Question: A 66 year old female with hepatitis C virus has the following lab results: AST 100, ALT 175, AP 200, Bilirubin 3.0, transferrin saturation 60%. You decide to perform transient elastography (TE) because you are suspecting cirrhosis. The result of TE is 13 kPa, a high score that suggests advanced fibrosis or cirrhosis. Which of the following variables might be responsible for this high score?
A. a biliary obstruction
B. the presence of hemochromatosis
C. her chronic hepatitis C virus
D. all of the above
Answer: Transient elastography is an excellent noninvasive tool when you want to make the diagnosis of cirrhosis. Scores above 13-14 kPa have excellent positive predictive value, but only when taken in the appropriate clinical context. In other words, you must be confident that you’ve excluded certain factors that might also increase liver stiffness and give you a high kPa value.
Biliary obstruction is one. Since this patient has an elevated AP and bilirubin, excluding obstruction might be indicated. Iron deposition also has a tendency to elevate TE scores, and her transferrin saturation > 45% suggests she might have hemochromatosis. Lastly, chronic hepatitis C virus. When HCV is associated with high aminotransferase levels, as in this patient, there is a possibility that this smoldering inflammation and edema will stiffen the liver and give you high TE readings (in the absence of advanced fibrosis!).
Therefore, it is difficult to conclude with confidence that this is a cirrhotic patient. The correct answer is D. A corroborating serologic fibrosis panel might be helpful, but liver biopsy will be the diagnostic standard. For more about HCV inflammation and TE, click on the link below: