Automatic detection of cirrhosis in hospitalized patients: a pragmatic experience Laure Lavaill a , Alain Dussaucy b , Karine Bardonnet c , Nicolas Duraffourg d , Elisabeth Monnet a , Thierry Thévenot a , Siamak Davani e and Vincent Di Martino a ; the DEFI-HOSP Group Background/aim We evaluated the relevance of a systematic automatic detection of cirrhosis using biochemical markers in hospitalized patients. Methods We automatically calculated three free biochemical tests (APRI, Fib-4, and Forns) in patients consecutively hospitalized in our university hospital between July and September, 2010. Patients > 18 years not known to suffer from chronic liver disease, were contacted to undergo liver stiffness measurement (LSM) as a reference diagnostic tool. To limit false positives, we required at least one APRI ≥ 2 (indicating cirrhosis) and Fib-4 >3.25 and/or Forns >6.9, without obvious overestimation. Results A total of 10 035 APRI, 9903 Fib-4, and 1250 Forns were available in 4074 patients. The fibrosis tests were independently influenced by the location of the patient, especially Cardiology (Lower Forns) and Hematology/Oncology Departments (higher APRI, Fib-4, and Forns). Overall, 101 patients (2.48%) were suspected to have cirrhosis. LSM identified two cases of cirrhosis (LSM > 13 kPa). In intent-to-diagnose analyses, the highest positive predictive values of the APRI, Fib-4, and Forns for the diagnosis of cirrhosis were 1.98, 1.98, and 11.76%, respectively. The positive predictive value never exceeded 50% in per-protocol analyses when considering patients with numerous positive results of the fibrosis tests. Conclusion In hospitalized patients, automatic detection of cirrhosis on the basis of APRI, Fib-4, and Forns was inefficient because of too many false-positive results. Eur J Gastroenterol Hepatol 28:74–81 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Introduction The evaluation of liver fibrosis in chronic liver disease is crucial to determine the treatment decisions and the screening for complications. The gold standard for the diagnosis of liver fibrosis is the analysis of a liver biopsy sample, which implies an invasive procedure [1], and is hampered by sampling variability [2], and intraobserver and interobserver variations [3]. In the last decade, non- invasive assessment of liver fibrosis has been developed, on the basis of composite tests using biochemical biomarkers [4–10], and ultrasonic transient elastography (TE) (FibroScan) [11]. The majority of these tools have been validated extensively, particularly in the context of chronic hepatitis C, and has limited the use of liver biopsy in clinical practice. More recently, because liver fibrosis progression is asymptomatic, the question of its screening in patients unknown to suffer from chronic liver disease, with or without risk factors, was raised. These noninvasive tools have thus been used to establish the prevalence of severe hepatic fibrosis in the general population [12,13] or in patients with risk factors of nonalcoholic fatty liver disease [14–16], but no evaluation of these procedures is available to date in hospitalized patients. Hospitalized patients may benefit from a systematic screening of liver fibrosis because the risk factors of chronic liver disease are probably more frequent than in the general population [17]. Moreover, during hospitalization, many routine biochemical tests are performed, which could be easily processed automatically to calculate noninvasive liver fibrosis scores without additional cost. The conditions for an easy-to-perform systematic detection of cirrhosis thus seem to be fulfilled. The aim of this study was therefore to evaluate the relevance of a systematic screening of cirrhosis using three free biochemical tests (APRI, Fib-4, and Forns), auto- matically calculated from routine biochemical tests per- formed in a whole tertiary referral hospital. Patients and methods Study design We carried out a monocentric, experimental intent-to- diagnose study, in two steps (retrospective and pro- spective), in a University hospital (Centre Hospitalier Régional Universitaire, de Besançon) on all patients older than 18 years of age admitted consecutively between 1 July and 30 September 2010. The first step consisted of har- vesting biochemical data and calculating fibrosis tests a Hepatology Department, b Department of Medical Information, c Department of Biochemistry, d Department of informatics and e Department of Clinical Pharmacology, Besançon University Hospital and University of Franche Comté, France DEFI-HOSP (DEpistage de la FIbrose hépatique chez les patients HOSPitalisés) Group: Jean-François Bosset, Gilles Capellier, Jean-Marc Chalopin, Sidney Chocron, Jean-Charles Dalphin, Eric Deconnink, Patrick Garbuio, Bruno Heyd, Bruno Hoen, Stéphane Koch, Nadine Magy-Bertrand, Xavier Pivot, Simon Rinckenbach, Emmanuel Samain, François Schiele, Yves Tropet, Daniel Wendling. Correspondence to Vincent Di Martino, MD, PhD, Hepatology Department, Jean Minjoz Hospital, 3 bld Fleming, 25030 Besançon Cedex, France Tel: + 33 381668421; fax: + 33 381668417; e-mail: vdimartino@chu-besancon.fr Received 29 April 2015 Accepted 23 July 2015 European Journal of Gastroenterology & Hepatology 2016, 28:74–81 Keywords: APRI, cirrhosis, Fib-4, FibroScan, Forns, systematic screening, tertiary referral hospital ’ Original article 0954-691X Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/MEG.0000000000000464 74 Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.