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SOUND JUDGMENT SERIES
Shear Wave Elastography for
Evaluation of Liver Fibrosis
Giovanna Ferraioli, MD, Parth Parekh, MD, Alexander B. Levitov, MD, RDCS, Carlo Filice, MD
Invited paper
The Sound Judgment Series consists of
invited articles highlighting the clinical value
of using ultrasound first in specific clinical
diagnoses where ultrasound has shown com-
parative or superior value. The series is meant
to serve as an educational tool for medical
and sonography students and clinical prac-
titioners and may help integrate ultrasound
into clinical practice.
Received August 19, 2013, from the Ultrasound
Unit, Department of Infectious Diseases, Fondazione
Istituto di Ricovero e Cura a Carattere Scientifico
Policlinico San Matteo, University of Pavia
Medical School, Pavia, Italy (G.F., C.F.); and
Division of Pulmonary and Critical Care
Medicine, Department of Internal Medicine,
Eastern Virginia Medical School, Norfolk,
Virginia USA (P.P., A.B.L.). Revision requested
September 3, 2013. Revised manuscript accepted
for publication September 11, 2013.
Drs Ferraioli and Filice received a research
grant from Philips Healthcare (Bothell, WA).
Address correspondence to Giovanna
Ferraioli, MD, Ultrasound Unit, Department of
Infectious Diseases, Fondazione Istituto di
Ricovero e Cura a Carattere Scientifico Policlinico
San Matteo, University of Pavia Medical School,
Via Taramelli 5, 27100 Pavia, Italy.
E-mail: giovanna.ferraioli@unipv.it
Abbreviations
SWE, ShearWave Elastography; VTTQ,
Virtual Touch Tissue Quantification
doi:10.7863/ultra.33.2.197
©2014 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2014; 33:197–203 | 0278-4297 | www.aium.org
The prognosis and management of chronic viral hepatitis mainly depend on the extent
of liver fibrosis, particularly in chronic hepatitis C. Liver histologic analysis is still con-
sidered the reference standard in the assessment of liver fibrosis despite the interob-
server and interobserver variability in staging and some morbidity and mortality risks.
Thus, noninvasive methods for assessing liver fibrosis are of great clinical interest. In
the last decade, ultrasound-based techniques to estimate the stage of liver fibrosis have
become commercially available. They all have the capability to noninvasively evaluate
differences in the elastic properties of soft tissues by measuring tissue behavior when a
mechanical stress is applied. Shear wave elastography relies on the generation of shear
waves determined by the displacement of tissues induced by the force of a focused ultra-
sound beam or by an external push. This article reviews the results that have been
obtained with shear wave elastography for assessment of liver fibrosis.
Key Words—chronic hepatitis; elastography; fibrosis; gastrointestinal ultrasound; liver;
ultrasound
I t is estimated that 500 million people are affected by chronic
viral hepatitis worldwide, of which 1 million people will die of
their illness every year, primarily from cirrhosis or hepato-
cellular carcinoma as a result of their infection.1 In the United States,
more than 4 million people have this disease, with an annual mor-
tality rate of 15,000 people.2 The prognosis and management of
chronic viral hepatitis mainly depend on the extent of liver fibrosis,
particularly in chronic hepatitis C. Long thought to be irreversible,
recent studies have shown this idea to be false, even in its advanced
stages, thus stressing the importance of early diagnosis.3
Liver histologic analysis is still considered the reference stan-
dard in the assessment of liver fibrosis despite the intraobserver and
interobserver variability in staging.4 Regev et al4 found approxi-
mately 25% of patients (30 of 124) to have a difference of at least
one grade and 33% (41 of 124) to have at least one stage difference
between the right and left lobes. Ultimately, Regev et al4 found an
underdiagnosis of cirrhosis in approximately 15% of patients. More-
over, liver biopsy is a painful technique that is not well accepted by
patients, has morbidity and mortality risks, and is not an ideal
method for following patients.
Thus, noninvasive methods for assessing liver fibrosis are of
great clinical interest. In the last decade, techniques to noninvasively
estimate the stage of liver fibrosis have become commercially avail-
able. They all have the capability to evaluate differences in the elas-
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Ferraioli et al—Shear Wave Elastography for Evaluation of Liver Fibrosis
tic properties of soft tissues by measuring tissue behavior
when a mechanical stress is applied. Ultrasound and mag-
netic resonance have been used for elasticity imaging.
