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The Advantages and Disadvantages of Liver Fibrosis Evaluation Methods


Editors at

Apr 10th, 2017

Liver fibrosis tests are necessary for those with chronic liver disease. Find out why your physician may order a combination of liver biopsy and/or non-invasive liver fibrosis testing, as well as the pros and cons of these methods.

Chronic liver disease severity is determined by the liver’s landscape; the more liver cells that are damaged and scarred, the more advanced the liver disease is. Even after an initial diagnosis, the current state of your liver’s tissue is a major factor for predicting prognosis and making ongoing therapeutic decisions. Liver biopsy is the globally accepted reference test, but non-invasive techniques are becoming increasingly reliable methods for evaluating liver damage.

When liver damage outpaces the rate of liver cell regeneration, scarring of the liver can gradually lead to cirrhosis (permanent scarring and hardening of liver tissue). In liver tissue, scarring is an accumulation of extracellular matrix components. Liver biopsy and its alternative evaluation methods are designed to assess the degree of extracellular matrix components present. Although the liver biopsy is the best standard approach for determining how much scarring is present in the liver, it has several flaws.


In general, the histological staging systems for liver fibrosis currently used derive from the initial Knodell fibrosis score, and consist of either a five or seven tier rating. The higher the number, the more advanced the liver disease. The five tier rating system is most common, where the fibrosis score ranges from 0 to 4:

  • 0 = no signs of fibrosis
  • 1 = mild fibrosis
  • 2 = moderate fibrosis
  • 3 = severe fibrosis; fibrosis has spread and has connected to other areas on the liver
  • 4 = cirrhosis

Liver Biopsy

A liver biopsy is a medical procedure used to remove a small piece of liver tissue so doctors can examine the sample under a microscope. This enables them to:

  • diagnose liver disease
  • determine a score for fibrosis
  • detect cancer and/or infections (although liver cancer is typically diagnosed via CT scan or MRI)

5 Drawbacks of Liver Biopsies

Although they are the accepted reference test, liver biopsies have drawbacks:

  1. There is a risk of pain and bleeding at the needle site.
  2. May be contraindicated for those with certain medical complications.
  3. There is a chance that the location being sampled does not represent the entire organ.
  4. They may not accurately sub-stage cirrhosis.
  5. Histological evaluation can be subjective; different clinicians may report different results.

6 Advantages of Non-Invasive Liver Fibrosis Tests

Liver biopsy is not the only way to evaluate liver tissue. Non-invasive methods are widely available, and their advantages include:

  1. The absence of contraindications and dangerous complications.
  2. Their reproducibility.
  3. The ability to evaluate fibrosis extent in the whole organ – not just the sampled section.
  4. Their potential ability to identify and differentiate between advanced fibrosis stages.
  5. Their high specificity and sensitivity to diagnose cirrhosis.
  6. Their easy application.

Categories for Non-Invasive Liver Fibrosis Tests

There are three basic categories for non-invasive liver fibrosis tests:

  1. Serologic Panels – The serologic fibrosis markers are broadly categorized into direct and indirect markers. Direct markers of fibrosis include indices reflecting collagen synthesis or collagen degradation. Indirect markers of fibrosis are simple routine blood tests reflecting alterations in liver function but not directly representing extracellular matrix metabolism. These panels are highly reproducible, well validated and easily available. However, they are unable to discriminate between intermediate stages of fibrosis.
  2. Combined Scores and Algorithms – The currently used clinical combined scores, also referred to as algorithms, utilize a combination of measurements to deliver information about the liver. The ones currently in use include Fibrotest,® Hepascore, Fibrospect, Fibrometer, Forns Index, Aspartate Aminotransferase-to-Platelet ratio index (APRI), European Liver Fibrosis panel (ELF), SAFE Biopsy (SAFE: Sequential Algorithm for Fibrosis Evaluation), BAAT score [body mass index (BMI), age, ALT, triglyceride (levels)], BARD score, NAFLD fibrosis score and FIB-4 score.
  3. Imaging Techniques – To improve non-invasive liver fibrosis detection and assessment, many imaging techniques have emerged. These techniques are based on classical tools such as ultrasonography, computed tomography and magnetic resonance imaging. These include transient elastography (TE), magnetic resonance elastography (MRE), acoustic radiation force impulses [ARFI, 2D-Shear wave elastography (2D-SWE)], and contrast-enhanced sonography. Imaging techniques are user-friendly and are good for identifying cirrhosis; however, they require a dedicated device.

Because each test has a different set of pros and cons, experts currently advise a combination of biopsy and non-invasive tests to get accurate fibrosis/cirrhosis information.

