values correlated with liver iron content measured by liver biopsy
(p < 0.001). Thus, to date, the evidence is still not strong enough to recommend liver
elastography as a reliable tool to assess the iron overload in thalassemia patients: in
the current guidelines, the combination of serum ferritin and T2* MRI data is
reported as the preferred strategy [10] to pursue during the management of patients
affected by beta-thalassemia.
Sickle cell disease (SCD) is another common hematological disorder, where

various forms of acute and chronic hepatic damage can occur. It is characterized
by deformation of red blood cells, thereby vaso-occlusion, ischemia/infarction,
and hemolysis involving different organs. The main reasons of liver damage are
acute vaso-occlusive crisis (VOC) involving the liver, with a frequency ranging
from 10% to 39% [24], iron overload, and concomitant viral hepatitis infection,
due to chronic transfusion therapy [25]. Liver serum biomarkers poorly correlate
with hepatic involvement during acute VOC, and a precise diagnostic definition
and strategy of hepatic involvement during VOC are not available. Thus in 2013
Koh et al. [26] investigated TE as a marker of hepatic involvement during VOC:
23 patients affected by SCD underwent laboratory tests and TE at steady state,
and during acute VOC, 15 of them had a liver biopsy at steady state, and all the
patients underwent transthoracic echocardiogram to measure tricuspid regurgita-
tion velocity. The results showed that TE at steady state correlated with liver
fibrosis (p = 0.01) and tricuspid regurgitation velocity (p = 0.0063) but not with
hepatic iron concentration. In this small population, according to histological
results, none of the patients had cirrhosis (Ishak’s score 5–6), 14 had no fibrosis
or portal fibrosis (Ishak’s score 0–2), and only one patient had bridging fibrosis
(Ishak’s score 3–4). Furthermore, the mean TE measurements increased during
acute VOC (6.2–12.3 kPa, p = 0.003) paralleling the concomitant increase of ala-
nine aminotransferase (ALT) and alkaline phosphatase (p = 0.009 and p = 0.01).
The authors concluded that TE can be a useful tool during VOC, even if the low
number of patients, the lack of a reference standard to diagnose hepatic damage
during VOC, and such possible confounding factors as hepatic and systemic
necroinflammation and right-heart dysfunction impose further studies to confirm
these results.
In the study of Bortolotti et al. [27], that enrolled 68 adult sickle cell patients (17
with sickle cell anemia (SCA), 38 with sickle cell thalassemia (HbS/β-Thal), and 13
with HbSC disease), structural liver abnormalities, defined by abdominal ultrasound
and liver stiffness values, resulted more severe in SCA and HbS/β-Thal than HbSC
patients. In addition, a statistically significant correlation was found between liver
structure at ultrasound and liver stiffness.
As regards the correlation between liver stiffness and liver fibrosis, another study
[28] has demonstrated a positive correlation between LS and Ishak’s score (r = 0.068,
p ≤ 0.0001) in a total of 50 patients with SCD, suggesting how LS could be a reli-
able non-invasive tool to assess hepatic fibrosis.
Finally, a few studies have investigated the correlation between LS and iron over-
load with conflicting results. For their prospective study, Delicou et al. [29] enrolled
15 patients affected by SCD and investigated them by TE and T2* MRI at baseline
and after 12 months on chelation therapy (deferasirox). The results showed a signifi-
cant improvement in liver stiffness values, from 9.7 to 6.7 kPa (p = 0.001), and in
LIC values, from 7.86 to 5.62 mg Fe/g dry weight (p = 0.043) after 12 months on
deferasirox. Furthermore, a correlation between LIC and LS at baseline (r = 0.6344)
and at the end of the study (r = 0.6075) was found. Also in the prospective study by
Drasar et al. [30] on 139 patients affected by SCD, there was a weak but significant
correlation between TE values and markers of iron overload (ferritin r = 0.24,
p = 0.006; total blood unit transfused r = 0.2, p = 0.02; and LIC r = 0.18 and
p = 0.04) even if LIC measured by MRI was available only for 35 patients. On the
contrary, in the retrospective study by Pinto et al. [31], no significant correlation
was found between mean liver stiffness (measured by FibroScan) and liver iron
concentration (measured by MRI), and no significant correlation was documented
between liver stiffness and ALT at baseline or at follow-up in 37 patients with
SCD. Also, the study by Costa et al. [32] on a pediatric population has showed no
correlation between iron quantification (measured by MRI) and LS (r = −0.077,
p = 0.769).
Overall, in the setting of patients with SCD, only a few studies are available; they
are based on small size samples and are highly heterogeneous in terms of aims and
study design formats. Thus, despite some promising results, no definitive data can
be obtained, and further investigation should be conducted.
Hemophilia is a genetic disorder characterized by spontaneous or provoked, often

uncontrolled, bleeding into joints, muscles, and other soft tissues. Chronic infection
with hepatitis C virus (HCV) has long been the dominant complication of substitu-
tion therapy in patients with inherited blood disorders and the cause of anticipated
death due to end-stage liver disease. In fact, the prevalence of HCV infection, until
a few years ago, has been quite high, because viral inactivation procedures and viral
screening of plasma products were not available before 1992. Liver biopsies are
generally not performed in these patients because of increased bleeding risk; thus,
the search for non-invasive approaches, such as elastography, for the assessment of
liver fibrosis is particularly attractive as regards patients with hemophilia and other
congenital bleeding disorders. In 2006, Posthouer et al. [33] enrolled 124 patients
affected by bleeding disorders and chronic hepatitis C and, using TE to assess LS,
found severe fibrosis in 18% and cirrhosis in 17% of them. In the study by Maor
et al. [34], 57 hepatitis C-infected patients with hemophilia were evaluated by
FibroTest and TE: the results showed that the corresponding concordance rates and
κ score for fibrosis stage ≥F2, ≥F3, or =F4 between FibroTest and TE were 62%,
69%, and 85% and 0.24, 0.32, and 0.44 respectively. Later, Moessner et al. [35]
found that among 73 patients with hemophilia A or B and chronic or past hepatitis
C, there was significant fibrosis in 17.1% and cirrhosis in 2.9% by LS ≥8 and
≥12 kPa. It is necessary to underline that all these studies are limited by the lack of
liver biopsy as the reference standard and the authors speculate that, knowing the
strong correlation of LS with histological results in patients without bleeding disor-
ders, there is no a priori reason to assume that LS would be less reliable in patients
with bleeding disorders. Anyway, there are no strict guidelines at present regarding
the best method to assess liver fibrosis in hemophilic patients, and the combination
of different non-invasive tests (including TE) seems a reliable strategy to apply in
most cases.
17.2 Spleen Elastography in Hematological Diseases
To date, a few studies have investigated the potential use of spleen stiffness for
evaluating the severity of hematological diseases and to predict prognosis.
In 2015 Webb et al. conducted a small study [36] on nine patients with myelofi-
brosis, 11 patients with cirrhosis, and eight healthy volunteers, showing that, as
determined by TE and shear wave elastography, SS has little ability to distinguish
between patients with myelofibrosis and those with cirrhosis, but it allows to dif-
ferentiate both patient groups from the healthy volunteers. More interestingly, in
2013 Fraquelli et al. [37], for the first time, showed that SS could be clinically use-
ful in patients with myeloproliferative disorders. During an investigation on the
diagnostic accuracy of combining LS and SS in order to predict liver fibrosis and
portal hypertension in patients with chronic viral hepatitis, the authors evaluated LS
and SS in a cohort of 48 patients with hematological malignancies, used as controls

