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6359077 tn?1441486304

Fibroscan results, not sure what next action should be

I have consistently had fibroscan readings in range of 4-5 kpa in the past

When I look at the history medium prob was used

We move around alot and need to wait on list to see a specialist every time

We live in interior BC Canada

When we moved here we found out there is no liver specialist in our area and we're referred to an I herbal medicine specialist who is newly studying Hep b

First fibroscan read approx 9kpa

They took a second reading at roughly 7kpa

Alt 22 ast 21 u/L

Viral load was below 2000 ui/ml and is now fluctuating between 200k ui/ml and 400k ui/ml

Was advised because Asian and small that we are likely needing a size small probe but hospital does not have one

We were told that based on ast and alt we can safely interpolate that fibroscan should be within normal range.

I was unhappy with this because I thought that blood test alone should not be used and do not like  leaving the fate of my liver based on interpolation based on bloodtests  and asked for a second opinion

We were referred to speak to a hepb specialist in Vancouver who suggested a shear wave elastrography and that anything higher than 8kpa should prompt a discussion

The guidelines in Canada suggest for women >2000 ui/ml with ast over 20u/L and alt over 40u/L and stage 2 or more fubrosis should be considered for treatment.  If I understand correctly.

The internal medicine specialist here is saying treatment should not be considered until lat stage 3 fibrosis unless alot is consistently high.

We have not heard anything from the internal specialist since.

My question

If we are unable to get shear wave should I accept results of the interpolated fibroscan?

Is interpolation of fibroscan considered adequate?

What I don't understand is how we got a much lower reading in the past using a medium prob.

Just looking for opinions on if this sounds reasonable by the internal specialist?

1 Responses
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Avatar universal
I am not a doctor or expert.

The medium probe is only used for obese patients. For ordinary patients, I believe the standard probe should be used. I have not heard of the interpolation of Fibroscan scores. You may like to direct your queries to Echosens, the maker of Fibroscan machines.

There are alternatives to Fibroscan to assess liver fibrosis. Platelet counts and FIB4 are good markers.

I am not sure about your interpretations of HBV treatment guidelines. Guidelines do vary and change quite frequently. The trend is towards "treat in all cases with non-zero hbvdna" , but there are still conservative approaches. To interpret the guidelines correctly, you must know the phases of the HBV life cycle - Immune Tolerant, Immune Active, Immune Control, and Immune Escape.

For patients in the Immune Tolerant phase: HBeAg positive, very high hbvdna, ALT normal, and Fibrosis stage  30 years, family history of HCC, and whether true Immune tolerance.

For patients in the Immune Control phase - HBeAg negative, hbvdna <= 2,000 iu/ml, ALT normal, no treatment is recommended.

Normal ALT is male < 35 IU/L for male, < 25 IU/L for female. N.B. They change too.

So do try to consult a HBV specialist. At least a checkup once a year. For men over 40 years and women over 50 years, twice-yearly checks with ultrasound and AFP for HCC are recommended. There are now very safe and effective treatments for HBV, a complete cure is still some way off, but can keep liver fibrosis from progressing, a reversal of existing fibrosis after long-term treatment is possible.
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3 Comments
-------------------------------------------------------------------------------------------------------------------------
Exam: US / ADB w ELASTROGRAPHY NO DOPPLER

Findings:
A targeted upper abdominal ultrasound waws performed.

Mild degree of diffusely increased echogenicity of the liver suggestive of mild diffuse hepatic steatosis.  No focal hepatic lesions are identified.

Shear wave elastrography shows a median value of 8.53 kPa with an IQR/median of 14% consistent with a good data set.

The gallbladder is thin demonstrate any echogenic stones.  The common bile duct measures within normal limits at 0.1cm.

The spleen measures 7.2 cm in length and appears unremarkable.  Incidental note is made of a splenule measuring up to 2.2 cm in diameter.  Unremarkable appearance of the pancreas.

IMPRESSION:
Suspected mild deffuse hepatic steatosis with elastrography measurements consistent with mild-to-moderate fibrosis (Metavir score F2).

