The Non Alcoholic Fatty Liver Strategy™ eBook by Julissa Clay. The program provided in this eBook is very reasonable and realistic as it neither restricts your diet miserably so that you cannot stick to the changes in diet suggested in it nor wants you to do intense exercises for many hours every week. This program helps in making big changes in your life by following a few easy-to-follow steps.
How is liver fibrosis diagnosed?
Liver fibrosis is the first stage of liver damage when the liver begins to form scar tissue. If it is not treated, it may turn into cirrhosis, but early diagnosis avoids complications. Several methods are used in diagnosing liver fibrosis ranging from non-invasive to invasive. Here is a rundown of how liver fibrosis is diagnosed:
1. Blood Tests
Liver Function Tests: While these tests (e.g., ALT, AST, ALP, and bilirubin) can suggest liver injury, they cannot directly assess the degree of fibrosis. However, an abnormal test can suggest liver dysfunction that needs to be investigated further.
Fibrosis Markers: Laboratory tests can measure some biomarkers that are indicative of liver fibrosis. These are:
FibroTest (also known as FibroSure): A blood test that analyzes a series of liver-related biomarkers (including ALT, AST, GGT, and bilirubin) to estimate the degree of fibrosis of the liver.
Enhanced Liver Fibrosis (ELF) test: A blood test that evaluates three markers (hyaluronic acid, procollagen III N-terminal peptide, and tissue inhibitor of metalloproteinases-1) to estimate the stiffness of the liver, which correlates with fibrosis.
AST to Platelet Ratio Index (APRI): This calculates the ratio of AST (aspartate aminotransferase) to platelet. A higher ratio may indicate greater liver fibrosis.
FIB-4: This index incorporates age, AST, ALT, and platelets to calculate the likelihood of advanced liver fibrosis.
2. Imaging Techniques
Imaging techniques that are not invasive can prove to be of great assistance in providing information in terms of liver stiffness, which is directly proportional to the level of fibrosis.
Transient Elastography (FibroScan): A special ultrasound device that measures liver stiffness by sending a pulse of vibration into the liver. The harder the liver tissue, the stiffer it will be, and the higher the level of fibrosis. It is one of the most common non-invasive tests to diagnose liver fibrosis.
Magnetic Resonance Elastography (MRE): A newer imaging technique that combines magnetic resonance imaging (MRI) and elastography. It is more precise in assessing liver stiffness than older imaging techniques.
Ultrasound: Standard ultrasound imaging cannot directly measure fibrosis but can detect changes due to liver injury, including liver enlargement or irregular texture. Some specialized ultrasound techniques, like elastography, can quantify liver stiffness.
CT or MRI Scans: CT and MRI scans may be used to detect structural abnormalities of the liver, like nodules or irregularities, which may reflect cirrhosis or fibrosis that is advanced. They are not usually used for diagnosing early fibrosis.
3. Liver Biopsy
Invasive Procedure: Liver biopsy is the reference standard for the diagnosis of liver fibrosis and its staging. During a biopsy, a small piece of liver tissue is excised with a needle passed through the skin (percutaneously) or through an endoscope (transjugular). The tissue is examined under a microscope to assess the degree of fibrosis.
Grading Fibrosis: Fibrosis of the liver is typically graded on a scoring system such as the Ishak score or METAVIR score, which scores the degree of fibrosis from stage 0 (zero fibrosis) to stage 4 (cirrhosis).
Risks: While liver biopsy is extremely accurate, it is invasive and carries risks such as bleeding or infection and is therefore less ideal for monitoring.
4. Liver Stiffness Measurement (LSM)
Advanced Elastography Techniques: Besides transient elastography (FibroScan), other advanced elastography techniques like Shear Wave Elastography (SWE) can be utilized to assess liver stiffness and diagnose liver fibrosis. These tests are non-invasive and can be performed in a clinic.
5. Clinical Assessment
Medical History: Doctors will examine the patient’s history, including any conditions that will contribute to fibrosis of the liver, including chronic viral hepatitis, alcoholism, non-alcoholic fatty liver disease (NAFLD), or metabolic disorders like diabetes.
Physical Examination: Physical examination cannot directly diagnose fibrosis, but presentation of signs of liver disease (e.g., jaundice, ascites, or hepatomegaly) can result in further assessment of liver function and fibrosis.
6. Other Specialized Tests
Endoscopy: In advanced liver disease patients, doctors can use endoscopy to look for signs of portal hypertension, such as esophageal varices (dilated blood vessels) that is a complication of cirrhosis and liver fibrosis.
Hepatic Venous Pressure Gradient (HVPG): A technical examination which measures the pressure in the portal vein, that can be used to measure how much liver fibrosis there is, especially for severe cases. This examination is used more within clinical research studies.
Strengths and Weaknesses of Each Method
Non-invasive Tests (e.g., blood tests, FibroScan, MRE, elastography) are employed for routine screening and follow-up since they are safer, cheaper, and less invasive. But they may be less sensitive to the detection of early fibrosis or discrimination between mild and moderate fibrosis.
Liver Biopsy is the best test but is dangerous and invasive so is less useful for daily usage. It would typically only be used if the other tests prove negative or an exact level of fibrosis is needed to assess.
Imaging techniques are being used increasingly as a less-invasive choice, with FibroScan and MRE as methods that have some good tools in place to evaluate liver stiffness and fibrosis advance.
