EASL clinical practical guidelines: management of alcoholic liver disease

2012 Journal of Hepatology 57, 2 (399-420)

Non-invasive tests to estimate liver fibrosis. [...]
Transient elastography (FibroScan)
Liver stiffness measurement (LSM) has been demonstrated to be a reliable tool for assessing hepatic fibrosis in patients with ALD. In patients with ALD, liver stiffness correlates with the degree of fibrosis. In the studies that did not consider the presence of ASH as a potential confounding factor, the cut off values for F3 and F4 fibrosis were considerably higher as compared to patients with viral hepatitis. In this regard, several studies have shown that patients with alcoholic cirrhosis had significantly higher values of liver stiffness than patients with viral cirrhosis, suggesting that the etiology may strongly affect the amount of fibrosis at the same stage. However, a recent study indicated that coexisting ASH markedly increases LSM in patients with ALD independent of fibrosis stage. The existence of inflammation, cholestasis or liver congestion may interfere with LSM, independently of fibrosis. Since all these conditions may occur during ALD, LSM should always be interpreted in the context of clinical, imaging and laboratory findings. A decision tree, taking into account those parameters has been proposed for the use of transient elastography in heavy drinkers. Importantly, elevated liver stiffness values in patients with ALD and ASAT serum levels >100 U/L should be interpreted with caution because of the possibility of falsely elevated liver stiffness as a result of superimposed ASH. In addition, alcohol consumption may also modify LSM as shown by the decrease in liver stiffness among abstainers and the increase in relapsers.
[...] Future studies are warranted to propose and validate diagnostic algorithm including liver biopsy and non-invasive tests.
Serum markers
Several new blood tests combining different biomarkers of fibrosis are now available. Although these tests were initially designed for patients with hepatitis C, some of them seem to be efficient in patients with ALD. However, different cut-offs may have to be considered when using such biomarkers for ALD instead of hepatitis C. [...]
FibroTest is a serum biomarker of fibrosis combining alpha-2-macroglobulin, haptoglobin, GGT, ApoA1, and bilirubin, corrected for age and sex. It seems to have high diagnostic potential for the detection of significant fibrosis in patients with ALD. In a study of 221 consecutive patients with biopsy-proven ALD, the mean FibroTest value ranged from 0.29 in those without fibrosis to 0.88 in those with cirrhosis and its AUROC for the diagnosis of cirrhosis was at 0.95. FibrometerA, combining PT, alpha-2-macroglobulin, hyaluronic acid, and age has similar diagnostic accuracy in ALD. In the validating step, the Fibrometer AUROC curve was 0.892 in overall patients and 0.962 in patients with ALD. Hepascore combines bilirubin, GGT, hyaluronic acid, alpha-2-macroglobulin, age, and sex. The diagnostic accuracies of Fibrotest, Fibrometer, and Hepascore were compared in patients with ALD. The diagnostic values of FibrometerA and Hepascore did not differ from that of FibroTest for advanced fibrosis (AUROCs around 0.80) and cirrhosis (AUROCs around 0.90), and were significantly greater than those of non-patented biomarkers (APRI, Forns, FIB4). The combination of any of these tests was useless in improving diagnostic performance.
In addition to their diagnostic performance in the screening of fibrosis, non-invasive tests may be useful in predicting liver related mortality as shown in a study of patients with ALD followed-up for more than 8 years, where survival was correlated with baseline non-invasive fibrosis score.

Pubmed : 22633836