Magnetic resonance elastography, even though promis-
ing, has some disadvantages. It cannot be performed in a
liver with an iron overload because of signal-to-noise lim-
itations, the examination time is longer with respect to
ultrasound elastography, and it is a costly procedure.5
Shear wave elastography relies on the generation of
shear waves determined by the displacement of tissues
induced by the force of a focused ultrasound beam or by
external pressure. The shear waves are lateral waves, with
a motion perpendicular to the direction of the force that
has generated them. They travel slowly (between 1 and 10
m/s) and are rapidly attenuated by tissue. The propaga-
tion velocity of the shear waves correlates with the elastic-
ity of tissue; ie, it increases with increasing stiffness of the
liver parenchyma.6
To correctly read the results, it should be kept in mind
that elastography assesses liver elasticity that could be
modified by factors other than fibrosis, such as edema,
inflammation, extrahepatic cholestasis, and congestion.7–10
In fact, these factors may lead to overestimation of the liver
stiffness for a sharp enlargement of the liver, which is cov-
ered by the Glisson capsule, a poor distensible envelope.
Thus, the results obtained should always be interpreted in
clinical settings. Examinations should be performed under
fasting conditions because it has been demonstrated that
food intake may produce false-positive results.11,12
Transient Elastography
The pioneer technique has been transient elastography,
which is performed with the FibroScan device (Echosens,
Paris, France). A single-element ultrasound transducer
operating at 5 MHz is built on the axis of a pistonlike vibra-
tor.13 By pushing a button, low-frequency (50 Hz) tran-
sient vibrations are transmitted, and the elastic shear waves
that are generated propagate through underlying tissues.
Pulse-echo ultrasound acquisitions are used to follow the
propagation of the shear wave and to measure its veloc-
ity.13 Transient elastography measures liver stiffness in a
volume that approximates a cylinder 1 cm wide and 4 cm
long between 25 and 65 mm below the skin surface. This
volume is at least 100 times bigger than a biopsy sample
and is therefore far more representative of the liver
parenchyma.14 Transient elastography is performed on a
patient lying supine with the right arm elevated to facilitate
access to the right liver. The tip of the probe contacts the
intercostal skin with coupling gel. The operator, assisted
198
by a time-motion image, locates a liver portion at least 6
cm deep and free of large vascular structures (Figure 1).
The device gives an estimate of the velocity of shear waves,
which can be also expressed in kilopascals through the
Young modulus: E = 3 (vs · ρ), where E is the Young mod-
ulus, vs is the shear wave velocity, and ρ is the density of tis-
sue, assumed to be the same as water.
The software of the device determines whether each
measurement is successful. When a shot is unsuccessful,
the machine does not give any value. The entire procedure
is considered to have failed when no value is obtained after
10 shots. Successful measurements are validated by these
criteria: (1) 10 valid shots; (2) a ratio of valid shots to the
total number of shots of 60% or higher; and (3) variability
of measurements less than 30% of the median value of liver
stiffness measurements.15 Transient elastography has excel-
lent intraobserver and interobserver reproducibility, with
an intraclass correlation coefficient of 0.98 even though the
interobserver agreement decreases in patients with a lower
degree of liver fibrosis, with liver steatosis, or with an
increased body mass index.16 In healthy blood donors, a
mean normal liver stiffness ± SD of 4.9 ± 1.7 kPa (1.28 ±
0.75 m/s) has been found.16 Several studies and meta-
analyses13–25 have examined the diagnostic performance of
transient elastography in staging liver fibrosis in patients
with different etiologies of chronic liver disease. Most of the
studies have been conducted in patients with chronic hep-
atitis C and have shown high diagnostic accuracy of tran-
sient elastography in staging liver fibrosis. It should be
pointed out, however, that a substantial overlap of liver stiff-
ness values between adjacent stages of liver fibrosis, partic-
Figure 1. Shear wave elastography with the FibroScan device: A, TM-
mode image; B, A-mode image; C, elastographic image. TM-mode and
A-mode images are used to locate a liver portion suitable for the meas-
urement. The slope of the white dotted line in C, which represents shear
wave velocity, is a function of the fibrosis stage.
