Biological or relational screening for liver disease?
Authors: P. Couzigou
Journal: Journal of Hepatology (2011)

First-line assessment of patients with chronic liver disease with non-invasive techniques and without recourse to liver biopsyJournal of HepatologyVol. 54Issue 3PreviewIt was initially an error that led me to develop non-invasive biomarkers of liver diseases [1]. After perforating the gallbladder of a friend in 1990, I wished that one day the assessment of patients with chronic liver disease could be carried out rapidly with non-invasive techniques and without the use of a liver biopsy. My first biomarker had no industrial development [2] but the others thereafter had professional developments, such as FibroTest with 500,000 tests prescribed worldwide in the last 7 years [3]. Full-Text PDF Open Access As a member of the “discordantist” family [[1]Castera L. Vergniol J. Foucher J. Le Bail B. Chanteloup E. Haaser M. et al.Prospective comparison of transient elastography, Fibrotest, APRI and liver biopsy for the assessment of fibrosis in chronic hepatitis C.Gastroenterology. 2005; 128: 343-350Abstract Full Text Full Text PDF PubMed Scopus (2095) Google Scholar] I agree with Dr. Poynard’s proposal of non invasive methods as a first line investigation for assessment of liver fibrosis [[2]Poynard T. First line assessment of patients with chronic liver disease with non-invasive techniques and without recourse to liver biopsy.J Hepatol. 2011; 54: 586-587Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar]. However, from a public health and financial point of view, a “sequentialist” attitude in case of liver disease could probably be a more preferable recommendation. Another aspect of Dr. Poynard’s proposal to screen general population for liver fibrosis by using biomarkers is very questionable: It seems more satisfactory to screen, at first line, the etiological factors, than for their liver consequences. As pointed in Dr. Poynard’s study [[3]Poynard T. Lebray P. Ingiliz P. Varaut B. Varsat B. Ngo Y. et al.Prevalence of liver fibrosis and risk factors in a general population using non-invasive biomarkers (Fibrotest).BMC Gastroenterol. 2010; 10: 40Crossref PubMed Scopus (162) Google Scholar], in a general population, almost 9 out of 10 cases of confirmed liver fibrosis can be attributed to metabolic causes (alcohol and more importantly non alcoholic fatty liver disease). Instead of considering new biological tests for screening, it is more important to teach and promote screening, by general practitioners and other first line health professionals, for premature mortality risk factors: overweight, obesity, and sedentarity related metabolic syndrome, at risk or excessive alcohol consumption, and tobacco, without forgetting risk factors for viral hepatitis B and C. Such a screening should be more efficient from a global individual and public health point of view: it is possible to have metabolic syndrome or alcohol excessive intake without confirmed liver fibrosis but (more frequently!) with other somatic complications (especially cardiovascular and/or tumoral diseases). The use of biomarkers without screening for overweight, obesity, sedentarity, at risk or excessive alcohol consumption, tobacco, or viral hepatitis B and C risk factors will be nonsense: if evaluation for confirmed liver fibrosis by biomarkers was positive, screening for these factors would be a secondary necessity. However, in case of confirmed liver fibrosis excluded by biomarkers, it will be necessary to screen for the same risk factors. So what is the interest to test the general population by biomarkers, instead of only screening for suspected liver fibrosis in patients with risk factors? At this state of the discussion, a frequent comment is: “you could be right but after the recognition of risk factors, what do you propose?” suggesting a negative answer. But the same answer is also possible (except in case of cirrhosis) after biomarkers screening for metabolic liver disease! And in fact this comment is wrong: a lot of Evidence Based Medicine (EBM) behavioral and cognitive data has been published, showing significant and durable results in weight loss and physical activity in patients with overweight, obesity, and diabetes. These results have been confirmed recently for patients with non alcoholic steatohepatitis [[4]Bellentani S. Dalle Grave R. Suppini A. Marchesini G. Fatty liver Italian network. Behavior therapy for non alcoholic fatty liver disease, the need for multidisciplinary approach.Hepatology. 2008; 47: 746-754Crossref PubMed Scopus (202) Google Scholar]. It is not the place to develop more extensively this aspect, but just one example: a very recent paper showed a strong association between practitioners saying clearly to the patient the diagnosis of obesity, its importance for health, and the obtention of significant and durable weight loss [[5]Singh S. Somers V.K. Clark M.M. Vickers K. Hensrud D.D. Korenfeld Y. et al.Physician diagnostic of overweight status predict attempted and successful weight loss in patients with cardiovascular disease and central obesity.Am Heart J. 2010; 160: 934-942Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar]. We have to look carefully not only for EBM data about biological and morphological tests, drug, or surgical treatment but also for behavioral and cognitive EBM data. Scientific rigour should not accept fragmentation and only partially taking into account available data. The author declared that he does not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.