without significant hepatic comorbidity. All the patients were characterized accord-
ing to the WHO histological classification of bone marrow fibrosis, and none of
them had splanchnic vessel thrombosis. The most interesting result found in these
patients was a correlation between SS and bone marrow fibrosis (r = 0.64, p < 0.01),
which was more pronounced in patients with primary myelofibrosis (PMF) than in
those with other hematological malignancies. In addition, SS values significantly
correlated with the longitudinal diameter and volume of the spleen (r = 0.39 and
r = 0.66, p < 0.001), and liver TE and spleen TE did not correlate with each other or
with age, gender, and BMI.
Following these results and given the critical association between bone marrow
fibrosis and spleen status in PMF patients, Iurlo et al. conducted a study [38] with
the aim to assess whether SS measured by TE can be used as a marker of the bone
marrow fibrosis and as a predictor of clinical prognosis. Liver and spleen TE were
successfully performed in 81.5% of the 108 consecutive PMF patients. Besides,
bone marrow fibrosis grade and clinical and laboratory features were collected. The
results showed a significant correlation, at univariate analysis, between SS and LS
with the severity of bone marrow fibrosis (p < 0.001 and p < 0.007, respectively),
with the values of Hb and LDH (p < 0.001 and p < 0.001) and with the three differ-
ent main prognostic scoring systems. More importantly, multivariate analysis has
shown that only SS, LDH, and International Prognostic Scoring System (IPSS)
maintained a significant correlation with bone marrow fibrosis, with the area under
the receiver operating characteristic curve being 0.909 (95% CI 0.850–0.968).
These parameters were incorporated in a diagnostic algorithm that allowed to clas-
sify 40% of the patients as being at pre-fibrotic/early fibrotic stage and 22% at
advanced fibrotic stage. An interesting small data set was also to show that in three
patients treated with ruxolitinib, the improvements in constitutional symptoms were
paralleled by reduction in SS.
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Part VI
Case Studies
Case 1: Unexpected High Liver Stiffness
as a Warning Sign 18
Ilaria Fanetti and Elisabetta Degasperi
18.1 Case Report
We report here on the case of an 80 year old patient, E.F., with a long-term history
of chronic hepatitis C virus (HCV) infection.
E.F. presented to the Hepatology Unit of our Hospital in 1996, just after evidence
of anti-HCV positivity at routine tests prescribed by his General Practitioner. The
patient’s medical history was not significant except for previous dental surgery and
appendicectomy, which he had undergone when he was 20 years old. He had a nor-
mal body mass index (BMI 23) and denied any significant smoking or alcohol con-
sumption, any prior blood transfusion, or use of intravenous drugs.
At admission he underwent complete blood testing: transaminases were slightly
above the upper normal limit, without alteration of the other liver function tests
(LFTs), while glucose, lipid panel, autoimmunity, and iron load were unremarkable
and the patient’s HBV profile was consistent with a previous exposure. HCV infec-
tion, genotype 1b, was confirmed. Abdominal ultrasound was normal and concomi-
tant causes of liver damage were considered unlikely. In order to assess the severity
of the disease, liver biopsy was performed and it showed a mild activity of disease
with low fibrotic changes according to Ishak’s staging. Therefore, by taking into
account the unfavorable HCV genotype, the transaminases pattern, and the low
Supplementary Information The online version of this chapter (https://doi.org/10.1007/

978-3-030-74132-7_18) contains supplementary material, which is available to authorized users.
I. Fanetti (*)
Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore
E. Degasperi
Gastroenterology and Hepatology Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore

https://doi.org/10.1007/978-3-030-74132-7_18
272 I. Fanetti and E. Degasperi
degree of fibrosis, he was not considered for IFN-based regimen and was regularly
followed up at the Center with no antiviral treatment.
In 2018, after the availability of IFN-free regimens, the patient was proposed for
HCV treatment with direct-acting antivirals (DAA) and he underwent a liver disease
re-assessment. The blood tests still showed a slight elevation in transaminases and a
mild increase in gGT level (83 U/L, nl <50 U/L); platelets were normal and HCV-
RNA viral load was 12,644 UI/ml. Physical examination and abdominal ultrasound
were normal, revealing a normal liver parenchyma, with smooth margins, and with-
out any indirect sign of portal hypertension (the spleen longitudinal diameter was
9 cm, the portal diameter was 1 cm); liver stiffness assessed by transient elastogra-
phy (Fibroscan®) resulted 6.1 kPa (IQR 1.2 kPa, SR 100%), consistent with a F0–F1
degree of fibrosis. Overall, the presence of advanced liver disease was deemed
unlikely.
The patient was treated with elbasvir/grazoprevir for 12 weeks: HCV-RNA
became undetectable at on-treatment week 4 and remained undetectable for
12 weeks after the end of treatment (EOT), resulting in the achievement of a sus-
tained virological response (SVR). Other blood exams were unremarkable.
Transient elastography was performed 6 months after EOT and, unexpectedly, the
liver stiffness value was 22.3 kPa (IQR 5.6 kPa, SR 100%). The blood tests, espe-
cially LFTs, were stable but a new abdomen ultrasound investigation revealed partial
portal vein thrombosis (Fig. 18.1) and a focal hypoechoic lesion 12 mm wide in seg-
ment VII. Alpha-fetoprotein (aFP) was 414 ng/ml and a subsequent abdominal CT
scan revealed multiple nodular lesions with arterial enhancement and portal
Fig. 18.1 Ultrasound image showing partial portal vein thrombosis represented by the presence
of echogenic material inside the portal vein (arrows)
18 Case 1: Unexpected High Liver Stiffness as a Warning Sign 273
wash-out, which were consistent with a multi-focal hepatocellular carcinoma (HCC).

