Diagnosis of fibrosis and cirrhosis. Liver biopsy is not always necessary

Needle biopsy of the liver is considered the "gold-standard" for diagnosis of hepatic fibrosis and cirrhosis. However, it is not risk-free, lacks accuracy, and is poorly accepted by some patients. This review examines available literature on the use and diagnostic performance of non-invasive methods for assessment of hepatic fibrosis and cirrhosis in adults, based on the standard Prescrire methodology. Transient elastography (FibroScan) measures liver stiffness in kilopascals. The results are less reliable in patients with a thick chest wall, hepatic congestion of cardiac origin, and acute exacerbations of hepatitis. Transient elastography has been evaluated in more than 8000 patients, most of whom had chronic hepatitis C. With a cutoff value of about 7-8 kPa, elastography identified about 70% of patients with histological signs of moderate to severe fibrosis. With a cutoff of 14-15 kPa, it identified about 85% of patients with histological signs of cirrhosis. Transient elastography is reliable in detecting moderate to severe fibrosis and cirrhosis and in ruling out cirrhosis, but is less reliable in ruling out moderate fibrosis. Composite scores based on blood assay values and complex calculations are unreliable when at least one of the score components is influenced by intercurrent conditions. FibroTest, FibroMeter and Hepascore have been tested in several thousand patients with chronic hepatitis C. With the manufacturers' recommended cutoff values, FibroTest identifies about 70% of patients with histological signs of moderate to severe fibrosis and about 90% of patients with histological signs of cirrhosis. It can reliably diagnose or rule out moderate fibrosis, and diagnose cirrhosis. It is also very reliable in ruling out cirrhosis. Hepascore has similar diagnostic performance. FibroMeter has been less extensively evaluated but also seems to have diagnostic performance similar to that of FibroTest. Some studies suggest that FibroTest has similar accuracy in forms of liver fibrosis other than chronic hepatitis C. In practice, the main issue involved in making therapeutic decisions in patients with chronic hepatitis C is the risk-benefit balance of available treatments rather than precise diagnosis of fibrosis.