Chronic liver disease (CLD) represents a major global health burden and is associated with significant morbidity and mortality. Progressive liver injury resulting from viral hepatitis, alcohol-related liver disease, non-alcoholic fatty liver disease (NAFLD), autoimmune disorders, and metabolic diseases leads to hepatic fibrosis, cirrhosis, portal hypertension, and hepatocellular carcinoma. Early identification and monitoring of liver fibrosis are essential for timely intervention and prevention of irreversible liver damage. Traditionally, liver biopsy has been considered the gold standard for assessing hepatic fibrosis. However, biopsy is invasive, associated with complications such as bleeding and pain, prone to sampling errors, and unsuitable for repeated follow-up assessments.[1]

Liver elastography has emerged as a valuable non-invasive imaging modality for evaluating liver stiffness, which correlates closely with the degree of hepatic fibrosis. Elastography techniques, including transient elastography (FibroScan), acoustic radiation force impulse imaging (ARFI), and shear wave elastography (SWE), provide quantitative measurements of liver stiffness and enable clinicians to assess fibrosis progression without the risks associated with biopsy. These techniques are rapid, reproducible, patient-friendly, and can be performed repeatedly for disease monitoring.[2]

The increasing prevalence of chronic liver diseases, particularly NAFLD and viral hepatitis, has created a need for reliable non-invasive tools to evaluate disease severity and progression. Liver elastography has demonstrated high diagnostic accuracy in differentiating various stages of fibrosis and identifying advanced fibrosis and cirrhosis. Furthermore, liver stiffness measurements have shown prognostic significance in predicting complications such as portal hypertension, hepatic decompensation, and liver-related mortality. Consequently, several international guidelines recommend elastography as a first-line modality for fibrosis assessment in chronic liver disease.[3]

Despite its widespread use, liver stiffness values may be influenced by factors such as inflammation, cholestasis, congestion, obesity, and operator expertise. Therefore, continuous evaluation of its clinical utility across different etiologies of liver disease remains important. Understanding the relationship between elastography findings and clinical, biochemical, and radiological parameters can improve patient management and facilitate risk stratification.[4]

The present study was conducted to evaluate the role of liver elastography in assessing the progression of liver disease and to determine its usefulness as a non-invasive tool for monitoring fibrosis severity. The findings of this study may contribute to optimizing the diagnostic approach and follow-up strategies for patients with chronic liver disease while reducing the dependence on invasive procedures such as liver biopsy.

AIM

To evaluate the role of liver elastography in assessing the progression and severity of liver disease in patients with chronic liver disorders.

OBJECTIVES

1. To measure liver stiffness using elastography in patients with chronic liver disease.
2. To correlate elastography findings with clinical, biochemical, and radiological parameters of liver disease.
3. To assess the usefulness of liver elastography in staging fibrosis and monitoring disease progression.