Portal vein thrombosis (PVT) appeared to be neoplastic and multiple abdominal
adenopathies were found at the hepatic hilum and close to the Inferior vena cava
(IVC). Liver biopsy confirmed the HCC diagnosis. A complete stadiation was per-
formed; thoracic computed tomography (CT) scan and scintigraphy were negative,
but the evidence of abdominal distant adenopathies was consistent with BCLC stage
C. Gastroscopy revealed F1 blue varices, without red signs. Therefore, the patient
was proposed for sorafenib but eventually died shortly after disease progression.
18.2 Comments
The present case report refers to a patient with a long history of HCV infection,
probably over more than 60 years; he develops a multi-focal HCC and neoplastic
portal vein thrombosis (PVT) after the achievement of SVR, despite the evidence of
persistently low-degree hepatic fibrosis. Transient elastography (TE) performed
before DAA treatment was consistent with F0-F1 disease and appeared to remain
stable for approximately 22 years, confirming the histological evaluation performed
at HCV diagnosis.
The patient achieved SVR, but his liver stiffness assessed by transient elastogra-
phy remarkably worsened shortly after treatment, significantly increasing from 6.1
to 22.3 kPa. However, subsequent imaging revealed PVT and the presence of a
multi-focal HCC, giving out a clue for the unpredicted liver stiffness increase, pos-
sibly being a “false positive” of transient elastography and not associated with any
“true worsening” of the liver fibrosis. Other causes of false-positive increase of TE
are extrahepatic cholestasis, vascular congestion secondary to cardiac insufficiency,
as well as liver damage due to acute hepatitis or transaminases flare and recent food
intake: these factors can reversibly increase liver stiffness and lead to the misdiag-
nosis of severe liver fibrosis [1]. In this case, a possible explanation of stiffness
increase, as hypothesized by Valla et al. [2], is the compensatory arterial buffer
response to the PVT that can happen in the hepatic vasculature, similarly to what
happens post-prandially because of the increased portal vein flow.
A similar case of increased liver stiffness and portal vein thrombosis was
described by Huang et al. [3], where a non-cirrhotic patient with a previous diagno-
sis of PVT was found to have an abnormal TE value (17.3 kPa). However, as they
reported, PVT was non-neoplastic and the patient was treated with antiretrovirals
for HIV; both these conditions might represent confounding factors since an addi-
tional vascular mechanism might have been associated. Also, no previous elastogra-
phy assessment was available.
Concerning HCC development, our patient showed a mild fibrosis stage and did
not present with any significant comorbidity (irrelevant alcohol consumption and no
metabolic syndrome associated), all accounting for a very low risk of HCC develop-
ment. Also, he had no clinical or radiological evidence of any advanced liver disease
and underwent abdominal ultrasounds on a 12-month interval, in agreement with
the available guidelines for non-cirrhotic patients [4]. However, the possibility of
274 I. Fanetti and E. Degasperi
HCC development in non-cirrhotic patients has been reported and the long history
of HCV infection might have played a role in this patient. HCC development in
patients without cirrhosis may be associated with different pathogenic pathways
and biochemical features [5]. Prospective studies on patients with eradicated HCV
infection are needed in order to identify subgroups of patients who still are at risk of
HCC development and who might still need active surveillance in spite of low fibro-
sis, the absence of comorbidities, and HCV eradication. In this setting, the role and
accuracy of such noninvasive methods as liver stiffness measurement need further
investigation.
References
1. Petitclerc L, Sebastiani G, Gilbert G, Cloutier G, Tang A. Liver fibrosis: review of current
imaging and MRI quantification techniques. J Magn Reson Imaging. 2017;45:1276–95.
2. Valla DC, Condat B. Portal vein thrombosis in adults: pathophysiology, pathogenesis and man-
agement. J Hepatol. 2000;32:865–71.
3. Huang R, Zu-Hua G, Tang A, Sebastiani G, Deschenes M. Transient elastography is an unreliable
marker of liver fibrosis in patients with portal vein thrombosis. Hepatology. 2018;68(2):783–5.
4. EASL Clinical Practice Guidelines: management of hepatocellular carcinoma. J Hepatol.
2018;69:182–236.
5. Gaddikeri S, McNeeley MF, Wang CL, Bhargava P, Dighe MK, Yeh MMC, et al. Hepatocellular
carcinoma in the non-cirrhotic liver. Am J Roentgenol. 2014;203:34–47.
Case 2: Liver and Spleen Stiffness
After TIPS 19
Simone Segato
19.1 Case Report
C.A., a 57 years old male, was first admitted to our hospital in October 2017 for the
occurrence of ascites. During hospitalization he was diagnosed with decompensated
liver cirrhosis with a double etiology: hepatitis C virus infection (HCV, genotype I)
and chronic alcohol abuse. He was treated with large-volume paracentesis, albumin
supplementation, and diuretic therapy with clinical benefit. He also underwent
esophagogastroduodenoscopy, which showed the presence of esophageal vari-
ces (F2).
After discharge he stopped alcohol consumption and started chronic diuretic
treatment.
Therapy with nonselective betablockers was also recommended for the primary
prevention of variceal bleeding, but because of patient reported intolerance
(fatigue), the treatment was stopped.
He was also treated with direct antiviral agents (sofosbuvir/velpatasvir + ribavi-
rin) over 12 weeks for chronic HCV infection obtaining sustained viral
response (SVR).
Despite these therapies, he progressively developed a condition of refractory
ascites, with the need for weekly large-volume paracentesis.
For this reason, in July 2019 he was put forward for trans-jugular intrahepatic
portosystemic shunt (TIPS) placement.
Supplementary Information The online version of this chapter (https://doi.

org/10.1007/978-3-030-74132-7_19) contains supplementary material, which is available to
authorized users.
S. Segato (*)
e-mail: simone.segato@unimi.it

https://doi.org/10.1007/978-3-030-74132-7_19
276 S. Segato
Table 19.1 The patient’s parameters measured by elastography and intravascular manometry
before and after TIPS placement
Intravascular manometry
TE (kPa) pSWE (kPa) (mmHg)
LS SS LS SS Portal Caval Gradient
Before 32 47 33.2 49.8 33 11 22
tips (IQR 12.2) (IQR 14) (IQR 4.7) (IQR 11.8)
After tips 28 36 35.4 36.5 20 12 8
(IQR 6) (IQR 7.5) (IQR 6.7) (IQR 10.1)
kPa kilo-Pascal, IQR inter-quartile range, SR success rate, SD standard deviation
Table 19.2 The patient’s parameters measured by color-Doppler ultrasound (CDUS)

