It is a scoring method using the patient's age and relevant lab values to calculate a score. Learn more about cirrhosis here. 3. Not histologically confirmed or unknown if histologically confirmed, Not applicable: Information not collected for this case Nearly every chronic liver condition eventually results in fibrosis, as each condition causes lasting inflammation in the liver. 2023 Healthline Media UK Ltd, Brighton, UK. In the patient cohort in which this formula was first validated, at least 70% patients had values <1.45 or >3.25. For example, an Ishak score of 0 to 4 indicates fibrosis and an Ishak score of 5 or 6 indicates cirrhosis, and then there are finer determinations once cirrhosis occurs. Ultrasound-based technique, Moderately convenient if facility has the equipment Patients with nonalcoholic fatty liver disease (NAFLD) and advanced liver cirrhosis are high risk for progression to end-stage liver disease. The National Institute for Health and Care Excellence (NICE) recommends considering the use of the Enhanced Liver Fibrosis (ELF) test to assess the risk of advanced liver fibrosis in people with suspected non-alcoholic fatty liver disease (NAFLD) [].Later recommendations also suggest using the NAFLD Fibrosis score (NFS) or the Fibrosis 4 score [Newsome, 2018a], [Royal College of General . 2011 Jan;53(1):325-35. Fatality - occurs in less than one in ten thousand biopsies, Prothrombin time 3-5 sec more than control (patients should discontinue anticoagulants at least 1 week prior to biopsy), Use of aspirin or NSAID within previous 7-10 days, Blood for transfusion unavailable or unwilling to accept transfusion in case of bleeding, Suspected hemangioma or other vascular tumor, Inability to identify an appropriate site for biopsy by percussion or ultrasonography, Suspected echinococcal cysts in the liver, Infection in the right pleural cavity or below the right hemidiaphragm, Patients must provide written informed consent, Patients are placed flat in bed and the liver is localized in the right mid-axillary line, Localization of the liver can be performed by percussion/palpation or by ultrasound, Some physicians administer conscious sedation prior to the liver biopsy, The skin over the biopsy site is cleaned with chlorhexadine or another suitable antiseptic and lidocaine is injected to anesthetize the skin and the capsule of the liver, Liver biopsy is performed by quickly inserting and then withdrawing a 15 to 18-gauge needle into the liver. However, research into antifibrotic drugs, which will reduce or prevent the fibrotic process, is ongoing. These initial symptoms can vary, but some of the most common indicators of early cirrhosis include: Some common signs of more advanced cirrhosis include: The best way to treat liver fibrosis is to address the root cause. Once fibrosis is extensive, cirrhosis installs and depending on stage, can also lead to liver failure. Various staging systems for assessment of fibrosis in chronic hepatitis. Treatment tends to involve clearing infections, making lifestyle changes, and taking certain medications. The medical record may show something like FIB-4 = 3.52. Do not code FIB-4 values in this data item. The term cirrhosis is reserved for stage 4 disease. For grading, these assign numbers to the severity of the necroinflammatory features (interface . Ellis, E. L., & Mann, D. A. Liver fibrosis occurs when excessive amounts of scar tissue build up in the liver due to repetitive or long-lasting injury or inflammation. Fibrosis score stated but cannot be assigned to codes 0 or 1 Some of these remedies include: When a person has advanced liver fibrosis or cirrhosis, they often require additional forms of treatment, and liver damage is generally irreversible. This Fibrosis 4 Fib4 score calculator employs the following formula: Fib 4 score = ( Age xAST) / ( Platelet count x ( square root of ALT )). Clinical evidence for the regression of liver fibrosis. [ CLOSE WINDOW] Slide 2. (If this item is required by your standard setter, use of code 8 will result in an edit error. Many scales also measure the extent of fibrosis and the location or number of septa, which are fibrous bands of tissue in the biopsy sample. This website is a service of the National Cancer Institute's Surveillance, Epidemiology, and End Results program and one of several resources for Cancer Registrars. a FIB-4 score <1.45 had a negative predictive value of 90% for advanced fibrosis (Ishak fibrosis score 4-6 which includes early bridging fibrosis to cirrhosis). If multiple biopsies are taken and have conflicting scores, use the results from the biopsy closest to the start of treatment. Although the damage may be limited and reversible when fibrosis is still in an early stage, more advanced fibrosis tends to cause widespread, irreversible damage that eventually leads to cirrhosis. Child