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Ferraioli et al—Shear Wave Elastography for Evaluation of Liver Fibrosis

ularly for lower fibrosis stages, has been observed. Transient
elastography more accurately detects cirrhosis than signif-
icant fibrosis. Several meta-analyses have confirmed that
transient elastography appears to be a reliable method for
the diagnosis and exclusion of cirrhosis as opposed to pre-
dicting cirrhosis. For the diagnosis of cirrhosis, transient
elastographic cutoff values have been found to be between
11.8 and 14.6 kPa (1.98 and 2.21 m/s). In clinical practice,
liver stiffness values from 2.5 to 7.0 kPa (0.91–1.53 m/s)
indicate mild or no fibrosis, and values greater than 12.5 kPa
(2.04 m/s) are suggestive of cirrhosis.17
The European Association for the Study of the Liver
has indicated that noninvasive methods can now be used
instead of liver biopsy in patients with chronic hepatitis C
to assess liver disease severity before therapy at a safe level
of predictability.26
Transient elastography cannot technically be per-
formed in patients with ascites and has a high rate of failure
in patients with body mass indices greater than 30 kg/m2.
The recent availability of the FibroScan XL probe has over-
come this latter limitation.
of liver stiffness at a single location is obtained (Figures 2
and 3). They have been categorized as point–shear wave
elastography.27 The SWE technique is based on an ultrafast
ultrasound imaging approach that allows detailed moni-
toring of the shear waves in a large area of liver parenchyma
with real-time color-coded elasticity imaging inside a sam-
ple box, and the measurement is obtained by placing a
region of interest inside the sample box (Figure 4). This
technique is 2-dimensional elastography.27
In all of the studies that have assessed the accuracy of
the different devices in staging liver fibrosis, right inter-
costal access has been used. The patient is examined in the
dorsal decubitus position with the right arm elevated above
the head for optimal intercostal access in a resting respira-
Figure 2. Shear wave elastography of the liver performed with the
Siemens system through intercostal access. The measurement is given
in meters per seconds.

Elastographic Techniques Based on Shear

Waves Generated by the Acoustic Beam

These techniques have the advantage of being integrated

into ultrasound systems; thus, conventional sonography,
which is advised every 6 to 12 months in patients with
chronic liver disease, could also be performed. As of today,
for the assessment of liver stiffness, these techniques are
commercially available in high-end ultrasound systems
made by Philips Healthcare (Bothell, WA; ElastPQ),
Siemens Medical Solutions (Mountain View, CA; Virtual
Touch Tissue Quantification [VTTQ]), and SuperSonic Figure 3. Shear wave elastography of the liver performed with the Philips
system through intercostal access. The measurement is shown in kilo-
Imagine, SA (Aix-en-Provence, France; ShearWave
pascals. In the bottom left corner, a scale shows the stiffness degree.
Elastography [SWE]). These techniques generate shear
waves inside the liver by using radiation force from a focused
ultrasound beam. The shear waves are generated near the
region of interest in the liver parenchyma and not on the sur-
face of the body, as happens with external vibration devices.
The ultrasound system monitors shear wave propagation
using a Doppler-like ultrasound technique and measures its
velocity. The shear wave velocity is displayed in meters per
second or kilopascals through the Young modulus. Unlike
transient elastography, the measurements are not limited by
the presence of ascites because the ultrasound beam, which
generates the shear waves, propagates through fluids.
With the VTTQ and ElastPQ techniques, the read-
ings of the shear wave speed are made by using a small sam-
ple box (usually 0.5 × 1 cm); thus, a quantitative estimate

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Ferraioli et al—Shear Wave Elastography for Evaluation of Liver Fibrosis
tory position. Measurements are performed at least 1.5 to
2.0 cm beneath the Glisson capsule to avoid reverberation
artifacts. In case of physical conditions affecting the signal-
to-noise ratio, the Philips and Siemens devices do not give
any measurement. With the SuperSonic Imagine device, a
measurement fails when no/little signals are obtained in
the sample box for all of the acquisitions.
Siemens Technique (VTTQ)
The first one available was the Siemens technique, which
is commonly referred to as acoustic radiation force impulse
in the literature, which is technically the same force that
generates shear waves for all 3 available techniques.27
Moreover, the term acoustic radiation force impulse is rather
generic and does not identify shear wave–based methods.