Shunt flow
Portal vein (flow Portal vein flow velocity (cm/ Intrahepatic portal vein
direction) velocity (cm/sec) sec) branches (flow direction)
Before Hepatopetal 17 – –
tips
After Hepatopetal 35 95 Hepatofugal
tips
According to our internal protocols, he underwent color-Doppler ultrasound

(CDUS) examination, and liver and splenic measurement by transient elastography
(TE, with Fibroscan by Echosens, Paris, France) and point shear-wave elastography
(pSWE, with ElastPQ, iU22 by Philips, Bothell, Washington DC, USA) before and
after TIPS placement.
Tables 19.1 and 19.2 provide the main measurements obtained by CDUS
examination and elastography (both TE and pSWE) before and after TIPS
placement.
19.2 Comments
The role of TIPS in the treatment of complications of portal hypertension is well

established.
Despite that, since TIPS dysfunction is often asymptomatic, an accurate screen-
ing test is required to confirm shunt patency. The reference standard for assessing
TIPS function is venography with portosystemic pressure gradient measurement:
evidence of a reduction of PPG to less than 12 mmHg is considered the pressure
target especially in those patients for whom bleeding was the indication for the
shunt [1].
CDUS has been extensively studied for measuring intra-stent and main portal
vein flow velocities and flow direction in the intrahepatic portal vein branches;
CDUS has shown to be a reliable qualitative indicator of TIPS malfunction [1]
(Fig. 19.1).
19 Case 2: Liver and Spleen Stiffness After TIPS 277
Fig. 19.1 Echo-Doppler ultrasound scan with portal vein velocity measurement
a b
Fig. 19.2 Liver (a) and spleen (b) stiffness measurement with ARFI technique (ElastPQ)
In addition, recent data has indicated the promising role of liver and
especially spleen stiffness (SS) in the assessment of portal hypertension thanks to its
good correlation with HVPG values (Fig. 19.2a and b). Several studies have
demonstrated the good diagnostic accuracy of SS, particularly in ruling the presence
of esophageal varices out [2–6].
More recently, several preliminary studies [7–11] have shown a progressive sig-
nificant reduction of SS values after successful TIPS implantation.
In a recent study Giunta et al. [12] have evaluated 24 patients undergoing
TIPS placement and suggested that spleen point shear-wave elastography (with
a 25-kPa cut off) and the assessment of blood flow direction in the intrahepatic
278 S. Segato
portal vein branches (considering hepatopetal flow as pathologic) are good

predictors of TIPS dysfunction.
In this clinical case, TIPS placement achieved good reduction of portal hyperten-
sion, with final pressures under the threshold of clinical significance (12 mmHg).
It must be noted that elastography values obtained with both methods (transient
elastography and point shear-wave elastography) decrease in parallel with the
degree of portal hypertension. In particular, spleen stiffness seems to have good
rapid reduction in response to portal hypertension changes, considering the fact that
the values reported were measured the day after TIPS placement. As concerns the
CDUS parameters, the finding of hepatofugal blood flow direction within the intra-
hepatic portal vein branches suggests good TIPS function.
Further studies are needed to confirm the role of these techniques for the nonin-
vasive evaluation of portal hypertension especially in the setting of portosystemic
shunt function, which remains an important clinical challenge. However, the current
knowledge on elastography and ultrasound parameters seems useful and
reproducible.
References
1. Fagiuoli S, Bruno R, Debernardi Venon W, et al. Consensus conference on TIPS manage-
ment: techniques, indications, contraindications. Dig Liver Dis. 2017;49(2):121–37. https://
doi.org/10.1016/j.dld.2016.10.011.
2. Calvaruso V, Bronte F, Conte E, Simone F, Craxì A, Di Marco V. Modified spleen stiffness mea-
surement by transient elastography is associated with presence of large oesophageal varices
in patients with compensated hepatitis C virus cirrhosis. J Viral Hepat. 2013;20(12):867–74.
https://doi.org/10.1111/jvh.12114.
Gastroenterology. 2012;143(3):646–54. https://doi.org/10.1053/j.gastro.2012.05.035.
4. Sharma P, Kirnake V, Tyagi P, et al. Spleen stiffness in patients with cirrhosis in predict-
ing esophageal varices. Am J Gastroenterol. 2013;108(7):1101–7. https://doi.org/10.1038/
ajg.2013.119.
5. Fraquelli M, Giunta M, Pozzi R, et al. Feasibility and reproducibility of spleen transient
elastography and its role in combination with liver transient elastography for predicting the
severity of chronic viral hepatitis. J Viral Hepat. 2014;21(2):90–8. https://doi.org/10.1111/
jvh.12119.
6. Boyer TD, Haskal ZJ. American Association for the Study of Liver Diseases Practice
Guidelines: the role of transjugular intrahepatic portosystemic shunt creation in the man-
agement of portal hypertension. J Vasc Interv Radiol. 2005;16(5):615–29. https://doi.
org/10.1097/01.RVI.0000157297.91510.21.
7. Gao J, Zheng X, Zheng Y-Y, et al. Shear wave elastography of the spleen for monitoring
transjugular intrahepatic portosystemic shunt function: a pilot study. J Ultrasound Med.
2016;35(5):951–8. https://doi.org/10.7863/ultra.15.07009.
8. Ran HT, Ye XP, Zheng YY, et al. Spleen stiffness and splenoportal venous flow: assessment
before and after transjugular intrahepatic portosystemic shunt placement. J Ultrasound Med.
2013;32(2):221–8. https://doi.org/10.7863/jum.2013.32.2.221.
9. Novelli PM, Cho K, Rubin JM. Sonographic assessment of spleen stiffness before and after
transjugular intrahepatic portosystemic shunt placement with or without concurrent emboliza-
19 Case 2: Liver and Spleen Stiffness After TIPS 279
tion of portal systemic collateral veins in patients with cirrhosis and portal hypertension: a
feasibility study. J Ultrasound Med. 2015;34(3):443–9. https://doi.org/10.7863/ultra.34.3.443.
10. De Santis A, Nardelli S, Bassanelli C, et al. Modification of splenic stiffness on acoustic radia-
tion force impulse parallels the variation of portal pressure induced by transjugular intrahe-
patic portosystemic shunt. J Gastroenterol Hepatol. 2018;33(3):704–9. https://doi.org/10.1111/
jgh.13907.
Liver Dis. 2018;50(1):54–60. https://doi.org/10.1016/j.dld.2017.09.138.
12. Giunta M, La Mura V, Conti CB, Casazza G, Tosetti G, Gridavilla D, Segato S, Nicolini A,
Primignani M, Lampertico P, Fraquelli M. The role of spleen and liver elastography and color-
Doppler ultrasound in the assessment of transjugular intrahepatic portosystemic shunt func-
tion. Ultrasound Med Biol. 2020; S0301-5629(20)30180-0.
Case 3: Congestive Hepatopathy
with High Liver and Spleen Stiffness 20
in a 17 Years Old Male Patient
Andrea Costantino, Mirella Fraquelli, Massimo Chessa,