Pugh Score Calculator for prognosis of liver disease, Lille Score for Alcoholic Hepatitis Calculator. Major resection was defined as resection of 3 Couinaud segments. The Mean Absolute Difference (MAD) in reference to the Scheuer and Ishak diagnostic staging scores are 0.22 and 1.00, respectively. Copyright 2018 NAACCR, Inc. All Rights Reserved | See NAACCR Partners and Sponsors. Fibrosis was staged with the Ishak scale (ranging from 0 = no fibrosis to 6 = cirrhosis). Some foods and drinks can help protect liver health. . Until recently, liver biopsy was the only technique available to detect and stage the degree of fibrosis. This measurement directly correlates to tissue stiffness. official version of the modified score here. Furthermore, biopsy should only be performed after written informed consent has been obtained. If multiple histologic assessments of the liver (biopsies or resections) are taken and have conflicting scores, record the highest score. official version of the modified score here. Patients with NAFLD should have their fibrosis scores trended over time to evaluate for progression or stabilization. Non-invasive techniques to assess fibrosis refer to any method other than a liver biopsy. Patients with already-decompensated liver disease by clinical or imaging evidence were also excluded. The advantages of APRI are convenience and low cost, since it uses routine laboratory tests. Background Alcohol is the main cause of chronic liver disease. Office of Accountability & Whistleblower Protection, Training - Exposure - Experience (TEE) Tournament, War Related Illness & Injury Study Center, Clinical Trainees (Academic Affiliations). Cookie Preferences. If no further information is available, code 9. Ishak fibrosis score definition. Developing cirrhosis There are several scoring systems for evaluating chronic hepatitis, and they all include 2 components: inflammatory activity and degree of fibrosis. The fibrosis score measures the stiffness of your liver to determine the amount of scarring, with results ranging from F0 to F4. The site does not guarantee the accuracy or authenticity of the information. Your medical provider can calculate your fibrosis score using the findings of your FibroScan test alone or in combination with the results of other tests. Hepatology 2006;43:1317-1325. Disclaimer: The information given by www.pediatriconcall.com is provided by medical and paramedical & Health providers voluntarily for display & is meant only for informational purpose. How are liver function and cholesterol production linked? The most common causes of liver fibrosis in the U.S. are: NAFLD and NASH tend to develop in people with excess weight, diabetes, or prediabetes and high levels of fat and cholesterol circulating in the blood. If no further information is available, code 9. The FIB-4 Index was shown to be superior to 7 other noninvasive markers of fibrosis in patients with NAFLD, including the. Aims To quantify the accuracy of the FIB-4 index in the diagnosis of HBV related fibrosis and . **Note 1:** Physician statement of fibrosis score can be used to code this data item when no other information is available. Batt-Ludwig score 4 Advanced/severe fibrosis People with fibrosis are usually unaware that they have it. The medical record may show something like "FIB-4 = 3.52." Do not code FIB-4 values in this data item. If no further information is available, code 9. Some organizations outside the VA have published recommendations on the preferred test for fibrosis staging. Fibrosis score stated but cannot be assigned to codes 0 or 1 The test has been validated for patients with hepatitis B, [24] hepatitis C [25] and non-alcoholic fatty liver disease. Stiffer livers have faster shear wave propagation. Fibrosis score stated but scoring system not recorded The liver may heal more slowly or quickly, depending on the cause of the fibrosis and its severity. **Note 7:** If a fibrosis score is stated but the scoring system is not recorded, consult with the physician. The choice of fibrosis test should take into account: The history, physical exam, routine laboratory tests, and routine abdominal imaging (ultrasound, CT scan, or MRI) will sometimes reveal clear morphological changes of cirrhosis, but are insufficient for determining other stages of fibrosis. Methods Observational cohort study . MNT is the registered trade mark of Healthline Media. In some chronic liver diseases, such as HCV, ALT levels do not correlate with the amount of liver tissue damage. Attention A T users. An important feature of all non-invasive assessments of liver fibrosis is that the functional parameters of the study are specifically related to the liver disease for which it was developed. The performance was compared with five other unpatented scores using ROC curves. FIB-4 allows for non-invasive liver fibrosis