Source of Data The data were collected from patients attending the Department of Radiodiagnosis and Department of Medicine/Gastroenterology of the tertiary care teaching hospital. Clinical records, laboratory investigations, ultrasonography findings, and liver elastography measurements were used for analysis. Study Design A hospital-based observational cross-sectional study was conducted. Study Location The study was conducted in the Department of Radiodiagnosis in collaboration with the Department of Medicine/Gastroenterology at a tertiary care teaching hospital. Study Duration The study was carried out over a period of 36 months, including patient recruitment, data collection, analysis, and interpretation. Sample Size A total of 100 patients diagnosed with chronic liver disease were included in the study. Inclusion Criteria • Patients aged ≥18 years. • Patients diagnosed with chronic liver disease of any etiology. • Patients willing to provide written informed consent. • Patients undergoing liver elastography as part of clinical evaluation. Exclusion Criteria • Patients with acute liver failure. • Patients with hepatic malignancy. • Patients with significant ascites preventing accurate elastography measurement. • Pregnant women. • Patients unwilling to participate in the study. • Patients with incomplete clinical or laboratory data. Procedure and Methodology After obtaining approval from the Institutional Ethics Committee, eligible patients were enrolled consecutively. Detailed demographic data, clinical history, risk factors, duration of liver disease, and physical examination findings were recorded. Relevant laboratory investigations including complete blood count, liver function tests, coagulation profile, viral markers, and serum albumin were obtained from hospital records. Conventional abdominal ultrasonography was performed to assess liver size, echotexture, portal vein diameter, splenomegaly, and presence of ascites. Liver elastography was subsequently performed using a standardized elastography system by experienced radiologists. Multiple valid measurements were obtained for each patient according to manufacturer recommendations, and the median liver stiffness value expressed in kilopascals (kPa) was recorded. Patients were categorized according to fibrosis stage based on established elastography cut-off values. Correlation between liver stiffness measurements and clinical, biochemical, and imaging parameters was evaluated to determine disease severity and progression. Sample Processing Blood samples collected during routine clinical evaluation were processed in the central laboratory using standard protocols. Hematological parameters were analyzed using automated hematology analyzers, while biochemical parameters including liver enzymes, bilirubin, albumin, and coagulation profiles were measured using automated biochemistry analyzers. Elastography measurements were recorded and entered into a structured data collection form. Data Collection Data were collected using a predesigned case record form. Information regarding demographic characteristics, etiology of liver disease, laboratory findings, ultrasonographic features, elastography measurements, and fibrosis stage was documented systematically and entered into a computerized database for analysis. Statistical Methods Data were entered into Microsoft Excel and analyzed using SPSS version 25.0. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were expressed as frequencies and percentages. Comparison between groups was performed using Student's t-test or ANOVA for continuous variables and Chi-square test or Fisher's exact test for categorical variables. Correlation between liver stiffness measurements and laboratory/imaging parameters was assessed using Pearson's or Spearman's correlation coefficient. A p-value <0.05 was considered statistically significant.

Table 1: Baseline Profile and Liver Disease Severity Among Study Participants (N=100)

Table 1 presents the baseline demographic and clinical profile of the 100 study participants with chronic liver disease. The mean age of the patients was 46.8 ± 12.7 years (95% CI: 44.3–49.3), which was statistically significant (t=36.85, p<0.001). Males constituted the majority of the study population, accounting for 63.0% (n=63), while females represented 37.0% (n=37), demonstrating a significant male predominance (χ²=6.76, p=0.009). Alcohol-related liver disease was the most common etiology, observed in 37.0% of patients, followed by NAFLD/NASH (23.0%), viral hepatitis (18.0%), cryptogenic chronic liver disease (11.0%), autoimmune/metabolic disorders (7.0%), and other causes (4.0%), with a statistically significant distribution among etiological categories (χ²=31.64, p<0.001). Regarding disease severity, 61.0% of patients had compensated liver disease, whereas 39.0% had decompensated disease, indicating a significantly higher proportion of compensated cases (χ²=4.84, p=0.028).

Table 2: Liver Stiffness Measurement Using Elastography in Chronic Liver Disease (N=100)

Table 2 summarizes liver stiffness measurements obtained using elastography among patients with chronic liver disease. The mean liver stiffness value was 15.9 ± 7.8 kPa (95% CI: 14.4–17.4), which was highly significant (t=20.38, p<0.001). Based on stiffness categories, severe liver stiffness (12.1–20 kPa) was the most common finding, observed in 33.0% of patients, followed by very severe stiffness (>20 kPa) in 26.0%, moderate stiffness (7–12 kPa) in 24.0%, and mild stiffness (<7 kPa) in 17.0% of patients. The overall distribution of stiffness grades was statistically significant (χ²=16.96, p<0.001), indicating a predominance of advanced fibrosis-related stiffness patterns. Elastography yielded valid measurements in 94.0% of cases, while only 6.0% had suboptimal readings (χ²=77.44, p<0.001). Furthermore, an acceptable median IQR/median ratio, reflecting good measurement reliability, was achieved in 88.0% of patients (χ²=57.76, p<0.001), highlighting the feasibility and reproducibility of liver elastography in this population.