and Vincenzo La Mura
20.1 Case Report
We hereby report on the case of F.C., a 17 years old male patient, who was initially
referred to our Unit on the advice of his cardiologist at a tertiary referral center. He
presented with an anatomic single ventricle, also known as univentricular heart, a
condition known since birth. The univentricular heart is defined as the presence of
only one well-developed ventricle and the other rudimentary ventricle (if present)
with less than 30% of its expected volume. The patient underwent a first surgical
procedure by Glenn in 2005, followed by Fontan surgery in 2008. The Fontan pro-
cedure, firstly described as a surgical palliation for a single ventricle with tricuspid
atresia, has become the standard operation for all patients with single-ventricle
physiology (e.g., hypoplastic left-heart syndrome, pulmonary atresia, unbalanced
atrio-ventricular canal defects) [1–4].
The Fontan operation is a palliative surgical procedure aimed at diverting the
systemic venous return to the lungs without a pump. The pulmonary blood flow is
Supplementary Information The online version of this chapter (https://doi.org/10.1007/

978-3-030-74132-7_20) contains supplementary material, which is available to authorized users.
A. Costantino (*) · M. Fraquelli

M. Chessa
IRCCS Policlinico San Donato, ACHD Unit – Pediatric and Adult Congenital Heart Centre,
San Donato M.se, Milan, Italy
V. La Mura
Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, “Angelo Bianchi Bonomi”
Haemophilia and Thrombosis Center, Fondazione Luigi Villa, CRC “A. M. and
A. Migliavacca” Center for Liver Diseases, Milan, Italy
Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy

https://doi.org/10.1007/978-3-030-74132-7_20
282 A. Costantino et al.
driven by central venous pressure and is augmented by changes in the intra-thoracic

pressure, active relaxation of the systemic ventricle (drawing blood forward), and
the peripheral skeletal muscle pump [5].
The first surgical step (called Glenn procedure) is performed at the age of 1 year
and consists of a direct anastomosis between the superior caval vein and the right
pulmonary artery. The Fontan operation is regularly carried out as a second surgical
step when the child is around 4 years old. It consists in a connection between the
inferior systemic vein drainage and the pulmonary branches. This connection is
achieved with an intra- or extracardiac prosthetic conduit of different sizes.
Following the Fontan procedure, patients can take morbidity and mortality risks
and require lifelong follow-up by cardiologists experienced in the care of patients
with complex congenital heart diseases.
F.C was diagnosed to have a univentricular heart already at prenatal age and
since birth he has received specialist support. He was operated by Fontan procedure
in May 2008. Since then he has been followed at the cardiological referral center
without specific problems, but a very mild progressive desaturation.
The patient underwent regular cognitive and neuropsychological development
assessments as well as all the mandatory immunization schedules for infants and
children plus antipneumococcal immunization.
As regards family history, his 50 years old father was in good health and his
50 years old mother presented congenital nystagmus. The patient was the elder of
two children, his 11-year-old brother being in good health.
The patient has been taking aspirin from childhood, except for a period of about
1.5 years on coumadin, interrupted on specialist indication with no history of drug
mismanagement. He has completely abstained from alcohol and drugs.
On first referral to our Hepatology Outpatient Clinic, he was asymptomatic and
had been conducting a normal lifestyle consistent with his age group. He only
reported a tendency to muscle exhaustion during physical education and his cardi-
ologist outlined the mild desaturation without other pathological signs.
Recent blood tests had revealed slightly increased hemoglobin levels (18.2 g/
dL), gamma glutamyl transpeptidase (GGT) levels (69 U/L; n.v. <55 U/L in men)
and alanine transaminases (ALT) levels (48 U/L, n.v. 5–40 U/L), and bilirubin
1.6 mg/dL (direct 1.1) with normal aspartate transaminases (AST) levels (31; n.v.
29–38 U/L). ProBNP levels resulted within the normal range (72 pg/mL, n.v.
100 pg/ml).
At physical examination the parameters were: blood pressure 130/75, heart rate
91 beats/min, BMI 20.8 kg/m2. On inspection the patient’s abdomen was flat, pain-
less at deep palpation, and the peristalsis was normal. The liver and spleen edges
were not palpable. A first reinforced sound (S1) could be heard at cardiac ausculta-
tion with no cardiac murmurs and peripheral bruits.
We performed an abdomen ultrasound scan (Epiq, Philips Ultrasound Inc.,
Bothell, WA) with shear-wave elastography and transient elastography (TE)
(Echosens, Paris, France).
The abdominal ultrasound test revealed a normal-sized liver with a normal echo-
texture with no focal liver lesions. The liver margins were regular without surface
20 Case 3: Congestive Hepatopathy with High Liver and Spleen Stiffness… 283
nodularity when assessed by high-frequency transducer. There were regular patent

hepatic veins with regular triphasic flow, a regular-sized portal vein (1 cm), hepato-
petal biphasic flow with average speed at 14 cm/s, and normal intrahepatic biliary
and main biliary tracts. The gallbladder was normally distended with no gallstones.
The patient’s spleen size was within normal values (bipolar diameter 11.7 cm,
area 49 cm2), with homogeneous echo-texture. The pancreas and kidneys showed
normal findings. There was no abdominal effusion.
The patient’s liver stiffness, as measured by TE, resulted 19.7 kPa, IQR/median
14% and spleen stiffness 50 kPa (IQR/median 7%).
These results were discussed with the patient’s cardiologist and in January 2019
a right catheterization was performed showing a normal low mean pressure in all the
“Fontan” system (inferior vena cava, prosthetic conduit, pulmonary branches) and a
telediastolic pressure of the systemic ventricle. The only anomalous finding was the
evidence of veno-venous fistulas, which were embolized. The veno-venous fistulas
are the aftermath of the pressure increase in the hemodynamic Fontan system as an
attempt of the vascular system to reduce the systemic venous pressure.
20.2 Comments
The different elastographic techniques applied showed increased liver and spleen
stiffness, likely to be due to an impaired venous outflow.
Hepatic congestion may develop if the venous outflow from the liver is obstructed.
Disorders leading to hepatic congestion that result in hepatomegaly and a firm tender
liver edge include: Budd-Chiari syndrome, hepatic sinusoidal obstruction syndrome
(SOS), previously termed veno-occlusive disease, and right-sided heart failure.
Any cause of right-sided heart failure can result in hepatic congestion, including
constrictive pericarditis, mitral stenosis, tricuspid regurgitation, cor pulmonale, and
cardiomyopathy. Tricuspid regurgitation in particular can be associated with severe
hepatic congestion because of the transmission of right ventricular pressure directly
into the hepatic veins. Liver dysfunction and passive congestion are common in
patients with congenital heart disease and single-ventricle physiology who have
undergone the Fontan intervention.
Patients with hepatic congestion are usually asymptomatic. In such patients,
hepatic congestion may be suggested only by abnormal liver biochemical tests dur-
ing routine evaluation. Symptomatic patients may present with jaundice, which may
be mistaken for biliary obstruction.
The most common liver biochemical abnormality of Fontan-associated liver dis-
ease (FALD) is a mild elevation in the serum bilirubin level, which occurs in up to
70% of patients. The total serum bilirubin is usually less than 3 mg/dL, most of
which is unconjugated [6].
The precise cause of the hyper-bilirubinemia is uncertain. Contributing fac-
tors may include: hepatocellular dysfunction, hemolysis, pulmonary infarction,
canalicular obstruction due to distended hepatic veins, medications, and super-
imposed sepsis.
284 A. Costantino et al.
Imaging studies to apply in such cases are: right-upper quadrant ultrasonography