assessment. "Advanced fibrosis" traditionally refers to stages 3 and 4. Veterans Crisis Line: The C-index of using the radiographic TBS to predict the . Test results must be interpreted based on the liver disease. Measurements of the shear wave speed are then taken along the direction of the ultrasound beam. No to moderate fibrosis **Note 4:** AJCC classifies Ishak fibrosis scores 0-4 (none to moderate fibrosis) as F0, and Ishak fibrosis scores 5-6 (cirrhosis/severe fibrosis) as F1. Medical News Today has strict sourcing guidelines and draws only from peer-reviewed studies, academic research institutions, and medical journals and associations. The presence of some other conditions can make the FibroSure less accurate: Gilbert's disease, acute hemolysis, extrahepatic cholestasis, post transplantation state, or renal insufficiency. Unlike healthy liver cells, scar tissue cells cannot self-repair or otherwise function. visit VeteransCrisisLine.net for more resources. It is a scoring method using the patient's age and relevant lab values to calculate a score. Histologic scoring systems for chronic liver disease are used to characterize and predict disease progression, to determine prognosis, to guide treatment strategies, and to provide standards in clinical trials. fibrosis-4 was created to link with Ishak fibrosis rates (by biopsy) and has three levels: 0 - 2 (slight fibrosis) . Cirrhosis can sometimes be diagnosed based on a combination of physical exam, routine laboratory tests, or routine imaging. Funding for this web site content was made possible in part by a contract with Federal funds from the National Cancer Institute, National Institutes of Health and Department of Health & Human Services under Contract number 75N91021D00018 / 75N91021F00001. When to Use Pearls/Pitfalls Why Use Age years BMI kg/m Impaired fasting glucose/diabetes In this article, we will discuss the causes of liver fibrosis, how doctors measure the extent of damage, how symptoms change over time, and the treatments available. Incomplete cirrhosis NAFLD (Non-Alcoholic Fatty Liver Disease) Fibrosis Score - MDCalc Log in to create a list of your favorite calculators! If a person has several risk factors and suspects that they may have liver fibrosis, they should consult a doctor. This information is for an older version of EOD. Patients studied to develop this score were screened for other causes of liver disease and were specifically evaluated closely for concomitant alcohol. The medical record may show something like "FIB-4 = 3.52." Do not code FIB-4 values in this data item. Log in to create a list of your favorite calculators! Importantly, the absence of these findings does not rule out cirrhosis or advanced fibrosis. . U.S. Department of Health and Human Services, Ishak fibrosis score 0-4 Last medically reviewed on April 30, 2019, Hemangiomas of the liver are the most common type of benign liver tumor. Not histologically confirmed or unknown if histologically confirmed, Not applicable: Information not collected for this case Cirrhosis, probable or definite Cirrhosis, probable or definite Background: Chronic hepatitis C (CHC) is associated with hepatic and extrahepatic complications, including cardiovascular disease (CVD). **Note 5:** If a fibrosis score is stated but the scoring system is not recorded, consult with the physician. Batts-Ludwig system is the most widely used scale for assessing grade (amount of necroinflammatory activity) and stage (degree of fibrosis) in chronic hepatitis Essential features Chronic hepatitis: liver fibrosis that occurs as a result of hepatocyte based injury and inflammation, most commonly due to viral or autoimmune hepatitis The PAGE-B score Other common causes of liver fibrosis include: Certain medications can also lead to liver fibrosis, including: Once a doctor finds the root cause of fibrosis, they will suggest a specific course of treatment. Some of the risks include the following: Requirements: If a biopsy is necessary, it should only be performed when the information will be useful for optimal patient care and cannot be obtained in another way. F2: portal fibrosis with infrequent septa, 1: an expansion of some portal areas, possibly with short, fibrous septa, 2: an expansion of most portal areas, possibly with short, fibrous septa, 3: an expansion of portal areas with sporadic portal-to-portal bridging, 4: an expansion of portal areas with significant portal-to-portal and portal-to-central bridging, 5: significant portal-to-portal and portal-to-central bridging with sporadic nodules, reduce overall function, including the purifying of blood, storing of energy, and clearing of infections, discomfort or mild pain in the upper right abdomen, increased sensitivity to medications and their side effects, problems with certain cognitive functions, such as memory, concentration, or