Listed below is a sampling of those pros and cons:

  • APRI – This test is good for predicting severe fibrosis/cirrhosis or low risk of significant fibrosis, but does not accurately differentiate intermediate fibrosis from mild or severe fibrosis.
  • FIB-4 – This test is easy-to-use, quick and inexpensive, and is good at excluding or confirming cirrhosis. However, mid-range values do not fully discriminate fibrosis and need an additional method to predict liver fibrosis.
  • Forns Index – This algorithm has good predictive value in selecting those with low risk of significant fibrosis, but does not reliably predict more advanced fibrosis or cirrhosis.
  • HepaScore – Also known as FibroScore, this method is good at excluding significant fibrosis but not as good at predicting cirrhosis.
  • TE – Transient elastography, also known as FibroScan®, helps with detecting advanced fibrosis and cirrhosis. However, liver inflammation, obesity, ascites and high central venous pressure can interfere with TE results. Most clinicians use FibroScan® in combination with other types of liver fibrosis tests.
  • MRE – This imaging test has similar limitations to TE, although its high sensitivity and specificity results are proving to be clinically valuable. Unfortunately, this test is costly.

An increasing number of clinicians are knowledgeable about the pros and cons of liver fibrosis evaluation techniques, leading to the individualization of testing. As liver fibrosis identification becomes more specific, reproducible and sensitive, finding out what degree of damage your liver has incurred will get easier. Until then, find a competent practitioner who knows the pros and cons of these methods. They will likely order a combination of biopsy, serological, algorithm and imaging tests to get the most accurate image of your liver’s current landscape.

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9 Comment(s)
  • David Varshavsky

    Wow!!… and not one word about a Fibroscan!! Or its rating score, or its method!! Who on earth is responsible for publishing this confusing article and ignoring the most common way to test a liver and monitoring it TODAY!! wether for the better or for the worse. Why are you trying to complicate and confuse people, when there’s a Fibroscan available in every liver clinic in Australia for the last nearly two years, and about seven years in Europe!!

    • CyberVagrant

      As described in the response to your earlier post, FibroScan testing was described by its more technical name: TE (transient elastography). Both terms refer to exactly the same test.

      It seems to me that your comments about the lack of information about the ratings score and and test methods arose from a gap between what you expected to learn by reading the article and the author’s purpose for writing it. According to the text describing the table, the commentary for each test is supposed to describe the pros and cons of the test. It doesn’t say that the commentary will describe how the results are reported and interpreted, or how the test works, what it actually measures, and how that lends insight into liver disease. I agree with you that this is critical information of great interest to both people with liver disease and those who treat us, and fortunately for us, this information is easily found on other web sites. But that’s not what this article is about. As the title suggests, this article was written specifically to compare and contrast different tests for liver fibrosis, identifying the advantages and disadvantages, pros and cons of each. You were expecting descriptions of the tests themselves, and explanations of how the test results are presented, and were (understandably) critical of the article because that’s not what you got. It happens a lot, sometimes to me as well. The only suggestion I might have is that if you had read the title more carefully, you might have realized that this article was not what you were looking for.

      Hope this helps.

  • David Varshavsky

    Why has my comment disappear? Is the truth too hard for Liversupport to handle?

    • The Editors

      All comments are moderated David. Your previous comment had not been seen yet to be moderated. There is no reason we would have deleted your comment.

  • t.w.

    No information on Fibroscan?

  • Marius Dan

    What about FibroMax?

    • The Editors

      FibroMax® is a combined score and algorithim approach to diagnosing a fatty liver. FibroMax® combines up to five non-invasive liver tests:

      1. FibroTest®
      2. ActiTest®
      3. SteatoTest®
      4. NashTest®
      5. AshTest®

      There are several conditions where FibroTest® may not be accurate (an integral part of FibroMax®), such as acute inflammation, haemolysis, Gilbert’s syndrome and those taking medications that can raise bilibrubin levels. FibroMax® may be a great non-invasive liver
      evaluator, but several studies indicate that a greater number of patients are required to assess its validity. If this test is a viable option for you, it is worth considering.

      • Marius Dan

        FibroMax is not just for diagnosis of fatty liver!

        • The Editors

          That is accurate, FibroMax assesses more than a
          fatty liver. According to the company behind the algorithm, FibroMax provides a complete assessment of the condition of the
          liver and the five main causes of liver disease. Because FibroMax is a
          combination of five different tests, there are many variations on how and why
          it is used. A majority of medical groups run all five tests of FibroMax for
          patients with a fatty liver; however, that is not exclusive.

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