with Doppler studies of the portal and hepatic veins and hepatic artery, electrocar-
diogram, and echocardiography.
Other imaging approaches to identify hepatic congestion and assess fibrosis,
including diffusion-weighted magnetic resonance imaging and magnetic resonance
elastography, are under investigation at present [7–10].
As regards the possible role of elastography techniques in these patients some
studies have reported high liver stiffness values [10, 11]. Whether the increased
stiffness depends on flow congestion or initial fibrosis is an important issue to be
ascertained and has been preliminary investigated. A recent review has underlined
that noninvasive liver stiffness measurements are of minimal utility as all patients
with congestive hepatopathy have elevated values, which cannot currently differen-
tiate between congestion and fibrosis. In addition, fibrosis staging by liver biopsy is
difficult to standardize because of heterogeneous collagen deposition in this dis-
ease [10].
In the Liver Adult-Pediatric-Congenital-Heart-Disease Dysfunction Study
(LADS) hepatic stiffness and vascular Doppler indices using ultrasound (US) and
liver stiffness measured by SWE were measured in a cohort of patients who had
undergone Fontan surgery.
In that study patients with Fontan physiology had significantly higher hepatic
stiffness (15.6 kPa vs. 5.5 kPa, p < 0.0001) as compared to the control group [11].
In fact, the elevated hepatic afterload in Fontan, manifested by high ventricular end-
diastolic pressures and pulmonary arterial wedge pressures, is associated with
remarkably increased hepatic stiffness, abnormal vascular flow patterns, and fibrotic
histologic changes. Correlation was explored between SWE, US, hemodynamic and
histopathologic data, obtained in a subset of patients, and greater stiffness corre-
lated with greater degrees of histopathologic fibrosis [11].
A prospective multicenter observational study enrolled 152 patients who had
undergone Fontan surgery [12]. The primary outcome was liver nodules detection at
US and magnetic resonance (MRI) or computer tomography (CT) scan. Liver nod-
ule prevalence was 29.6% on US and 47.7% (95% CI 39–56%) on MRI/CT. The
sensitivity and specificity of US were 50% (95% CI 38–62%) and 85.3% (95% CI
75–92%), respectively. Hepatocellular carcinoma was histologically diagnosed in 2
of the 8 patients with hypervascular liver nodules displaying washout. While liver
nodules are frequent in Fontan patients, they may go unnoticed at US. Liver nodules
are usually hyperechoic, hypervascular, and predominantly peripheral. This popula-
tion is at risk of hepatocellular carcinoma, the diagnosis of which requires confirma-
tory biopsy.
It is worth noting that, in a recent study involving 145 patients [13], the severity
of FALD has significantly correlated with Fontan duration and impaired Fontan
hemodynamics and that in the majority of patients hepatic abnormalities suggestive
of FALD have been detectable by liver ultrasound, transient elastography, and labo-
ratory analysis. At multivariate analysis Fontan duration has shown the only vari-
able independently associated with FALD development.
20 Case 3: Congestive Hepatopathy with High Liver and Spleen Stiffness… 285
In conclusion, FALD is increasingly recognized as more patients survive into

