Table 2.

What the clinician needs to know about transient elastography (Fibroscan®)

1 Clinical indications for TE
Liver disease	Indications for TE	Potential clinical applications
Chronic liver disease	To assess for severity of fibrosis	Assist in treatment decisions in CHC and CHB
		Selection of patients for treatment trials
		Decision to continue or stop MTX
	To diagnose early cirrhosis	Commence variceal screening and HCC surveillance, monitor for decompensation
	Longitudinal assessment of fibrosis	Assess for progression of fibrosis in untreated patients and for regression of fibrosis/cirrhosis in treated patients
Patients with NAFLD	Assess severity of fibrosis and steatosis (with Fibroscan-CAP)	Aggressive control of risk factors
		Selection of patients for treatment trials
		Selection of patients for liver biopsy
Post-liver transplant	Assess for fibrosis in recurrent CHC post liver transplant	Avoid protocol liver biopsies for diagnosis of fibrosis
Non-cirrhotic portal hypertension	Exclude cirrhosis	Assists in differentiating cirrhotic vs non-cirrhotic portal hypertension
Patients with cirrhosis	Predict significant portal hypertension and risk of liver-related events	Stratify frequency of follow-up in low-risk vs high-risk cirrhotics
	Predict absence of varices	Avoid/delay endoscopy screening in cirrhotics at low risk for varices
2 Conditions that affect accuracy of TE
Condition	How it affects the TE result	What the clinician should do
Post-meal	LSMs are elevated after meals due to increased hepatic venous flow	Patients should fast for at least 3 h before TE measurement
Elevated ALT	LSMs are elevated due to hepatic inflammation	Repeat or delay TE till after ALT has returned to baseline/normal levels
		Use ALT-based LSM cut-off values to interpret LSM result
		Use probability-based LSM interpretation scores which account for ALT
Cardiac failure	LSMs are elevated due to hepatic congestion in right heart failure	Repeat or delay TE until after patient’s heart failure is treated
Cholestasis	LSMs are elevated due to increased stiffness from biliary dilatation	Repeat or delay TE until after biliary obstruction is resolved
Operator experience	Operator inexperience may lead to higher rate of unsuccessful or invalid LSM results	TE should be performed by operators with prior experience of at least 50-100 examinations
Obesity	Higher rate of unsuccessful LSMs due to increased SCD because of increased subcutaneous fat	Use XL probe if SCD > 3.4 cm (with the current Fibroscan 502 Touch®, the machine will automatically advise when the XL probe should be used)
		If LSM is unsuccessful with XL probe, use alternative non-invasive test
Ascites	High rate of unsuccessful LSM due to interruption of shear waves by ascites	Use alternative non-invasive test
Pregnancy, cardiac pacemaker, AICD	Safety of TE in these conditions have not been assessed	TE contraindicated

TE: Transient elastography; CHC: Chronic hepatitis C; CHB: Chronic hepatitis B; MTX: Methotrexate; HCC: Hepatocellular carcinoma; CAP: Controlled attenuation parameter; NAFLD: Non-alcoholic fatty liver disease; LSM: Liver stiffness measurement; ALT: Alanine transaminase; SCD: Skin-capsule distance; AICD: Activation-induced cell death.