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Extrahepatic cholestasis and liver stiffness by transient elastography

In their recent study, Millonig and colleagues1 concluded that extrahepatic cholestasis increases liver stiffness regardless of fibrosis and that once extrahepatic cholestasis is excluded, transient elastography (TE) is a valuable tool for assessing liver fibrosis in chronic liver diseases. The methods and interpretation of the results, however, raise several concerns. TE should be performed to evaluate disease progression in chronic liver diseases by liver stiffness measurement even if liver stiffness measurement is not a reliable instrument for detecting the presence of advanced fibrosis and cirrhosis in patients presenting with a clinical picture of acute hepatitis.2 Also, the time at which TE should be performed after the resolution of extrahepatic cholestasis for the evaluation of disease progression in chronic liver diseases is very important. In other words, it is very important to determine when liver stiffness values by TE correspond well to the histological degree of fibrosis ascertained by liver biopsy after the resolution of extrahepatic cholestasis. In the study by Millonig et al.,1 however, liver biopsy was not performed. Therefore, the aforementioned question needs to be further confirmed. It is well known that liver stiffness values in the general population are influenced independently by gender, body mass index, and metabolic syndrome and tend to be higher with age.3 In the study by Millonig and colleagues,1 decreases in liver stiffness after successful biliary drainage were different among the enrolled patients. Moreover, were there any relationships between the differences in the decreases in liver stiffness after successful biliary drainage and gender, body mass index, metabolic syndrome, and age? In other words, did the liver stiffness values from TE correspond well to the histological degree of fibrosis ascertained by liver biopsy after the resolution of extrahepatic cholestasis? This also needs to be further confirmed.