In fact, acoustic radiation force impulse push pulses are also
used in strain imaging of other organs, such as the breast
and thyroid. In recent years, the diagnostic accuracy of the
VTTQ technology for quantification of liver stiffness,
mainly in patients with chronic hepatitis C, has been
investigated in several studies and a meta-analysis.28–34
The technology has shown high interobserver agreement,
with an intraclass correlation coefficient of 0.86.35 Opera-
tor training does not seem to be required.28 The cutoff val-
ues obtained in a large meta-analysis were 1.34, 1.55, and
1.80 m/s for significant fibrosis (METAVIR fibrosis score
of F2 or greater), severe fibrosis (METAVIR fibrosis
score of F3 or greater), and cirrhosis (METAVIR fibrosis
score of F4), respectively.34 In this meta-analysis, which
included patients with several etiologies of chronic liver
Figure 4. Shear wave elastography of the liver performed with the Super-
Sonic Imagine system through intercostal access. The shade of blue in
the box is related to the speed of the shear waves. The velocity range (in
kilopascals) is shown in the vertical bar on the right: the colors go from
dark blue (soft tissues) to red (hard tissues).
200
disease, the diagnostic accuracy was comparable with that
of transient elastography for the assessment of severe fibro-
sis, whereas higher performance of transient elastography
was seen for significant fibrosis and liver cirrhosis. In a
study by Rizzo et al,33 the technique was significantly more
accurate than transient elastography for diagnosing signif-
icant and severe fibrosis, whereas this difference was only
marginal for cirrhosis.
SuperSonic Imagine Technique (SWE)
The reproducibility of the SWE method is very high, with
intraobserver intraclass correlation coefficients of 0.95 and
0.93 for an expert and a novice operator, respectively, and
interobserver agreement of 0.88.36 As for conventional
sonography, it is user dependent; thus, it is recommended
that at least 50 supervised scans and measurements should
be performed by a novice operator to obtain consistent
measurements. Values obtained in a small series of healthy
participants ranged from 4.92 kPa (1.28 m/s) to 5.39 kPa
(1.34 m/s).36
In a pilot study conducted on 121 patients with
chronic hepatitis C undergoing liver biopsy, the optimal
cutoff values were 7.1 kPa (1.54 m/s) for significant fibro-
sis (METAVIR fibrosis score of F2 or greater), 8.7 kPa
(1.70 m/s) for advanced fibrosis (METAVIR fibrosis
score of F3 or greater), and 10.4 kPa (1.86 m/s) for
cirrhosis (METAVIR fibrosis score of F4), and the
technique was more accurate than transient elastography
in assessing significant fibrosis.37 In another study, with
respect to transient elastography, the technique showed
higher accuracy in assessing mild and intermediate stages
of fibrosis.38
Philips Technique (ElastPQ)
The ElastPQ technique was the most recent to enter the
market; thus, only a few studies have been published so far.
With this technique, liver stiffness values in healthy volun-
teers have been reported to be less than 4.0 kPa (1.15
m/s).39,40 Ling et al39 found that men had higher values
than women (3.8 ± 0.7 versus 3.5 ± 0.4 kPa, or 1.13 ± 0.48
versus 1.08 ± 0.37 m/s) and liver stiffness was comparable
with different probe positions, examiners, and age groups.
In a series that comprised 88 patients with chronic viral
hepatitis and 33 healthy volunteers, the technique com-
pared favorably with transient elastography in staging liver
fibrosis, and healthy volunteers showed significantly lower
values than patients with nonsignificant fibrosis.40
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Ferraioli et al—Shear Wave Elastography for Evaluation of Liver Fibrosis
Limitations and Pitfalls
Working on phantoms, the Quantitative Imaging Bio-
marker Alliance created by the Radiological Society of
North America has shown that a limitation of the tech-
nique is that there is a statistically significant difference in
the shear wave velocity estimates among systems and with
depth into the phantom, which was shown with all imaging
systems, whereas no statistically significant differences
were found among appraisers using the same or equivalent
systems.41 Because most studies have been conducted in
patients with chronic hepatitis C, the cutoffs need to be
further validated for other etiologies of diffuse liver disease.
In acute hepatitis, values could be very high even in
the absence of fibrosis, and there is a progressive normal-
ization of stiffness values in parallel with the decrease in
aminotransferase levels. In a study by Coco et al,8 the val-
ues of liver stiffness assessed by transient elastography were
correlated with aminotransferase levels at the onset of
acute viral hepatitis, when the presence of tissue inflam-
mation and edema is likely to be maximal.
