الفهرس 
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Abstract
The operating characteristics of TE in the setting of chronic hepatitis C are sufficient to allow its place in the algorithms for management. Liver biopsy limitations have been discussed at length, but the most pressing difficulty with biopsy is probably increasing patient reluctance to have one. It is not expected that TE can replace biopsy in all settings. If the operating characteristics of TE are taken into consideration, specific questions can be answered with accuracy so that our reliance on biopsy is reduced.
Optimal liver stiffness cut-off values for the entire included population:
- F > II with a cut off value= 8.8kPa has sensitivity of 94% and specificity 33%.
- F > III with a cut off value = 9.6 kPa has sensitivity of 58% and specificity 89%.
- F= IV with a cut off value = 22.1 kPa has sensitivity of 89% and specificity 96%.
Optimal evaluation of liver stiffness measurement:
- F0= 2.5 – 4.9 KPa.
- F1= 5 – 8.7 KPa.
- F2= 8.8 – 9.6 KPa.
- F3= 9.7 – 22 KPa.
- F4= > 22.1 KPa.
Our results show that no statistical significant difference was found in pure HCV and mixed HCV-bilharzial patients according to mild, moderate or severe periportal fibrosis evaluated by abdominal ultrasonography.
Our results show that no statistical significant difference was found between mild <30% moderate (30-60%), severe >60% steatosis in chronic HCV patients.
Correlation of liver stiffness and fibrosis stage is not affected by steatosis, bilharzial disease or activity grade. We have outlined an algorithm, for HCV, which can be used to guide management decisions. Thresholds for treatment will always be influenced by patient and clinical preference, but it would seem that in the absence of biopsy, TE will facilitate by allowing the decision to be tailored more closely to the patient’s liver disease.
Chronic hepatitis C for HCV infection, attitudes to treatment are dynamic, and take into consideration the efficacy and safety of current therapies, tailored to genotype. Some clinicians prefer to offer therapy to those with significant fibrosis, although some are willing to treat the infection, independent of whether significant liver injury has yet occurred. However, it is always relevant to know whether the patient has cirrhosis or not. Once a decision has been made to treat, those with advanced fibrosis genotype 4 (which is the prevelant in Egypt) benefit from an extended duration of therapy. Those with cirrhosis have a lower chance of SVR and higher risk of treatment toxicity, and can be counseled appropriately. Those with HCV cirrhosis are at risk of liver cancer and varices and should participate in surveillance programmes, even if they achieve SVR with therapy, but especially if they do not.
How can TE help here? We suggest that all patients considering treatment for HCV, could have a TE performed. The result might encourage the ambivalent patient to have therapy, or steer the borderline patient away from it. Those with well compensated cirrhosis benefit from extended treatment duration for genotype 4. The optimal cutoff for this diagnosis is 22.1 kPa, maximizing sensitivity and specificity on the basis of the largest meta-analysis. Those with TE scores >22.1kPa need ongoing surveillance for HCC and oesophageal varices, as well as indefinite management by the liver clinic. Those with TE scores <22.1kPa (without cirrhosis) who achieve SVR after therapy can be safely discharged from the clinic. A liver biopsy could be used for clarification when the TE score falls close to this cutoff. Finally, using a cutoff of 8.8 kPa, which was found to be the most accurate to diagnose F >1 in the large meta-analysis, an option for genotype 4 patients with scores <8.8 kPa could wait as newer therapies are developed. In most cases, a liver biopsy is unlikely to contribute greatly in the decision algorithm for HCV treatment, unless other diagnoses. Dynamic monitoring of elastography could be an alternate, although to date unproved, way to identify those patients with progressive liver disease not appreciated on the baseline examination.
In our study a similar observation is also valid for the combination of Fib-4 plus Fibroscan for the discrimination of significant fibrosis. With regard to severe and significant fibrosis, we found that the combination of Fib-4 with TE also increased the accuracy of the non-invasive methods. Fib-4 with TE agreed on the discrimination of minimal fibrosis, significant fibrosis, cirrhosis consistent with the results of liver biopsy in 94% of cases.