The clinical usefulness of elastography in the evaluation of nonalcoholic fatty liver disease patients: A biopsy-controlled study Samar K. Darweesh, Heba Omar, Eman Medhat, Rasha A. Abd-Al Aziz, Hedy Ayman, Yasmin Saad and Ayman Yosry Background We aimed at determination of the usefulness of elastography [acoustic radiation force impulse (ARFI) and FibroScan] for evaluation of nonalcoholic fatty liver disease (NAFLD) patients. Patients and methods A prospective cross-sectional study included 60 biopsy-proven NAFLD patients (mean age: 45 years) was carried out. All patients were subjected to lab works, liver biopsy, and measurement of liver stiffness by ARFI and FibroScan and steatosis by controlled attenuation parameter (CAP). CAP measurements were adjusted for the presence of NAFLD and presence or absence of diabetes and according to BMI. Results Linear regression analysis showed that CAP is an independent predictor for significant hepatic steatosis (P < 0.001). No significant difference was found in diagnostic accuracy between adjusted and nonadjusted CAP values for diagnosis of mild ( > S1) or significant ( > S2) hepatic steatosis (P =0.17 and 0.29 respectively). The median ARFI velocities for F1, F2, F3, and F4 were 0.92, 1.08, 1.07, and 2.58 m/s, respectively. Although there was an overall significant increase in ARFI values across the fibrosis grades (P < 0.04), the difference in ARFI values was only significant between fibrosis grades F1 and F4 (P = 0.02). Conclusion Elastography is a promising noninvasive tool for diagnosis and grading of hepatic steatosis and fibrosis in patients with NAFLD/nonalcoholic steatohepatitis with good sensitivity and specificity, especially in moderate to marked grades. Eur J Gastroenterol Hepatol 31:1010–1016 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. Introduction Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of liver disease worldwide. It can potentially progress to advanced liver disease, cirrhosis, and hepatocellular carcinoma even in patients without liver cirrhosis. Moreover, it has been recognized as an important cause of cryptogenic liver cirrhosis [1] and it is considered the second leading indication for liver trans- plantation in the USA after chronic hepatitis C [2]. At present, the global prevalence of NAFLD is esti- mated to be 24% [3] and it is highly expected that NAFLD will emerge as the leading cause of end-stage liver disease in the coming few decades. The new epidemic in chronic liver disease related to the burden of NAFLD paralleling the worldwide increase of obesity, although some NAFLD patients are lean ‘Lean NAFLD’ [4]. The classical reference standard for diagnosing and staging NAFLD and assessing fibrosis is a liver biopsy. However, liver biopsy is an invasive procedure with a small but real risk of complications and many drawbacks (e.g. sampling errors and subjective interpretation) [5]. In an attempt to overcome the drawbacks of liver biopsy, several noninvasive modalities for evaluation of hepatic steatosis and fibrosis have been studied in the last decades. Controlled attenuation parameter (CAP) is real-time, noninvasive, inexpensive physical parameter based on the properties of ultrasonic signals obtained by FibroScan. It can be utilized for steatosis identification and quantifica- tion. Even more, it can be performed, simultaneously to liver stiffness (LS) measurement in the same liver volume making it conceivable to, at the same time, assess both fibrosis, and steatosis. Several recent studies had confirmed the usefulness of CAP in the detection and quantification of hepatic steatosis [6–12] including large meta-analysis that discussed factors significantly associated with elevated CAP and determined well-defined cutoffs for CAP in hepatic steatosis grading [12]. Similarly, accurate determination of the presence and extent of liver fibrosis is essential for prognosis and for treatment planning in NAFLD patients. Acoustic radiation force impulse (ARFI) imaging is a newly-developed elas- tography technique integrated into a conventional ultra- sound machine and can be performed with ultrasound probes during an abdominal ultrasound examination. The aim of the current study was to evaluate the clinical usefulness of elastography (FibroScan and ARFI) for fibrosis staging and steatosis grading in Egyptian cohort of NAFLD patients, aiming finally to replace liver biopsy by these noninvasive methods. Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt Correspondence to Heba Omar, MD, GCSRT, Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo 11652, Egypt Tel: + 20 100 703 2146; e-mail: hebaomar1202@hotmail.com Received 4 November 2018 Accepted 3 December 2018 European Journal of Gastroenterology & Hepatology 2019, 31:1010–1016 Keywords: acoustic radiation force impulse, controlled attenuation parameter/FibroScan, elastography, fibrosis, nonalcoholic fatty liver disease/nonalcoholic steatohepatitis, noninvasive, steatosis ’ Original article 0954-691X Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/MEG.0000000000001365 1010 Copyright r 2019 Wolters Kluwer Health, Inc. All rights reserved.