adulthood and it is considered a significant prognostic factor.
The availability of reliable noninvasive markers of liver disease in these patients
would be of great value, and liver stiffness as measured by elastography technique is
very promising in association with imaging techniques to predict disease severity.
Liver stiffness increases can be related either to hepatic congestion or, later on, to
subsequent hepatic fibrosis. Therefore, liver stiffness deserves not only a role to iden-
tify the severity of a potential fibrogenic disease of the liver, but it also deserves poten-
tial interest as a noninvasive diagnostic tool to identify Fontan circuit dysfunction in a
preclinical phase. Along this line, the evaluation of splenic stiffness is a further inter-
esting issue to account for and that may be added in the clinical management of these
patients. Further studies are required to confirm the possible prognostic role of these
noninvasive tools in stratifying patients according to their risk of more severe disease.
References
1. Rychik J, Atz AM, Celermajer DS, Gatzoulis MA, Gewillig MH, Hsia MA, et al. Evaluation
and management of the child and adult with Fontan circulation: a scientific statement from the
american heart association. Circulation. 2019; CIR0000000000000696.
2. Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM, et al. 2018 AHA/
ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the
American College of Cardiology/American Heart Association Task Force on Clinical Practice
Guidelines. J Am Coll Cardiol. 2019;73:e81.
3. Driscoll DJ. Long-term results of the Fontan operation. Pediatr Cardiol. 2007;28:438.
4. Fontan F, Baudet E. Surgical repair of tricuspid atresia. Thorax. 1971;26:240.
5. Shafer KM, Garcia JA, Babb TG, et al. The importance of the muscle and ventilatory blood
pumps during exercise in patients without a subpulmonary ventricle (Fontan operation). J Am
Coll Cardiol. 2012;60:2115.
6. Dunn GD, Hayes P, Breen KJ, Schenker S. The liver in congestive heart failure: a review. Am
J Med Sci. 1973;265:174.
7. Wells ML, Fenstad ER, Poterucha JT, Hough DM, Young PM, Araoz PA, et al. Imaging find-
ings of congestive hepatopathy. Radiographics. 2016;36:1024.
8. Dogan Y, Soylu A, Kilickesmez O, Demirtas T, Kilickesmez TA, Dogan SN, et al. The value
of hepatic diffusion-weighted MR imaging in demonstrating hepatic congestion secondary to
pulmonary hypertension. Cardiovasc Ultrasound. 2010;8:28.
9. Elsayes KM, Shaaban AM, Rothan SM, Javadi BL, Castillo RP, et al. A comprehensive
approach to hepatic vascular disease. Radiographics. 2017;37:813.
10. Lemmer A, Van Wagner LB, Ganger D. Assessment of advanced liver fibrosis and the risk for
hepatic decompensation in Patients with Congestive Hepatopathy. Hepatology. 2018;68:1633.
11. Kutty S, Peng Q, Danford D, Fletcher SE, Perry D, Talmon GA, et al. Increased hepatic stiff-
ness as consequence of high hepatic afterload in the fontan circulation: a vascular doppler and
elastography study. Hepatology. 2014;59:251–60.
12. Téllez L, Rodríguez de Santiago E, Minguez B, Payance A, Clemente A, Baiges A, et al.
Prevalence, features and predictive factors of liver nodules in Fontan surgery patients: The
VALDIG Fonliver prospective cohort. J Hepatol. 2020;72(4):702–10.
13. Schleiger A, Salzmann M, Kramer P, Danne F, Schubert S, Bassir C, et al. Severity of Fontan-
associated liver disease correlates with fontan hemodynamics. Pediatr Cardiol. 2020;41(4):
736–46.
Case 4: To Operate or Not to Operate?
A Case of Crohn’s Disease When 21
Elastography Helped
Stefano Mazza and Mirella Fraquelli
21.1 Case Report
D.S., a 45 years old man, was diagnosed with ileal Crohn’s disease when he was
36 years old. At his first presentation in July 2011, the patient complained of a
6-month history of diarrhea with 3–4 bowel movements per day, recurrent abdomi-
nal pain mainly located at the right flank/iliac fossa, and some episodes of food
vomiting.
Ileo-colonoscopy revealed aphthous ileitis for a 10-cm (at least) length of the
distal ileum, a rigid and ulcerated ileocecal valve, and a normal colonic and rec-
tal mucosa.
The histological examination of the ileal biopsies was suggestive of Crohn’s
disease.
The patient was initially treated with azathioprine (2 mg/kg/die) with improve-
ment of bowel habits, but persistence of recurrent abdominal pain and nausea. After
2–3 years, during 2014 the frequency of the pain episodes increased (about 5–6
occurrences per year), so in March 2015 the patient was started on biological ther-
apy with anti-TNF-alfa (infliximab 5 mg/kg). Symptoms subsequently improved
and the patient was well for about a year. However, in February 2016 he experienced
a subocclusive episode with intense abdominal pain and repeated vomiting, which
resolved spontaneously with fasting. At this point, the choices were: to optimize the
infliximab treatment (i.e., to shorten the infusion frequency from 8 down to 4 weeks),
to change the drug, or to proceed to surgery. In order to differentiate between a
prevalent inflammatory disease activity that would benefit from therapy enhance-
ment, and a fibrotic disease in which surgery would be the only effective approach,
both bowel ultrasound (US) with ultrasound strain elasticity imaging (UEI) and
S. Mazza · M. Fraquelli (*)

e-mail: mirella.fraquelli@policlinico.mi.it

https://doi.org/10.1007/978-3-030-74132-7_21
288 S. Mazza and M. Fraquelli
magnetic resonance enterography (MRE) were performed. US revealed a distal

ileum involvement for at least 10 cm, with a thickened bowel wall (max 9–10 mm),
slight wall hypervascularity at color-Doppler, and prevalently hypoechogenic pat-
tern (Fig. 21.1a). Elastographic examination showed a predominantly hard (blue)
pattern at the color scale (Fig. 21.1b), and a strain ratio of 2.4 at post-examination
analysis (Fig. 21.1c). This strain ratio value was considered as indicative of severe
ileal fibrosis, as reported [1, 2]. MRE, performed a week later, was basically in
agreement with US: it showed a 9-cm segment of the distal ileum with wall thicken-
ing up to 12 mm and contrast hyperenhancement. Moreover, at delayed enhance-
ment study the wall appeared stratified at the early phase (70 s, Fig. 21.2a) and
homogeneous at the late phase (7 min, Fig. 21.2b), with enhancement progression
over time. This contrast medium behavior has been reported as indicative of severe
intestinal fibrosis at MRE [3]. Thus, the conclusion was that the patient had a fibrotic
disease and in June 2016 he underwent surgery with a “classic” ileocecal resection
a b
Fig. 21.1 Intestinal ultrasound image showing a thickened terminal ileum with a prevalently
hypoechogenic pattern (a). Ultrasound elasticity image (UEI) at color scale with the selection of
regions of interest in the mesenteric tissue [ROI 1] and in the bowel wall [ROI 2] to calculate tissue
strain. The semiquantitative real-time assessment of wall stiffness shows a predominantly hard
(blue) pattern (b). Quantitative strain values of ROI 1 [mesenteric tissue] and ROI 2 [ileal wall]
plotted over time (c)
21 Case 4: To Operate or Not to Operate? A Case of Crohn’s Disease When… 289
a b
Fig. 21.2 Magnetic resonance (MR) enterography test showing a 9-cm segment of the distal
ileum with wall thickening and contrast hyperenhancement. At delayed enhancement study the
wall appeared stratified at the early phase (a) and homogeneous at the late phase (7 min) (b) with
enhancement progression over time
Fig. 21.3 Histopathology image of affected terminal ileum stained with hematoxylin/eosin
(H&E) confirming the diagnosis of Crohn’s disease with a typical finding of mucosal epithelioid
cell granuloma
with ileo-colonic anastomosis; the postoperative course was regular. Histological

examination confirmed the diagnosis of Crohn’s disease with a typical finding of
mucosal epithelioid cell granuloma (Fig. 21.3).
Azathioprine was reintroduced after surgery for prevention of postoperative dis-
ease recurrence. At ileo-colonoscopy 1 year after surgery, endoscopic remission
(Rutgeerts i1) was observed. Clinical remission was maintained for nearly 2 years
until 2018, when the patients started complaining of recurrent right flank pain and a
290 S. Mazza and M. Fraquelli
slight increase in bowel movements. US with elastography was again performed to

reveal a short (2–3 cm) thickened intestinal segment at the site of the anastomosis,
with a soft (green) pattern, and a strain ratio of 0.9 at elastographic examination.
Therefore, the treatment was enhanced with the starting of the patient on adalim-
umab (i.e., a 160/80 scheme of induction followed by 40 mg every other week) in
June 2018, with the subsequent resolution of abdominal pain. To date, the patient
still maintains clinical remission on adalinumab therapy Ileo-colonoscopy, per-
fomed in September 2020, evidenced endoscopic remission.
References
1. Fraquelli M, Branchi F, Cribiù FM, Orlando S, Casazza G, Magarotto A, et al. The role of
ultrasound elasticity imaging in predicting ileal fibrosis in Crohn’s disease patients. Inflamm
Bowel Dis. 2015;21:2605–12.
2. Orlando S, Fraquelli M, Coletta M, Branchi F, Magarotto A, Conti CB, et al. Ultrasound elas-
ticity imaging predicts therapeutic outcomes of patients with Crohn’s disease treated with anti-
tumour necrosis factor antibodies. J Crohns Colitis. 2018;12:63–70.
3. Rimola J, Planell N, Rodríguez S, Delgado S, Ordaas I, Ramirez-Morro A, et al. Characterization
of inflammation and fibrosis in Crohn's disease lesions by magnetic resonance imaging. Am J