In patients with congestive heart failure, it has been
shown that liver stiffness directly depends on venous pres-
sure. The stiffness increase could be due to the congestion
of the liver with dilatation of both venae cavae and hepatic
veins that causes enlargement of the liver, which is
enveloped by the Glisson capsule.9 Moreover, it has been
reported that cholestasis represents a confounding factor in
liver stiffness measurement.10
Transient elastography cannot be performed in
patients with ascites. Failure to obtain any measurement
with transient elastography has been observed in 4% of
examinations, and unreliable results were obtained in 17%;
Figure 5. Images from 43-year-old man infected with chronic hepatitis C for 20 years. Shear wave elastography of the liver performed with the Philips
system (A) and the SuperSonic Imagine system (B) show advanced fibrosis.
A B
J Ultrasound Med 2014; 33:197–203
both were associated with obesity or limited operator expe-
rience.42 Measurement failure with elastographic tech-
niques based on shear waves generated by the acoustic
beam has been reported in less than 3% of patients.34–37
Clinical Cases
Case 1
A 43-year-old man has been infected with chronic hepatitis
C for 20 years. He has had transiently elevated serum
aminotransferase levels in the past but has had normal val-
ues at follow-up for 2 years. To start an antiviral treatment,
he has been scheduled for liver biopsy by the referring
physician. Biochemical test results obtained the day before
liver biopsy are within the normal range. Two shear wave
elastographic techniques are performed on the same day as
liver biopsy (Figure 5). The results of the noninvasive meth-
ods are discordant with that of liver biopsy. In fact, both tech-
niques give values of advanced fibrosis, whereas liver
histologic analysis shows METAVIR stage F1 (nonsignifi-
cant fibrosis). On the basis of the concordance between the
two noninvasive methods the physician has decided to start
antiviral therapy, and the patient is now receiving treatment.
Considering that liver biopsy is not a perfect reference
standard, these different results could be due to a failure of
liver biopsy in correctly assessing liver fibrosis and could
be explained by the uneven distribution of fibrosis. In fact,
histologic staging is based on a biopsy specimen that rep-
resents at most 1/50,000 of the total liver mass. In this
regard, the sample size of elastographic techniques is more
representative of liver tissue than a liver biopsy specimen,
and the evaluation could be done in several areas of the
liver parenchyma. On the other hand, even when an expe-
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Ferraioli et al—Shear Wave Elastography for Evaluation of Liver Fibrosis
rienced physician performs a liver biopsy and an expert
pathologist interprets the results, liver biopsy has a sam-
pling error in diffuse liver disease staging.4,43
Case 2
A 57-year-old woman has been infected with chronic hep-
atitis C for 28 years. Biochemical test results are within the
normal range. She has had follow-up with sonography
every 6 months. Sonographic findings are normal, whereas
elastography gives a value compatible with liver cirrhosis
(Figure 6), which is confirmed by a liver biopsy performed
3 weeks later.
Sonography is a noninvasive and inexpensive proce-
dure for diagnosis of diffuse liver disease; however, the
value of sonography for distinguishing a low degree of liver
fibrosis from cirrhosis is limited. In a study by Colli et al,44
28 of 107 patients with severe fibrosis or definite cirrhosis
(26%) had negative results for liver surface nodularity and
caudate lobe hypertrophy and had normal hepatic venous
flow. In this regard, elastography integrated into ultrasound
systems is an effective adjunctive tool for quantifying liver
fibrosis.
Conclusions
In patients with chronic viral hepatitis, particularly in
patients with hepatitis C virus infection, all noninvasive
methods are ready to be used for detecting and staging liver
fibrosis before therapy at a safe level of predictability.
As with transient elastography, elastographic techniques
based on shear waves generated by the acoustic beam are
more accurate in detecting cirrhosis than significant fibro-
sis. They have the advantage of B-mode guidance, which
Figure 6. Image from a 57-year-old woman infected with chronic hepa-
titis C for 28 years. Elastography gives a value indicating liver cirrhosis.
202
allows one to choose an area of liver parenchyma better
suited for stiffness assessment (ie, free of large vessels and
focal lesions).
These methods are all valid when information about
fibrosis is needed. Liver biopsy should still be performed
when biochemical tests and imaging studies are inconclu-
sive or information other than liver fibrosis is required.
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