Comparative accuracy of endosonographic shear wave elastography and transcutaneous liver stiffness measurement: a pilot study

Published:August 28, 2022DOI:

      Background and Aims

      Vibration-controlled transient elastography (VCTE) is a validated test for assessing liver fibrosis but may be unreliable in select patients, including those with morbid obesity. The limitations of VCTE may be overcome by EUS-guided shear wave elastography (EUS-SWE).


      This single-center, prospective, nonrandomized tandem study compared the diagnostic accuracy of EUS-SWE and VCTE in consecutive patients undergoing liver biopsy sampling because of unreliable noninvasive testing. EUS-SWE of the left and right lobes were separately performed and then compared with VCTE. Liver elasticity cutoffs for different stages of fibrosis were estimated in 3 ways: optimized sensitivity and specificity using the Youden index; and with sensitivity and specificity fixed at 90% each, Diagnostic accuracy for fibrosis was compared with liver histology using the area under the receiver-operating characteristic curve (AUROC). The primary outcome was the diagnostic accuracy of EUS-SWE for advanced fibrosis. Secondary outcomes were diagnostic accuracy of VCTE, EUS-SWE for left and right hepatic lobes for significant/advanced fibrosis, and cirrhosis.


      Forty-two patients (39 men, aged 54.5 ± 12.1 years) underwent EUS-SWE, VCTE, and liver biopsy sampling. The cross-validated AUROCs for advanced fibrosis were as follows: VCTE, .87 (95% confidence interval [CI], .76-.97); EUS-SWE left lobe, .8 (95% CI, .64-.96); and EUS-SWE right lobe, .78 (95% CI, .62-.95). The corresponding AUROCs for cirrhosis were as follows: VCTE, .9 (95% CI, .83-.97); EUS-SWE left lobe, .96 (95% CI, .9-1); and EUS-SWE right lobe, .9 (95% CI, .8-1). VCTE was unreliable in 8 patients who successfully underwent EUS-SWE. There was no statistically significant difference in the AUROCs for EUS-SWE and VCTE.


      EUS-SWE correlates well with liver histology and is a safe and reliable diagnostic test for assessing liver fibrosis with accuracy comparable with VCTE. (Clinical trial registration number: NCT04533932.)

      Graphical abstract

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Angulo P.
        • Kleiner D.E.
        • Dam-Larsen S.
        • et al.
        Liver fibrosis, but no other histologic features, is associated with long-term outcomes of patients with nonalcoholic fatty liver disease.
        Gastroenterology. 2015; 149: 389-397
        • Sanyal A.J.
        • Van Natta M.L.
        • Clark J.
        • et al.
        Prospective study of outcomes in adults with nonalcoholic fatty liver disease.
        N Engl J Med. 2021; 385: 1559-1569
        • Younossi Z.M.
        • Koenig A.B.
        • Abdelatif D.
        • et al.
        Global epidemiology of nonalcoholic fatty liver disease—meta-analytic assessment of prevalence, incidence, and outcomes.
        Hepatology. 2016; 64: 73-84
        • Rockey D.C.
        • Caldwell S.H.
        • Goodman Z.D.
        • et al.
        Liver biopsy.
        Hepatology. 2009; 49: 1017-1044
        • Siddiqui M.S.
        • Vuppalanchi R.
        • Van Natta M.L.
        • et al.
        Vibration-controlled transient elastography to assess fibrosis and steatosis in patients with nonalcoholic fatty liver disease.
        Clin Gastroenterol Hepatol. 2019; 17: 156-163
        • Tapper E.B.
        • Challies T.
        • Nasser I.
        • et al.
        The performance of vibration controlled transient elastography in a us cohort of patients with nonalcoholic fatty liver disease.
        Am J Gastroenterol. 2016; 111: 677-684
        • Wong V.W.S.
        • Vergniol J.
        • Wong G.L.H.
        • et al.
        Liver stiffness measurement using XL probe in patients with nonalcoholic fatty liver disease.
        Am J Gastroenterol. 2012; 107: 1862-1871
        • Samarasena J.
        • Chang K.J.
        Endo-hepatology: a new paradigm.
        Endosc Ultrasound. 2018; 7: 219-222
      1. Kohli DR, Baillie J. How endoscopes work. In: Chandrasekhara V, Elmunzer BJ, Khashab MA, et al, editors. Clinical gastrointestinal endoscopy, 3rd ed. Philadelphia, PA: Elsevier, 2019. p. 24-31.

