New Tech Tools to Evaluate Hepatitis C and Fatty Liver

There are some epidemics of liver disease that are worthy of contemporary notice. One of note is the hepatitis C infection—and we now can finally talk of cure with a selection of new antivirals. The interferon treatment era was fraught with side effects without substantial cure rates. And, with routine screening for hepatitis C recommended in everyone born from 1945-1965, we are all going to see a lot more individuals with the disease. 

Another epidemic in parallel with obesity and the increasing prevalence of diabetes is steatohepatitis and fatty liver. Like hepatitis C, this is not a benign disease.

Diagnostic Technology

With new antiviral regimens, there are other burgeoning technologies that will simplify the evaluation of patients infected with hepatitis C and fatty liver. In the past, the only way to diagnosis was invasive in the form of a liver biopsy. As the authors of this month’s Top Paper¹ observe, “there is a critical need for a noninvasive, safe, quick, inexpensive, and reliable tool to evaluate [liver patients].” 

Enter the recently FDA-approved vibration-controlled transient elastography (VCTE).

VCTE measures shear wave velocity in tissue, such as the liver. A probe is placed over the liver and returning shear waves are converted into a measure of liver stiffness. Stiffer livers are livers with fibrosis and cirrhosis. Discovering this stiffness may obviate biopsy and identify people who will benefit from therapy. 

In patients with hepatitis C, the Top Paper¹ authors use VCTE as the “first critical point-of-care test to exclude cirrhosis.”  VCTE has also demonstrated a decrease in liver stiffness for those individuals treated with antivirals for viral hepatitis. 

Limitations

Despite VCTE’s potential and noninvasive advantages, it has significant limitations as well. 

Not surprisingly, obese individuals are more likely to develop fatty livers. Well, when patients have a body mass index consistent with obesity, the VCTE is less likely to be accurate. However, progress is being made in this area. An XL probe has been developed that may improve detection of fibrosis in obese individuals. 

Ascites, like obesity, interferes with the test. So do inflammation, cholestasis, congestion, and food. 

Algorithm 

The authors offered their algorithm for use of VCTE in contemporary practice. At the initial visit, serological markers for fibrosis (METAVIR and Ishak scores) and VCTE are obtained. 

• If both the serological markers and VCTE are negative for cirrhosis, follow the patient. 

• If both agree that cirrhosis is present, screen for varices and hepatocellular carcinoma.

• If tests are discordant (1 yes for fibrosis, 1 no), repeat them. If they remain discordant, consider liver biopsy.

We are early in the era of  VCTE, but the test has promise. It may help us diagnose liver disease without a biopsy. Stay tuned for a learning curve with greater use. ■

Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the editorial board of Consultant. Dr Rutecki reports that he has no relevant financial relationships to disclose.

Reference: 

1.Tapper EB, Castera L, Afdhal NH. FibroScan (vibration-controlled transient elastography): where does it stand in the United States practice. Clin Gastroenterol Hepatol. 2015;13(1):27-36.