Normal to mild/F1: 5.48 - 8.29 kPA ( 1.35 - 1.66 m/s)
Mild to moderate/F2: 8.29 - 9.4 kPA (1.66 - 1.77 m/s)
Moderate to severe/F3: 9.4 - 11.9 kPA (1.77 - 1.99 m/s)
Cirrhosis/F4: >11.9 kPA (>1.99 m/s)

-------------------------------------------------------------------------------------------------------------------------------

Thank you so much for your detailed response Steven,  I would assume that being
- E Antigen Negative
- High Viral Load
that I am now in IMMUNE ACTIVE part of the life cycle.

Recap of last discussion:

Last September we consulted a Hepatologist via video call from Vancouver for a second opinion. This specialist proved to be quite knowledgeable and attentive to our concerns. However, we were told to keep seeing the internal specialist and that we could email with questions if we had concerns.

Due to the scarcity of family doctors in our area, we still lack a consistent primary care physician.  Despite the province advocating for Nurse Practitioners as an alternative, the reality hasn't matched the promise, leaving us without a dedicated healthcare provider.  When inquiring about prioritization for a family doctor, we encountered resistance from the assistant of our local internal specialist, who seemed dismissive of the importance of having a family doctor.

The Hepatologist recommended a ShearWave Elastography procedure last September, with follow-up scheduled for October.  However, no communication regarding this was received, leading us to assume it might coincide with our annual appointment in January.  Unfortunately, this assumption was incorrect, and further attempts to clarify the situation were met with frustration due to perceived resistance from the hospital staff.

Update:

we reached out for clarification on the overdue procedure. Shockingly, we were informed that our September consultation with the Hepatologist supposedly exempted us from any further appointments until the following September.  Moreover, we were told that ShearWave Elastography could only be conducted alongside a scheduled appointment.  Yes, you read that correctly; this was the official stance.

Attempting to inject reason into the conversation, I queried why we should wait a staggering one year and seven months simply because we had consulted another Hepatologist. Surely, if routine Fibroscans were to be conducted annually, this extended delay seemed illogical.  However, my attempts at rationale were met with the same dismissive response: having seen the other Hepatologist meant we were exempt from appointments for a full year thereafter.

After persistently advocating for our healthcare needs, a begrudging agreement was reached to schedule the ShearWave Elastography.  However, it was made abundantly clear that we would not be granted another appointment in September.  Which I completely agree with and never expressed any issue over.

Feeling a sense of apprehension, I hesitate to reach out to the internal specialist for fear of exacerbating my anxiety.  The interaction with the nurse at the hospital has been particularly challenging; she frequently interrupts me mid-sentence, necessitating that I assertively request to complete my thoughts. Despite my efforts to communicate effectively, I've been accused of not allowing her to speak, which only adds to the frustration of an already strained situation.

While I understand the strain on hospital staff due to overwhelming demand, it's disheartening that such pressures are affecting the quality of service provided.  This underscores the critical need for a dedicated family doctor who can serve as a liaison and advocate, especially during moments of uncertainty or concern. A family doctor would not only facilitate communication but also provide invaluable support in navigating the complexities of our healthcare system.

Here are the latest results from the ShearWave Elastography, which appear to align closely with the findings from the earlier Fibroscan. However, uncertainty arises as the technician who conducted the procedure conveyed doubt, mentioning it was their first time performing it.

Additionally, it's essential to consider that the interpretation of kPa readings in a fibroscan can vary significantly between for example Hepatitis C and Hepatitis B cases. Given these nuances, I'm unsure if the values for F2 are accurate for patients with Hepatitis B using ShearWave Elastrography.

I'm eager to gather opinions and insights on these results. If anyone has thoughts, your input would be greatly appreciated.  What would you do in this situation if it was you or your loved one?

