11 WORLD GASTROENTEROLOGY NEWS JANUARY 2016 Gastro 2015: AGW-WGO | Expert Point of View | Gastro 2016: EGHS-WGO | WDHD News | WGO & WGOF News | WGO Global Guidelines | Calendar of Events directed towards finding the optimal therapy for NAFLD and NASH, but still there is no universal proto-col to treat this growing problem. Cardiovascular risk factors are highly prevalent among NASH patients and general lifestyle interventions includ-ing dietary changes and increased physical activity remain the backbone of treatment regimens for the NASH patients.10 In the absence of approved treatment modalities for NAFLD/ NASH, care should be taken on the detection of advanced fibrosis. NASH is the major predictor of advanced fibrosis. Liver biopsy is still consid-ered the gold standard to distinguish NASH from simple steatosis. How-ever, because of its invasive nature, non-invasive diagnostic modalities are rapidly evolving for identifying high-risk patients who should undergo liver biopsy. Another complicating factor is that liver enzyme levels (mainly serum alanine aminotransferase and γ-glutamyltransferase) are within normal limits in more than half of patients with NAFLD.6, 11 Gastroen-terologists and hepatologists are thus left with more questions than answers when it comes to deciding which pa-tients with NAFLD need a liver biop-sy. 6 Accordingly to the current guide-lines from the American Association for the Study of Liver Diseases, liver biopsy should be considered in all patients with NAFLD, who are at an increased risk of NASH and advanced fibrosis.12 Patients with NAFLD who have coexisting MS or T2DM are at higher risk of developing NASH and advanced fibrosis as well as at an increased risk of liver-related mor-bidity and mortality.6, 12 Therefore, development of some non-invasive method that will help us to identify high-risk NAFLD patients that have a truly need for liver biopsy is of great importance. Recently, a novel physi-cal parameter based on the proper-ties of ultrasonic signals acquired by the transient elastography (TE; FibroScan®) has been developed. This novel parameter, named Controlled Attenuation Parameter (CAP), can be used for steatosis detection and quantification. Also, CAP can be performed simultaneously with liver stiffness measurement (LSM) on the same measured liver volume, making possible for the simultaneous evaluation of both fibrosis and steatosis, consequently enhancing the spectrum of non-invasive methods for the detection and follow-up of patients with NAFLD. With the development of the new XL probe the obese patients can now be as-sessed accurately for liver steatosis and fibrosis using the FibroScan®.13, 14 In our Center we have started to use CAP and LSM in patients with suspected NAFLD three years ago. TE with CAP is non-invasive, accurate, reproducible, convenient, and useful for serial measurement in patients with various CLD. Despite the increasing popularity and reliability of LSM and CAP measurements using TE to assess the degree of liver fibrosis and steatosis in subjects with various CLD, there are still little data regarding the association of CAP and LSM measurements in population of Western patients with one or more components of the MS. However, according to recent inves-tigations and to our unpublished data, CAP is closely related to MS com-ponents and has a good correlation with liver biopsy findings.14, 15 In the study performed by Kwok et al 15 in which diabetic patients were screened for NAFLD using TE-CAP the prevalence of increased CAP and LSM were 72.8% and 17.7%, respectively. Ninety-four of their patients (80% had increased LSM) underwent liver biopsy: 56% had steatohepatitis and 50% had fibrosis grade 3-4 disease. Regarding the preliminary observa-tions that CAP and LSM have a good correlation with MS components and liver biopsy findings, the presence of MS with high CAP values, and espe-cially with elevated LSM may be used for identifying patients who are at risk for developing NASH and advanced fibrosis and consequently that have a need for a liver biopsy. Because CAP and LSM are quanti-tative methods, it can be hypothesized that we will be able to follow patients with NAFLD. TE with CAP could be a reasonable initial assessment for patients with suspected NAFLD, especially in those with one or more components of MS. Further stud-ies for this implications are urgently needed. References 1. McPherson S, Hardy T, Hender-son E, Burt AD, Day CP, Anstee QM. Evidence of NAFLD pro-gression from steatosis to fibros-ing- steatohepatitis using paired biopsies: implications for prog-nosis and clinical management. J Hepatol. 2015;62:1148-1155. 2. Rinella ME. Nonalcoholic fatty liver disease: a systematic review. JAMA. 2015;313:2263-2273. 3. Armstrong MJ, Adams LA, Canbay A, Syn WK. Extrahepatic complications of nonalcoholic fatty liver disease. Hepatology. 2014;59:1174-1197. 4. You SC, Kim KJ, Kim SU, Kim BK, Park JY, Kim do Y, et al. Factors associated with signifi-cant liver fibrosis assessed using transient elastography in general population. World J Gastroenterol. 2015;21:1158-1166. 5. Pais R, Charlotte F, Fedchuk L, Bedossa P, Lebray P, Poynard T, et al. A systematic review of follow-up biopsies reveals disease progres-sion in patients with non-alcoholic fatty liver. J Hepatol 2013;59:550– 556.
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