Liver Elastography Report (Transient Elastography)

Report Title: Liver Elastography Report (Transient Elastography)

Patient Name: [Patient name] (If unavailable, enter "Not documented")

DOB: [Date of birth] (If unavailable, enter "Not documented")

MRN: [Medical record number] (If unavailable, enter "Not documented")

Ordering Clinician: [Ordering clinician name and credentials] (If unavailable, enter "Not documented")

Location: [Facility/Clinic] (If unavailable, enter "Not documented")

Study Date/Time: [Date and time of exam] (If unavailable, enter "Not documented")

Interpreting Clinician: [Interpreter name and credentials] (If unavailable, enter "Not documented")

Operator: [Operator name and credentials] (If same as interpreter, state "Same as interpreter"; if unavailable, enter "Not documented")

Indication & Clinical Context

• Indication: [fibrosis staging / steatosis assessment / treatment response monitoring / post-SVR surveillance / portal hypertension risk stratification]
• Etiology: [MASLD/MASH / alcohol-associated / HBV / HCV / cholestatic/autoimmune / other: specify / not provided] (If not provided, explicitly document "Etiology: not provided")
• Recent labs: [ALT, AST, total bilirubin, platelet count with values and dates] (Include only if explicitly available; omit line if none provided)
• Known confounders: [heart failure / acute hepatitis / biliary obstruction / recent alcohol use / recent strenuous exercise / other: specify] (Include only if applicable; omit line if none)
• Prior elastography/biopsy for comparison: [Prior VCTE date and results / prior biopsy date and stage / none available]

Technique

• Modality: Vibration-controlled transient elastography (VCTE)
• Device: [Device name/model] (If unavailable, enter "Not documented")
• Probe: [M / XL / S]; Selection rationale: [body habitus / BMI / skin-to-capsule distance / operator judgment]
• Anatomic approach: [Right lobe intercostal / other: specify]
• Fasting status: [Fasted, duration in hours / Not documented] (If unknown, state "Not documented" rather than assuming fasted)
• Measurement attempts: Total attempts: [number]; Valid measurements obtained: [number]
• Preparation deviations: [None / specify] (Omit line if none)

Data Quality & Reliability

• Valid measurements: [number]
• Success rate: [percentage] (Include only if reported by device)
• LSM IQR: [value] kPa; IQR/Median: [value]%
• CAP IQR: [value] dB/m (Include only if CAP performed)
• Reliability classification: [Reliable / acceptable quality / Technically limited / potentially unreliable / Non-diagnostic]
• If technically limited or non-diagnostic—Reason: [insufficient valid measurements / high IQR/median / excessive motion / obesity / limited acoustic windows / ascites / other: specify]; Recommendation: [Repeat under standardized conditions in specified timeframe / use different probe / consider MR elastography] (Include this line only if study is technically limited or non-diagnostic)

Quantitative Results

• Median LSM: [value] kPa
• LSM IQR: [value] kPa; IQR/Median: [value]%
• LSM range: [range] kPa (Include only if provided by device)
• Median CAP: [value] dB/m; CAP IQR: [value] dB/m (Include only if CAP was performed and interpretable; omit entirely if CAP not performed)

Interpretation

• Fibrosis: In the setting of [etiology / etiology not provided], liver stiffness of [value] kPa (quality: [reliable / limited]) is most consistent with [no/mild fibrosis / significant fibrosis / advanced fibrosis / cirrhosis likely], based on [cutoff set used]. (Use probabilistic language; avoid numeric METAVIR stages unless validated for patient's context. If etiology not provided, state that interpretation depends on underlying etiology and recommend clinical correlation.)
• Steatosis: CAP of [value] dB/m suggests [presence / absence] of hepatic steatosis [with grade per institutional scheme if adopted]. (Include only if CAP available and interpretable; note any limited precision due to high CAP IQR or other factors.)
• Portal hypertension/cACLD risk: [Risk assessment based on LSM and platelet count] (Include only if platelet count is available and clinical context supports assessment; otherwise omit or state that assessment requires additional data.)
• Comparison: Compared with prior elastography on [date], LSM changed by [value] kPa ([percentage]%). (Include only when both studies are reliable, conditions are comparable, and change exceeds expected test-retest variability; otherwise state that comparison is limited. Do not assign fibrosis or steatosis stages from non-diagnostic exams.)

Limitations

(Include this section only if specific limitations apply; omit entirely if none.)

• [Applicable limitations: non-fasting or unknown fasting status / marked transaminase elevation or active inflammation / suspected obstructive cholestasis / venous congestion or heart failure / recent alcohol intake or strenuous exercise / obesity or increased skin-to-capsule distance / narrow intercostal spaces / poor acoustic window / ascites / other technical factors]

Impression

1. Technical quality: [Reliable / Technically limited / Non-diagnostic] [with reason if limited or non-diagnostic].
2. Fibrosis: LSM [value] kPa (IQR [value] kPa, IQR/Median [value]%) is most consistent with [no/mild fibrosis / significant fibrosis / advanced fibrosis / cirrhosis likely] in the setting of [etiology / etiology not provided].
3. Steatosis: CAP [value] dB/m indicates [presence / absence] of hepatic steatosis [with grade if institutionally adopted]. (Include only if CAP performed)
4. Fibrosis staging is not recommended from this study alone due to [limitation]. (Include only if non-diagnostic or technically limited)

Recommendations

• [Recommendation based on study quality and findings] (Select appropriate recommendation based on results: For non-diagnostic/limited studies, recommend repeat VCTE under standardized conditions in 2–8 weeks or when confounder resolves, or consider MR elastography. For reliable low-risk studies, reassess in 2–3 years. For intermediate results or ongoing risk factors, reassess in 1–2 years with hepatology follow-up consideration. For advanced fibrosis or cirrhosis, recommend specialist-directed management with ~12-month monitoring intervals and appropriate surveillance. For post-SVR patients, recommend annual elastography monitoring with notation that risk may persist despite stiffness improvement.)

Interpreting Clinician Signature: [Name, credentials, and signature]

Date/Time: [Date and time of final interpretation]