For added Context:
Asian Female age between 40 and 45

Hepatitis B Virus DNA; Ser/Pl; PCR/NAAT
05/Jan/2024 | 284000 [IU]/mL
29/Sep/2023 | 458000 [IU]/mL
05/Jun/2023 | 280000 [UI]/mL
08/Mar/2023 | 131000 [UI]/mL
30/Dec/2022 | 204000 [UI]/mL
14/Nov/2022 | 59900  [UI]/mL

ALT
05/Jan/2024 | 21 U/L
29/Sep/2023 | 20 U/L
06/Jun/2023 | 32 U/L
03/Mar/2023 | 17 U/L
16/Jan/2023 | 25 U/L
21/Dec/2022 | 18 U/L
14/Nov/2022 | 25 U/L

AST
05/Jan/2024 | 22 U/L
29/Sep/2023 | 19 U/L
06/Jun/2023 | 28 U/L
03/Mar/2023 | 21 U/L
16/Jan/2023 |   NA   |  ~~ Specimen is hemolyzed. Unable to provide result.
21/Dec/2022 | 20 U/L
14/Nov/2022 | 25 U/L

-------------------------------------------------------------------------------------------------------------------------
Exam: US / ADB w ELASTROGRAPHY NO DOPPLER

Findings:
A targeted upper abdominal ultrasound waws performed.

Mild degree of diffusely increased echogenicity of the liver suggestive of mild diffuse hepatic steatosis.  No focal hepatic lesions are identified.

Shear wave elastrography shows a median value of 8.53 kPa with an IQR/median of 14% consistent with a good data set.

The gallbladder is thin demonstrate any echogenic stones.  The common bile duct measures within normal limits at 0.1cm.

The spleen measures 7.2 cm in length and appears unremarkable.  Incidental note is made of a splenule measuring up to 2.2 cm in diameter.  Unremarkable appearance of the pancreas.

IMPRESSION:
Suspected mild deffuse hepatic steatosis with elastrography measurements consistent with mild-to-moderate fibrosis (Metavir score F2).

Normal to mild/F1: 5.48 - 8.29 kPA ( 1.35 - 1.66 m/s)
Mild to moderate/F2: 8.29 - 9.4 kPA (1.66 - 1.77 m/s)
Moderate to severe/F3: 9.4 - 11.9 kPA (1.77 - 1.99 m/s)
Cirrhosis/F4: >11.9 kPA (>1.99 m/s)

-------------------------------------------------------------------------------------------------------------------------------

We thank you for your update. I can certainly understand your frustration with the Canadian medical system, and this is a surprise to me. Let me stress again that I am not a doctor or researcher. So, the following comments are my personal opinion only:
1. Your viral load is considered high, yet your ALT is normal. So, I cannot place you in the usual stages. I am sure a liver specialist will do much better.
2. You are HBeAg negative, so usually you should have low hbvdna(viral load). Since your ALT is normal, you do not seem to be in the Immune Escape Phase(aka HBeAg negative chronic hepatitis). Immune activity is usually indicated by ALT.
3. Given your high viral load, you may consider antiviral treatment with either Entecavir or TAF. You must consult your doctor, as you may have to take the drug for a long period of time. The drug can be costly and have side effects.
4. On the other hand, is drug treatment needed? Your ALT is normal, so the high viral load may not be doing any damage. A liver specialist will be able to answer this.
5. Your recent US / ADB w ELASTROGRAPHY NO DOPPLER scans seem to show hepatic steatosis. I understand this means you have a fatty liver, which can cause liver fibrosis by itself. There are new treatments for fatty liver, such as diet, exercise and drugs. So, should you consider treatment for a fatty liver, treatment for your HBV, or both?
6 As you can see, I am out of my depth here.  I suggest you may like to visit hepbcommunity.org and post your questions there; they have experts there.

I hope this helps.
I find this article quite informative: B-mode US and Deep Learning Rivals Shear-Wave Elastography in Screening for Fibrosis, https://pubs.rsna.org/doi/10.1148/radiol.240868.
This is purely from a radiologist's perspective and is not related to HBV. The general comments about Shear-Waver Elastography are quite interesting.

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