Conclusion
Liver fibrosis can be diagnosed with a group of tests involving blood tests, imaging tests, and in some cases, liver biopsy. FibroScan and elastography are now routinely utilized due to their safety and simplicity, although liver biopsy is the gold standard for staging of fibrosis. Early diagnosis of liver fibrosis is necessary because treatment can be successful in preventing cirrhosis and liver failure if initiated early.
Diagnosis of cirrhosis utilizes a combination of clinical examination, laboratory, and imaging to arrive at a measure of liver function and evidence of liver injury. Cirrhosis develops gradually over time and lacks symptoms during early stages; the diagnosis, therefore, tends to be made throughout the duration of liver disease. Below is the summary of diagnostic process:
1. Medical History and Physical Examination
Medical History: The doctor will ask for the medical history of the patient and for risk factors of cirrhosis such as:
Chronic alcohol use
Hepatitis (more specifically hepatitis B or C)
Obesity, diabetes, or metabolic syndrome
Family history of liver disease
Use of medication or drugs affecting the liver
Physical Examination: The physician will examine the abdomen for signs of liver enlargement or ascites (fluid buildup). He or she can also check for jaundice (yellow skin and eyes) and signs of portal hypertension, such as spider angiomas or palmar erythema (red palms).
2. Lab Tests
Blood tests play a crucial role in assessing liver function and if cirrhosis is present:
Liver Function Tests (LFTs): These are tests for liver enzyme levels (e.g., AST and ALT), bilirubin, and liver-derived proteins (e.g., albumin). In cirrhosis:
Elevated liver enzymes (AST, ALT), although in advanced cirrhosis, they are low.
Low albumin and high bilirubin occur in cirrhosis due to liver dysfunction.
Prothrombin Time (PT) and INR: These are measures of the ability of the liver to produce clotting factors. An abnormal PT or INR can indicate a severe dysfunction in the liver, which is common in cirrhosis.
Level of Ammonia: Ammonia above normal levels might suggest hepatic encephalopathy, one of the brain function impairment cirrhosis complications.
Hepatitis Panel: Hepatitis B or C screening to determine if chronic viral hepatitis is causing damage to the liver.
Alpha-1 Antitrypsin Levels: This is a screening test for alpha-1 antitrypsin deficiency, an inherited disorder that leads to cirrhosis.
Autoimmune Tests: Autoimmune hepatitis tests (eg, antinuclear antibody, anti-smooth muscle antibody) are requested if autoimmune liver disease is suspected.
3. Imaging Studies
Imaging techniques are required to assess size, liver shape, and extent of damage:
Ultrasound: Ultrasound of the abdomen is typically the first imaging study to evaluate the liver for signs of cirrhosis, including enlargement of the liver, nodularity, and ascites. It can also identify varices (dilated veins) or other complications.
CT Scan (Computed Tomography): CT scan provides a clear image of the liver and can be employed to identify liver masses, ascites, or vascular abnormalities observed in cirrhosis.
MRI (Magnetic Resonance Imaging): MRI is used in certain cases to evaluate the liver’s structure and search for fibrosis. MRI is more valuable than ultrasound in some cases.
Elastography (FibroScan): This is a procedure in which liver stiffness is assessed using a non-invasive technique. A stiffer liver indicates fibrosis and cirrhosis. It is increasingly being used as a standard tool to grade the degree of liver damage as a substitute for liver biopsy.
4. Liver Biopsy (Not Typical)
Liver Biopsy: In some instances, a liver biopsy may be performed to finalize cirrhosis and identify the degree of fibrosis. A small piece of liver tissue is removed and examined under a microscope to assess for scarring, fat accumulation, and inflammation.
Although liver biopsy is accurate, it is generally reserved for cases where other interventions have not been sufficiently informative or a specific diagnosis (e.g., autoimmune liver disease) is necessary.
5. Complications Assessment
As cirrhosis progresses, portal hypertension, hepatic encephalopathy, and varices are some of the complications that may occur. To assess such complications:
Endoscopy: An upper GI endoscopy is performed to screen for esophageal varices (dilated esophageal veins), a common complication of portal hypertension in cirrhosis.
Ascitic Fluid Analysis: If ascites is present, fluid can be tapped (by paracentesis) to search for signs of infection or liver failure.
6. Severity Assessment and Staging
Child-Pugh Score: Child-Pugh score is used to decide the severity of cirrhosis and prognosis estimation based on bilirubin, albumin, ascites, and encephalopathy.
MELD Score: Model for End-Stage Liver Disease (MELD) score is used to assess the severity of cirrhosis in patients considered for liver transplant evaluation. It is calculated from laboratory results like bilirubin, creatinine, and INR.
Conclusion
Cirrhosis is diagnosed using a combination of clinical assessment, laboratory examinations, imaging examinations, and sometimes liver biopsy. Early diagnosis is needed to prevent further liver injury and complications. When cirrhosis is suspected, a thorough evaluation needs to be performed to confirm the diagnosis, determine the cause, and assess the degree of liver damage.
If you have a question about cirrhosis or wish for additional information on a specific aspect of the diagnosis, please ask!
The Non Alcoholic Fatty Liver Strategy™ eBook by Julissa Clay. The program provided in this eBook is very reasonable and realistic as it neither restricts your diet miserably so that you cannot stick to the changes in diet suggested in it nor wants you to do intense exercises for many hours every week. This program helps in making big changes in your life by following a few easy-to-follow steps.