But the truth is that often you can get a good result from ultrasound-based elastography. So the usual ultrasound machines, you can buy add-ons, and they're called shear wave elastography. The problem is that the quality control on some of these scans is not the best. So that's why I shy away from it. And sometimes I'm doing these transient elastography tests to confirm that. And one of the problems with transient elastography is that it assesses the liver at a fixed depth from the skin, which for people with a lot of central adiposity makes that test ineffective. So as the BMI rises above 40, the failure rate of this test starts to climb. And that's when we reach for magnetic resonant elastography. This test has different units of measure effectively. And we should talk a little bit about the numbers that I'm looking for on these Fiberscan tests. So the number you get on an MRE is like a third to a quarter lower than the number you get on the other elastographic tests. So you have to be careful how you interpret it. Because on a fiber scan is five, but five on an MRE is very, very stiff. That is cirrhosis. The data for MRE is pretty limited and it's really only from a couple of centers. It hasn't been validated outside of that. And it's obviously, it's an MRI. So it's like the most expensive thing that you can do in this case. But we will reach for that if a patient has a high BMI and we don't think that biopsy would otherwise be useful.

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Yeah. So the kinds of values that you get from shear wave elastography and transient elastography are basically interchangeable. And if you Google it, you might get trapped in older data where we were focused on cutoffs that would go down to the second decimal point. But we have simplified things now, and it's very helpful for teaching in clinic to patients. So most of these scanners can get up to a liver stiffness of 75, and the higher you go, the stiffer you are, the sicker your liver can be, or could become. A 5 is stone-cold normal. 10 is someone who is, there's a probability, about a 40% chance they have advanced fibrosis. So they could have cirrhosis, but many of them do not. 15, the likelihood of cirrhosis is very high. 20, the likelihood of cirrhosis is nearly definite. And 25, the patient probably has portal hypertension. There's a two in three chance that this person could have varices or enough pressure in their liver to develop varices in the short term. And these numbers are so solid that we will now make decisions based on them.