sleeping, nonalcoholic steatohepatitis (NASH), a subtype of NAFLD, stopping or limiting alcohol use and using supportive therapies to help with this in the long-term, treating chronic viral hepatitis infections with antiviral medications, treating NAFLD and NASH by balancing the diet, losing at least, taking medications that remove heavy metals, such as iron and copper, from the body, dissolving or removing bile duct obstructions, stopping the use of medications linked with fibrosis, taking medications that reduce the activity of the immune system, taking medications to remove excess fluid from the body, taking medications to remove toxins from the brain, taking medications that reduce pressure in the veins of the stomach and esophagus, having transplantation surgery to replace the damaged liver with a healthy one from a donor. This website is a service of the National Cancer Institute's Surveillance, Epidemiology, and End Results program and one of several resources for Cancer Registrars. Cirrhosis, NOS Hepatology. Aims: We aim to assess the dynamics of Fibrosis-4 (FIB-4) and Atherosclerotic Cardiovascular Disease 2013 (ASCVD) scores up to three years after . To enter and activate the submenu links, hit the down arrow. In HCV infection, advanced fibrosis is defined as either stage 4 to 6 using the Ishak system 10 or stage 3 to 4 using the Meta-analysis of Histological Data in Viral Hepatitis (META-VIR) system. Developing cirrhosis This leads to irreversible damage and may cause conditions such as cirrhosis. **Note 6:** Use code 7 if there is a clinical diagnosis (no microscopic confirmation) of severe fibrosis or cirrhosis. Centers for Disease Control and Prevention Cooperative Agreement (CDC-RFA-PS21-2105), Current Version: nhcvc-master-b20347d6-2023-04-13-235547, Screening and Diagnosis of Hepatitis C Infection, Recommendations for Hepatitis C Screening, Counseling for Prevention of HCV Transmission, Evaluation, Staging, and Monitoring of Chronic Hepatitis C, Initial Evaluation of Persons with Chronic HCV, Counseling Persons with Chronic HCV Infection, Evaluation and Prognosis of Persons with Cirrhosis, Surveillance for Hepatocellular Carcinoma, Extrahepatic Conditions Related to HCV infection, Management of Cirrhosis-Related Complications, Recognition and Management of Spontaneous Bacterial Peritonitis, Screening for Varices and Prevention of Bleeding, Diagnosis and Management of Hepatic Encephalopathy, Evaluation and Preparation for Hepatitis C Treatment, Making a Decision on When to Initiate HCV Therapy, Addressing Structural Barriers to HCV Treatment, Treatment of Chronic Hepatitis C Infection, Monitoring During and After HCV Treatment, Treatment of Key Populations and Unique Situations, Treatment of HCV in Persons with HIV Coinfection, Treatment of HCV in Persons with Renal Impairment, Treatment of HCV in Persons with Cirrhosis, Treatment of HCV in Persons with Substance Use, Treatment of HCV in a Correctional Setting, Management of Health Care Personnel Exposed to HCV, Enter the e-mail address of the recipient, Screening and Diagnosis of Hepatitis C Infection: Overview, Evaluation, Staging, and Monitoring: Self-Study, Evaluation, Staging, and Monitoring of Chronic Hepatitis C: Overview, Management of Cirrhosis-Related Complications: Self-Study, Management of Cirrhosis-Related Complications: Overview, Evaluation and Preparation for Treatment: Self-Study, Evaluation and Preparation for Hepatitis C Treatment: Overview, Treatment of Chronic Hepatitis C Infection: Overview, Treatment of Key Populations and Unique Situations: Self-Study, Treatment of Key Populations and Unique Situations: Overview, University of Washington School of Nursing. Understanding the fibrosis stage impacts clinical care decisions. Procedure: A liver biopsy can usually be safely performed as an outpatient procedure. Transition to cirrhosis **Note 7:** If no score is mentioned, descriptive terms may be used to assign codes 0 and 1 - see specific terms in the table below. No to moderate fibrosis The grade indicates the activity or degree of inflammation while the stage represents the amount of fibrosis or scarring. Non-invasive methods of fibrosis assessment, World Health Organization (WHO) guidelines, American Association for the Study of Liver Diseases (AASLD) guidelines, Call TTY if you Fibrosis regression was defined as at least 1-point decrease in Ishak fibrosis scores. Enter the email address you signed up with and we'll email you a reset link. . The AUROC of the index was 0.765 for differentiation between Ishak stage 0-3 and 4-6. It is a scoring method using the patient's age and relevant lab values to calculate a score. Also, seek medical attention for any symptoms of advanced fibrosis or cirrhosis. Not all patients develop fibrosis and those who do may not progress to advanced stages. In addition to an accurate reproduction of fibrosis staging by human pathologists, the model predicts the overall NASH CRN and Ishak fibrosis scores for each pixel within the image, which enables computation of continuous measures of disease severity summarizing their disease state (Fig. There are four variables taken into account: This is not the same as METAVIR score F0 or F1. While FIB-4 offers an easy and essentially free assessment of liver fibrosis, it is not without limitations. A cutoff of >3.25 had a positive predictive value of 65% and a specificity of 97%. To access the menus on this page please perform the following steps. 