Elastography of The Liver and Beyond 2021

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Elastography

Elastography of the Liver

ISBN 978-3-030-74131-0 ISBN 978-3-030-74132-7 (eBook)

© Springer Nature Switzerland AG 2021

stratification for surveillance versus therapeutic interventions. Not surprisingly, the

Milan, Italy Mirella Fraquelli

Part I Introduction to Elastography

Part II Liver Diseases

10 Elastography Methods to Assess Chronic Liver Diseases:

Part III Extrahepatic Diseases: Pancreas

Part IV Extrahepatic Diseases: Bowel

Part V Spleen Involvement in Liver and Non-Liver Diseases

Part VI Case Studies

At the end of the twentieth century, such techniques as ultrasonography, computer-

© Springer Nature Switzerland AG 2021 3

1. Validity: the extent to which a test measures what it is intended to measure.

considered acceptable. Moreover, the modalities of test performance, which ensure

Index test: a diagnostic test under assessment

Diagnostic accuracy: the proportion of correct results of the index test.

The 2-by-2 table:

Positive likelihood ratio:

Negative likelihood ratio:

Fig. 1.1 Glossary and definitions of diagnostic studies

non-diseased participants, i.e. the proportion of non-diseased participants correctly

Clinically relevant cohort

Spectrum bias Spectrum variation

randomized clinical trial (RCT): consecutive participants suspected of having the

As an example, a large-cohort study compared the accuracy of liver stiffness

2.1 Preamble: The Concept of Normality in Medicine

As underlined by Agostino Colli and colleagues in Chap. 1, studies on normal (or

D. Prati (*) · A. Berzuini

© Springer Nature Switzerland AG 2021 15

2.2 Healthy Ranges in Liver Disease Diagnostics

2.3 Definition of Healthy Ranges for Liver Stiffness

individuals provide a necessary background to set healthy thresholds for LS to be

Age, years LS measurement Healthy

Data on LS measurement by TE in healthy children are limited. In a group of 270

Probabilistic theories are extensively being used to summarize medical observations

Marta Cilla and Emmanuel A. Tsochatzis

M. Cilla · E. A. Tsochatzis (*)

© Springer Nature Switzerland AG 2021 27

3.2 Assessment of Liver Disease Severity

3.2.1 Role of Liver Biopsy

Histopathological examination of a liver specimen obtained by percutaneous liver

3.2.2 Non-Invasive Assessment of Liver Fibrosis in CHC

3.3  ransient Elastography for the Assessment of Liver

Transient elastography (TE), performed by using FibroScan (FS), is a non-invasive,

Consideration must be given to factors that may adversely affect TE perfor-

3.3.1 Combination Algorithms

The accuracy of the different non-invasive methods developed in CHC may be

3.3.2 TE vs. Other Elastography Techniques

3.4  ransient Elastography for the Assessment of Liver

3.5  ransient Elastography for Diagnosing

3.5.1 Portal Hypertension

Portal hypertension is the haemodynamic abnormality associated with the most

3.5.2 Gastro-Oesophageal Varices (GEV)

delayed the introduction of appropriate primary prophylaxis. Therefore, careful

3.5.3 Hepatocellular Carcinoma (HCC)

treatment was an independent predictor of HCC development. A possible explana-

Milan, Italy Mirella Fraquelli

Part I Introduction to Elastography

Part II Liver Diseases

10 Elastography Methods to Assess Chronic Liver Diseases:

Part III Extrahepatic Diseases: Pancreas

Part IV Extrahepatic Diseases: Bowel

Part V Spleen Involvement in Liver and Non-Liver Diseases

Part VI Case Studies

2.1 Preamble: The Concept of Normality in Medicine

2.2 Healthy Ranges in Liver Disease Diagnostics

2.3 Definition of Healthy Ranges for Liver Stiffness

3.2 Assessment of Liver Disease Severity

3.2.1 Role of Liver Biopsy

3.2.2 Non-Invasive Assessment of Liver Fibrosis in CHC

3.3 ransient Elastography for the Assessment of Liver

3.3.1 Combination Algorithms

3.3.2 TE vs. Other Elastography Techniques

3.4 ransient Elastography for the Assessment of Liver

3.5 ransient Elastography for Diagnosing

3.5.1 Portal Hypertension

3.5.2 Gastro-Oesophageal Varices (GEV)

3.5.3 Hepatocellular Carcinoma (HCC)

3.6 Transient Elastography to Determine Prognosis

4.2 Liver Stiffness Cofactors and Confounders

4.3 TE in Untreated HBV Carriers

4.3.1 HBsAg Carriers Without Liver Disease

4.3.2 Untreated CHB Patients

4.4 TE in Treated CHB Patients

4.4.1 LS Kinetics During Antiviral Treatment

intrahepatic necro-inflammation play a major role in LS values variation. Later

4.4.2 orrelation Between LS Changes During Treatment

5.1 Fibrosis in NAFLD: The Burden

5.2 Transient Elastography: The Technique

5.2.1 The Procedure

5.2.3 The Role of Controlled Attenuation Parameter (CAP)

5.3 Transient Elastography in NAFLD: The Quote

5.3.1 Diagnostic Accuracy

5.3.2 The Issue of Rule-In and Rule-Out

5.3.3 Confounding Factors

5.3.4 Liver Stiffness as Predictor of Liver Events

6.1 Acute Rejection

6.2 Recurrent Hepatitis C

6.3 “Non-viral” Graft Disease After Transplantation

6.4 Non-alcoholic Fatty Liver Disease (NAFLD)

6.5 Elastography Outcome After Liver Transplantation

6.6 Spleen Stiffness and Liver Transplant

7.2 Primary Biliary Cholangitis

7.3 Primary Sclerosing Cholangitis

7.4 Autoimmune Hepatitis

Fig. 8.1 Alcohol- All global deaths