Research Article: High risk of misinterpreting liver and spleen stiffness using 2D shear-wave and transient elastography after a moderate or high calorie meal

Date Published: April 4, 2017

Publisher: Public Library of Science

Author(s): Maria Kjærgaard, Maja Thiele, Christian Jansen, Bjørn Stæhr Madsen, Jan Görtzen, Christian Strassburg, Jonel Trebicka, Aleksander Krag, Matias A Avila.


Food intake increases liver stiffness, but it is believed that liver stiffness returns to baseline two hours after a meal. The aim of this study was to investigate the impact of different sized meals on liver stiffness. Liver and spleen stiffness was measured with transient elastography (TE) and real-time 2-dimensional shear wave elastography (2D-SWE). Patients ingested a 625 kcal and a 1250 kcal liquid meal on two consecutive days. We measured liver and spleen elasticity, Controlled attenuation parameter (CAP) and portal flow at baseline and after 20, 40, 60, 120 and 180 minutes. Sixty patients participated, 83% with alcoholic liver disease. Twenty-eight patients had METAVIR fibrosis score F0-3 and 32 patients had cirrhosis. Liver stiffness, spleen stiffness and CAP increased after both meals for all stages of fibrosis. False positive 2D-SWE liver stiffness measurements caused 36% and 52% of patients with F0-3 fibrosis to be misclassified with higher stages of fibrosis after the moderate and high caloric meal. Likewise, 10% and 13% of compensated cirrhosis patients were misclassified with clinically significant portal hypertension after the two meals. We observed similar misclassification rates with TE. After three hours, liver stiffness remained elevated more than 20% from baseline in up to 50% of patients. In conclusion: Liver stiffness, spleen stiffness and CAP increase after a meal across all stages of fibrosis and across elastography techniques. Up to half of patients may be misclassified with higher stages of fibrosis, if they are assessed after less than three hours fasting period.

Partial Text

Cirrhosis is the 8th leading cause of life years lost in the United States and are responsible for 1.2 million deaths every year world-wide.[1] Treatment of underlying cause and co-factors might prevent progression and complications; accurate and timely diagnosis of chronic liver disease is therefore of crucial importance. For the diagnosis and staging of chronic liver disease information on the amount of fibrosis, portal hypertension and steatosis, especially in case of alcoholic and non-alcoholic fatty liver disease, are important.

In this study food intake caused up to half of the non-cirrhotic patients to be misclassified with higher stages of fibrosis and 10–14% of cirrhotic patients to be misclassified with clinically significant portal hypertension. Liver stiffness, spleen stiffness and controlled attenuation parameter all increased after a moderate and high calorie meal, assessed with both transient and 2-dimensional shear wave elastography. Liver stiffness remained substantially elevated from baseline in 24–50% of patients three hours after the meal, depending on elastography technique and meal size. We also observed that one in six patients did not peak before 180 minutes, equally distributed among F0-3 fibrosis patients and cirrhosis patients.




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