        • Ohno E.
        • Kawashima H.
        • Ishikawa T.
        • et al.
        Diagnostic performance of endoscopic ultrasonography-guided elastography for solid pancreatic lesions: shear-wave measurements versus strain elastography with histogram analysis.
        Dig Endosc. 2021; 33: 629-638
        • Ohno E.
        • Hirooka Y.
        • Kawashima H.
        • et al.
        Feasibility and usefulness of endoscopic ultrasonography-guided shear-wave measurement for assessment of autoimmune pancreatitis activity: a prospective exploratory study.
        J Med Ultrason. 2019; 46: 425-433
        • Schulman A.R.
        • Lin M.V.
        • Rutherford A.
        • et al.
        A prospective blinded study of endoscopic ultrasound elastography in liver disease: towards a virtual biopsy.
        Clin Endosc. 2018; 51: 181-185
        • Song J.E.
        • Lee D.W.
        • Kim E.Y.
        Endoscopic ultrasound real-time elastography in liver disease.
        Clin Endosc. 2018; 51: 118-119
        • FDA-NIH Biomarker Working Group
        BEST (Biomarkers, EndpointS, and other Tools) resource.
        (Available at:)
        Date accessed: February 24, 2022
        • Cagney D.N.
        • Sul J.
        • Huang R.Y.
        • et al.
        The FDA NIH Biomarkers, EndpointS, and other Tools (BEST) resource in neuro-oncology.
        Neuro Oncol. 2018; 20: 1162-1172
        • Kwo P.Y.
        • Cohen S.M.
        • Lim J.K.
        ACG clinical guideline: evaluation of abnormal liver chemistries.
        Am J Gastroenterol. 2017; 112: 18-35
        • Aggarwal S.N.
        • Magdaleno T.
        • Klocksieben F.
        • et al.
        A prospective, head-to-head comparison of 2 EUS-guided liver biopsy needles in vivo.
        Gastrointest Endosc. 2021; 93: 1133-1138
        • Brunt E.M.
        • Kleiner D.E.
        • Wilson L.A.
        • et al.
        Nonalcoholic fatty liver disease (NAFLD) activity score and the histopathologic diagnosis in NAFLD: distinct clinicopathologic meanings.
        Hepatology. 2011; 53: 810-820
        • Castellana M.
        • Donghia R.
        • Guerra V.
        • et al.
        Fibrosis-4 index vs nonalcoholic fatty liver disease fibrosis score in identifying advanced fibrosis in subjects with nonalcoholic fatty liver disease: a meta-analysis.
        Am J Gastroenterol. 2021; 116: 1833-1841
        • Bhati C.
        • Idowu M.O.
        • Sanyal A.J.
        • et al.
        Long-term outcomes in patients undergoing liver transplantation for nonalcoholic steatohepatitis-related cirrhosis.
        Transplantation. 2017; 101: 1867-1874
        • Vuppalanchi R.
        • Siddiqui M.S.
        • Van Natta M.L.
        • et al.
        Performance characteristics of vibration-controlled transient elastography for evaluation of nonalcoholic fatty liver disease.
        Hepatology. 2018; 67: 134-144
        • DeLong E.R.
        • DeLong D.M.
        • Clarke-Pearson D.L.
        Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach.
        Biometrics. 1988; 44: 837-845
        • Kohli D.R.
        • Vachhani R.
        • Shah T.U.
        • et al.
        Diagnostic accuracy of laboratory tests and diagnostic imaging in detecting biliary strictures after liver transplantation.
        Dig Dis Sci. 2017; 62: 1327-1333
        • Sigrist R.M.S.
        • Liau J.
        • Kaffas A.E.
        • et al.
        Ultrasound elastography: review of techniques and clinical applications.
        Theranostics. 2017; 7: 1303-1329
        • Imajo K.
        • Honda Y.
        • Kobayashi T.
        • et al.
        Direct comparison of US and MR elastography for staging liver fibrosis in patients with nonalcoholic fatty liver disease.
        Clin Gastroenterol Hepatol. 2022; 20: 908-917.e11
        • Furlan A.
        • Tublin M.E.
        • Yu L.
        • et al.
        Comparison of 2D shear wave elastography, transient elastography, and MR elastography for the diagnosis of fibrosis in patients with nonalcoholic fatty liver disease.
        AJR Am J Roentgenol. 2020; 214: W20-W26
        • Jiang W.
        • Huang S.
        • Teng H.
        • et al.
        Diagnostic accuracy of point shear wave elastography and transient elastography for staging hepatic fibrosis in patients with non-alcoholic fatty liver disease: a meta-analysis.
        BMJ Open. 2018; 8e021787
        • Choi A.Y.
        • Kolb J.
        • Shah S.
        • et al.
        Endoscopic ultrasound-guided portal pressure gradient with liver biopsy: 6 years of endo-hepatology in practice.
        J Gastroenterol Hepatol. 2022; 37: 1373-1379
        • McCarty T.R.
        • Bazarbashi A.N.
        • Njei B.
        • et al.
        Endoscopic ultrasound-guided, percutaneous, and transjugular liver biopsy: a comparative systematic review and meta-analysis.
        Clin Endosc. 2020; 53: 583-593
        • Kohli D.R.
        • Desai M.
        • Kennedy K.F.
        • et al.
        Cholecystectomy for biliary pancreatitis is often not performed during index hospitalization and is associated with worse outcomes.
        Clin Gastroenterol Hepatol. 2022; 20 (233-5.e1)
        • Kohli D.R.
        • Kennedy K.F.
        • Desai M.
        • et al.
        Comparative safety of endoscopic vs radiological gastrostomy tube placement: outcomes from a large, nationwide Veterans Affairs database.
        Am J Gastroenterol. 2021; 116: 2367-2373