1) Martnez SM1, Crespo G, Navasa M, Forns X. Noninvasive assessment of liver fibrosis. Taking the case of a patient aged 34 with a measured AST value of 65 IU/L; an ALT value of 70 IU/L and the platelet count at 67 109/L. Batt-Ludwig score 0-3, Any of the following histologically confirmed An important fact is that . Decreased values indicate that the liver doesnt produce enough clotting factors. Additionally, funding for this web site content was made possible in part by a cooperative agreement with Federal funds from the Centers for Disease Control and Prevention Cooperative Agreement number 5NU58DP006458. However, code 7 when the physician statement of fibrosis score is not based on histologic examination of the liver. Your result may be higher than the normal range if you have liver disease. This information should not be used for the diagnosis or treatment of any health problem or disease. Patients with cirrhosis could also have an unremarkable history and normal physical findings, labs, and imaging. All liver biopsy specimens were imaged by Genesis200 TM . The first score was introduced as the Delta Fibrosis Score (DFS) by Lutterkort et al., in 2017, but this was aimed at detecting advanced fibrosis (Ishak fibrosis 3) ( Lutterkort et al., 2017). non-alcoholic fatty liver disease (NAFLD). Do not code FIB-4 values in this data item. Any clinical event was de- . The FIB-4 Index is a blood-based diagnostic test that looks at underlying fibrosis that can be used as a measure to help determine NAFLD/NASH status. Medical data comprised baseline demographics [race (White, Black, or Other), sex, age at diagnosis (65 years old or >65 years old), year of diagnosis (2010-2011, 2012-2013, or 2014-2015), marital status (married or other), preoperative alpha- fetoprotein (AFP) status (negative/normal or positive/elevated), and fibrosis score (Ishak 0 . The identical test is named differently in Europe, where it is referred to as the FibroTest-ActiTest. U.S. Department of Health and Human Services, Ishak fibrosis score 0-4 Methods of fibrosis assessment that are not yet integrated into practice or are under investigation are not covered here. The major advantage of FibroSure is convenience. Stated in medical record that patient does not have advanced cirrhosis/advanced fibrosis, not histologically confirmed or unknown if histologically confirmed Our understanding of fibrosis regression is evolving and emerging data is encouraging. A pathologist, which is a doctor who specializes in finding the root cause of disease, will then examine the sample under a microscope. Enter the required values to calculate the FIB-4 value. Scientists use genetic rewiring to increase lifespan of cells, Beyond amyloid and tau: New targets in developing dementia treatments, Napping longer than 30 minutes linked to higher risk of obesity and high blood pressure, Activity 'snacks' could lower blood sugar, complication risk in type 1 diabetes. Advanced/severe fibrosis Transition to cirrhosis Long-term clinical follow-up data were used to calculate the slopes (change over time) for autoantibodies, platelet count, Ishak fibrosis score, biopsy copper, and number of portal areas with bile ducts. Cirrhosis, NOS, Clinical statement of advanced/severe fibrosis or cirrhosis, AND Other patients develop fibrosis within a short period of time and progress quickly, sometimes developing cirrhosis within less than 20 years. If inflammation continues, possibly because a person has not received treatment, liver fibrosis can develop into more serious liver conditions. Batt-Ludwig score 0-3, Ishak fibrosis score 5-6 **Note 6:** If no score is mentioned, descriptive terms may be used to assign codes 0 and 1 - see specific terms in the table below. Log in NAFLD (Non-Alcoholic Fatty Liver Disease) Fibrosis Score Estimates amount of scarring in the liver based on several laboratory tests. (n.d.). SHG/TPEF imaging for establishment of qFibrosis. Information collected after the start of treatment may not be used to code this data item. It can also be used to detect the stage of fibrosis, as well as monitor response to NAFLD treatment. APRI is also an ultrasound-based method that measures shear wave speeds, producing similarly accurate and rapid