1Service d'Hépatologie, INSERM U773, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université Denis Diderot Paris 7, Clichy, France.
The prognosis and management of chronic liver diseases greatly depend on the amount and progression of liver fibrosis with the risk of developing cirrhosis. Liver biopsy, traditionally considered as the reference standard for the staging of fibrosis, has been challenged over the past decade by the development of novel noninvasive methodologies. Key Messages: Noninvasive methods rely on two different but complementary approaches: a 'biological' approach based on the dosage serum biomarkers, and a 'physical' approach based on the measurement of liver stiffness using transient elastography (TE). There are two clinically relevant endpoints for the staging of liver fibrosis: (1) significant fibrosis (indication for antiviral treatment in viral hepatitis B and C), and (2) cirrhosis (indication for screening of esophageal varices and hepatocellular carcinoma). TE (FibroScan®), FibroTest® and APRI have been the most extensively studied and validated methods, mainly in chronic hepatitis C. Combining two unrelated methods, such as TE and biomarkers, is an attractive approach that increases diagnostic performance and limits the drawback of both methodologies. TE appears to be an excellent tool for the early detection of cirrhosis with likely prognostic value in this setting. Thus far, however, it cannot replace upper endoscopy for screening of esophageal varices. The main limitation of TE in clinical practice is the impossibility of obtaining reliable liver stiffness measurements in around 20% of cases, mainly comprising obese patients.
An increasing number of reliable noninvasive methods are now available that are widely used in clinical practice, mostly in viral hepatitis, resulting in a significant decrease in the need for liver biopsy.