S13 * NONINVASIVE SCREENING FOR LIVER CIRRHOSIS IN ADDICTIVE PATIENTS * S13.1 * IS LIVER STIFFNESS THE NOVEL GOLD STANDARD TO ASSESS LIVER CIRRHOSIS?

Abstract

Noninvasive screening for liver cirrhosis in patients addicted to drugs or alcohol has been a continuing problem in internal and addictive medicine. This has dramatically changed with the recent introduction of transient elastography (Fibroscan) to directly measure liver stiffness (LS). This novel technique is expanding rapidly around the globe since it allows the diagnosis of liver cirrhosis in a true bed-side manner within minutes. LS is an excellent screening parameter for cirrhosis with a high negative predictive value. Thus, a normal LS of <6 kPa indicates an ongoing liver disease while an LS of 8 and 12.5 kPa represent generally accepted cut-off values for F3 and F4 fibrosis. Meanwhile, LS has also been successfully used to monitor the treatment outcome of patients with alcoholic liver cirrhosis and as a prognostic parameter for hepatic complications such as the risk of variceal bleeding or hepatocellular carcinoma. However, it is important to conceive that several other factors, apart from cirrhosis stage, may affect LS. Such factors include liver inflammation, liver congestion, cholestasis and rare conditions such as amyloidosis or mastocytosis. Thus, although LS is an excellent screening tool for liver disease, it should always be interpreted in the clinical context. For such a hepatological expert interpretation of LS values, a concomitant ultrasound and laboratory parameters are required, which will increase the diagnostic accuracy over 99%. Novel actual algorithms will be discussed especially with regard to alcoholic liver disease, how to interpret increased LS values within the clinical setting. # S13.2 HOW USEFUL ARE SERUM MARKERS TO DETECT LIVER CIRRHOSIS IN ADDICTIVE PATIENTS? {#article-title-2} Alcoholic liver disease (ALD) is characterized by a spectrum of damage, ranging from hepatic steatosis to cirrhosis. In people consuming more than 50 g of alcohol per day for more than 5 years, hospital-based studies using systematic liver biopsy have estimated the prevalence of severe fibrosis and cirrhosis at between 15 and 40%. However, it is probable that cirrhosis is under-diagnosed in routine clinical practice, due to the invasiveness of liver biopsy. At the same time, early diagnosis would be essential to motivate patients undergoing alcohol withdrawal treatment and to implement preventive measures for cirrhosis complications. For these reasons, non-invasive serum markers for liver fibrosis have been investigated in alcoholic patients. Among direct serum markers, hyaluronan showed a very good performance for cirrhosis, with an area under the curve (AUC) of 0.91–0.93. Among the patented panels that combine a series of serum parameters, in few reports Fibrotest was very accredited for the diagnosis of cirrhosis (AUC range: 0.84–0.95). A good performance for the diagnosis of cirrhosis was also reported for other patented tests, such as Fibrometer (AUC range: 0.85–0.94), Hepascore (AUC = 0.92) and ELF panel (AUC = 0.94). Overall, comparative studies showed that simple, indirect serum markers, such as APRI, Forns' index and Fib-4, may exhibit a significantly lower performance than the more sophisticated patented panels. In conclusion, serum markers, and particularly the patented panels, show promising results for detection of cirrhosis in ALD. They may be useful to reduce the number of liver biopsies needed to correctly diagnose cirrhosis. However, large-scale, independent studies are pending. # S13.3 SCREENING FOR CIRRHOSIS IN DRUG USERS BY LIVER STIFFNESS MEASUREMENT {#article-title-3} Aims. Liver stiffness measurement (LSM) is a non-invasive sensitive tool for diagnosing cirrhosis in hospital-based cohorts. This study aimed to evaluate LSM as an outreach screening tool for cirrhosis among drug users. Methods. In a cross-sectional study among drug users attending treatment centres, LSM was performed using the Fibroscan device and blood collected for serological testing. Individuals with LSM >8 kPa were referred to the hospital for treatment evaluation and individuals with LSM >2 kPa were recommended a liver biopsy. Results. Among 175 drug users negative for hepatitis C, 13% had an LSM of 8–11.9 kPa and 4% had an LSM of >12 kPa; elevated LSM was associated with a body mass index of >30. Among 128 drug users with chronic hepatitis C, 20% had an LSM of 8–11.9 kPa and 21% had an LSM of >12 kPa ( P 16 kPa predicted cirrhosis with 88.9% sensitivity and 90% specificity. Conclusions. The LSM is a feasible screening tool for cirrhosis among drug users, but management of these patients should not be based on a single elevated LSM. # S13.4 MEASURING LIVER STIFFNESS IN A COMMUNITY-BASED POPULATION: IS LIVER CIRRHOSIS AN EPIDEMIC PLAQUE? {#article-title-4} The frequency of chronic liver disease is increasing due in particular to non-alcoholic fatty liver disease (NAFLD) and chronic hepatitis C. The exact prevalence of cirrhosis is unknown. Until recently, no simple screening tool for cirrhosis was available and liver biological tests were the most common procedure to uncover liver involvement in apparently healthy individuals. Liver stiffness measurement (LSM) has been developed to detect cirrhosis and liver fibrosis in many types of hepatic disease. This procedure has been demonstrated to provide an excellent negative predictive value for cirrhosis. However, its usefulness as a screening procedure in apparently healthy people had not been evaluated. We consecutively enrolled 1358 subjects aged >45 years from a general population attending a medical check-up. All subjects were submitted to medical examination and laboratory tests in addition to LSM, performed the same day by a single operator. Subjects with LSM values over 8 kPa were referred to a liver unit for further investigation. Subjects with missing data ( n  = 23), LSM failure ( n  = 51) or unreliable LSM values ( n  = 94) were not considered for the analysis. Among the 1190 remaining subjects, 89 (7.5%) had LSM over 8 kPa, including 9 patients with LSM above 13 kPa. Although normal liver tests were observed in 43% of them (38 of 89), a specific cause of chronic liver disease was found in all cases. NAFLD was the likely cause of chronic liver disease in 52 patients, alcoholic liver disease (ALD) in 20, both causes being associated in 7 additional patients. HCV and HBV chronic hepatitis were documented in five and four cases, respectively, and primary biliary cirrhosis in one. Liver biopsy was obtained for 27 patients, including the nine patients with LSM above 13 kPa. Among these nine patients, all showed liver cirrhosis due to ALD in five cases, chronic hepatitis C in three and chronic hepatitis B in one case. The 18 remaining biopsies showed liver fibrosis in all cases except one (isolated steatosis), with ALD and NAFLD being present in six and eight cases, respectively. In conclusion, LSM proved to be a useful and specific procedure to screen for cirrhosis in the general population and to detect undiagnosed chronic liver disease in apparently healthy subjects. Liver cirrhosis is an important public health problem involving 0.7% of the general population.