results. Code the absence (code 0) or presence (code 1) of fibrosis as documented in the pathology report. All serum biomarkers, except AAR, were weakly or moderately correlated with liver biopsy results (ISHAK fibrosis score). The medical record may show something like "FIB-4 = 3.52." This information is not intended to replace clinical judgement or guide individual patient care in any manner. Commonly used scoring systems are the Knodell score/Histological Activity Index (HAI), the METAVIR score, and the Ishak score (modified Knodell score). The Ishak system [23] is also known as the modified Knodell or modified histology activity index (HAI) score. No to moderate fibrosis If a doctor believes that someone has liver fibrosis, they will carefully collect a small tissue sample, or biopsy, from the liver using a large needle. Inter- and intraobserver variability - the assessment by the pathologist may be subject to differences in interpretation, leading to differences in assessment. Elimination of the damaging element often improves inflammation and allows for remodeling of the fibrosis. We compared rates of prespecified clinical outcomes of hepatic decompensation and hepatocellular carcinoma across individual Ishak fibrosis stages. Background Liver fibrosis stage is an important factor in determining prognosis and need for treatment in patients infected with hepatitis B virus (HBV). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NCI and CDC. The scarring is called fibrosis. Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a healthcare professional. Beyond conventional medications, research shows that a few natural remedies may help reduce fibrosis in certain circumstances. Fibrosis Score not assessed or unknown if assessed. Liver biopsy also comes with substantial morbidity. In terms of accuracy, it is most reliable for excluding or confirming cirrhosis but is less reliable for the intermediate fibrosis scores. Sterling RK, Lissen E, Clumeck N, et. 11. Periportal or periseptal interface hepatitis (piecemeal necrosis), Focal (spotty) lytic necrosis, apoptosis and focal inflammation. For diagnosing significant fibrosis (F2), it has an estimated sensitivity of 70 percent and an estimated specificity of 84 percent. The MELD utilizes log scale calculations and thus any value less than 1 is automatically given a lower limit value of 1 to prevent generating a negative score. In O'Brien et al. Biopsy fragmentation and length as well as number of portal tracts were recorded. Ishak uses a scale of 0-6 with 6 indicating cirrhosis. This scale runs from 0 to 4: Using the BattsLudwig scale, the most advanced stage of fibrosis a person can have before developing cirrhosis is stage 3. FIB-4 was developed to correlate with Ishak levels of fibrosis (by biopsy) with 3 levels: While liver biopsy is the gold standard for the diagnosis of liver fibrosis, it is not ideal; biopsy only evaluates a minute portion of the liver itself, so sampling errors can occur. There are four criteria to be followed in the model as explained below: Age There is a correlation between age increase and the progression of fibrosis in the liver, especially in the case of hepatitis C and chronic alcohol consumption but the biological mechanism behind is yet to be established. If you are in crisis or having thoughts of suicide, If you want to skip this dialog please Always allow popup windows for the online course. Some patients progress slowly for 20 years and then accelerate in later years. The first is a comment on etiology. NASH - Nonalcoholic steatohepatitis is similar to alcoholic liver disease but occurs in patients who consume little to no alcohol and is due to fatty deposits in the liver, inflammation and fibrosis. Normal liver (stage 0) has very little fibrous tissue in the portal areas (dark circles) and the walls of central veins (open circles). Risks: Liver biopsy carries a small risk of complications. Chronic hepatitis C (CHC) and non-alcoholic fatty liver disease (NAFLD) are also amongst the causes. Fibrosis Score not assessed or unknown if assessed. Commonly used scoring systems are the Knodell score/Histological Activity Index (HAI), the METAVIR score, and the Ishak score (modified Knodell score). The Enhanced Liver Fibrosis (ELF) test is a serological biomarker for fibrosis staging in chronic liver disease, however its utility in alcohol-related liver disease warrants further validation. At a cutoff of <1.45 in the validation set, the negative predictive value to exclude advanced fibrosis (stage 4-6) was 90% with a sensitivity of 70%. These are real scientific discoveries about the nature of the human body, which can be invaluable to physicians taking care of patients. Acoustic Radiation Force Impulse (ARFI) is an alternative to transient elastography. Do all patients with liver disease need to have fibrosis testing?