Liver Stiffness and Cholestasis

  • Sebastian MuellerEmail author


Mechanic cholestasis is an established important and independent clinical confounder of liver stiffness (LS) elevation. As rule of thumb, during mechanic cholestasis, an elevation of bilirubin by 1 mg/dL corresponds to an increase of LS by 1 kPa. For instance, a patient with a bilirubin of 4 mg/dL and an obstructed common bile duct can develop a LS of 8–10 kPa which will normalize after e.g., removal of the bile stone. This information can be very helpful when looking at patients with a combination of established liver cirrhosis and additional choletasis due to bile duct obstruction.

Moreover, due to the elevated LS, imaging studies will not show dilatation of the bile ducts. Here, comparison of bilirubin with LS can help to dissect cirrhosis from mechanic cholestasis.

Notably, severe hemolysis does not directly increase LS within short-term periods of time but only later due to hepatocellular damage. Although the data of rare genetic cholestatic diseases are still scarce (e.g., Alagille syndrome), all diseases with impaired bile and bilirubin excretion are expected to show elevated LS including DILI (during induced liver injury) of the cholestatic type. In contrast, conjugation problems such as the rather common Gilbert–Meulengracht syndrome are not causing LS elevation. Mechanic cholestasis even of the small canaliculi also contributes to LS elevation in more common etiologies such as PSC/PBC but also alcoholic liver disease.


Cholestasis Intrahepatic cholestasis Gilbert–Meulengracht syndrome Liver stiffness Transient elastography TE 


  1. 1.
    Millonig G, Reimann FM, Friedrich S, Fonouni H, Mehrabi A, Büchler MW, et al. Extrahepatic cholestasis increases liver stiffness (FibroScan) irrespective of fibrosis. Hepatology. 2008;48(5):1718–23.CrossRefGoogle Scholar
  2. 2.
    Harata M, Hashimoto S, Kawabe N, Nitta Y, Murao M, Nakano T, et al. Liver stiffness in extrahepatic cholestasis correlates positively with bilirubin and negatively with alanine aminotransferase. Hepatol Res. 2011;41(5):423–9.CrossRefGoogle Scholar
  3. 3.
    Trifan A, Sfarti C, Cojocariu C, Dimache M, Cretu M, Hutanasu C, et al. Increased liver stiffness in extrahepatic cholestasis caused by choledocholithiasis. Hepat Mon. 2011;11(5):372–5.PubMedPubMedCentralGoogle Scholar
  4. 4.
    Attia D, Pischke S, Negm AA, Rifai K, Manns MP, Gebel MJ, et al. Changes in liver stiffness using acoustic radiation force impulse imaging in patients with obstructive cholestasis and cholangitis. Dig Liver Dis. 2014;46(7):625–31.CrossRefGoogle Scholar
  5. 5.
    Pfeifer L, Strobel D, Neurath MF, Wildner D. Liver stiffness assessed by acoustic radiation force impulse (ARFI) technology is considerably increased in patients with cholestasis. Ultraschall Med. 2014;35(4):364–7.CrossRefGoogle Scholar
  6. 6.
    Ehlken H, Lohse AW, Schramm C. Transient elastography in primary sclerosing cholangitis-the value as a prognostic factor and limitations. Gastroenterology. 2014;147(2):542–3.CrossRefGoogle Scholar
  7. 7.
    Cetin O, Karaman E, Arslan H, Akbudak I, Yildizhan R, Kolusari A. Maternal liver elasticity determined by acoustic radiation force impulse elastosonography in intrahepatic cholestasis of pregnancy. J Med Ultrason (2001). 2017;44(3):255–61.CrossRefGoogle Scholar
  8. 8.
    Sagir A, Erhardt A, Schmitt M, Haussinger D. Transient elastography is unreliable for detection of cirrhosis in patients with acute liver damage. Hepatology. 2008;47(2):592–5.CrossRefGoogle Scholar
  9. 9.
    Nguyen-Khac E, Thiele M, Voican C, Nahon P, Moreno C, Boursier J, et al. Non-invasive diagnosis of liver fibrosis in patients with alcohol-related liver disease by transient elastography: an individual patient data meta-analysis. Lancet Gastroenterol Hepatol. 2018;3(9):614–25.CrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of Medicine and Center for Alcohol Research and Liver Diseases, Salem Medical CenterUniversity of HeidelbergHeidelbergGermany

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