Table 3: Correlation of Elastography Findings with Clinical, Biochemical and Radiological Parameters (N=100)

Table 3 demonstrates the correlation between liver stiffness measurements and various clinical, biochemical, and radiological parameters. Liver stiffness showed a moderate positive correlation with serum bilirubin levels (r=0.46, p<0.001), AST levels (r=0.41, p<0.001), and ALT levels (r=0.34, p=0.001), suggesting that increasing liver stiffness was associated with worsening hepatic injury and dysfunction. Conversely, significant negative correlations were observed with serum albumin (r=-0.52, p<0.001) and platelet count (r=-0.49, p<0.001), indicating that higher liver stiffness was associated with poorer synthetic liver function and features of portal hypertension. Radiological findings also demonstrated significant associations with increased liver stiffness. Splenomegaly was present in 43.0% of patients (χ²=18.92, p<0.001), ascites in 29.0% (χ²=9.64, p=0.002), and portal vein dilatation greater than 13 mm in 34.0% (χ²=12.96, p<0.001).

Table 4: Usefulness of Liver Elastography in Fibrosis Staging and Monitoring Disease Progression (N=100)

*Significant at p<0.05.

Table 4 evaluates the usefulness of liver elastography in fibrosis staging and monitoring disease progression. Fibrosis staging revealed that 19.0% of patients had no or mild fibrosis (F0–F1), 27.0% had significant fibrosis (F2), 31.0% had advanced fibrosis (F3), and 23.0% had cirrhosis (F4). Although the distribution of fibrosis stages was not statistically significant (χ²=4.88, p=0.181), advanced fibrosis and cirrhosis together accounted for more than half of the study population (54.0%). Elastography identified advanced fibrosis or cirrhosis in 54.0% of patients, though this finding did not reach statistical significance (χ²=0.64, p=0.424). Clinical progression of liver disease was observed in 38.0% of patients and showed a significant association (χ²=5.76, p=0.016), while radiological progression was noted in 36.0% and was also statistically significant (χ²=7.84, p=0.005). Biochemical progression was present in 42.0% of patients but was not statistically significant (χ²=2.56, p=0.110). Importantly, liver elastography was considered useful for fibrosis staging in 91.0% of cases, demonstrating a highly significant result (χ²=67.24, p<0.001).

In the present study, the mean age of patients was 46.8 ± 12.7 years, with male predominance 63.0%. Alcohol-related liver disease was the commonest etiology 37.0%, followed by NAFLD/NASH 23.0% and viral hepatitis 18.0%. Compensated liver disease was observed in 61.0%, while 39.0% had decompensated disease. These findings are comparable with Sharma et al. (2023)[1], who described chronic liver disease as a progressive condition commonly associated with fibrosis, cirrhosis and functional hepatic deterioration. Similarly, Castera et al. (2019)[2] emphasized that chronic liver disease due to alcohol, viral hepatitis and metabolic causes requires accurate non-invasive assessment for fibrosis staging. The mean liver stiffness measurement in the present study was 15.9 ± 7.8 kPa, suggesting a substantial burden of advanced fibrosis. Severe stiffness was observed in 33.0% and very severe stiffness in 26.0% of patients. Valid elastography readings were obtained in 94.0%, and acceptable IQR/median ratio was achieved in 88.0%, indicating good reliability. These results are consistent with Sandrin et al. (2003)[3], who introduced transient elastography as a rapid and reproducible non-invasive method for assessing hepatic fibrosis. Castera et al. (2008)[4] also reported that transient elastography performs well in identifying significant fibrosis and cirrhosis, especially when quality criteria are fulfilled. In the present study, liver stiffness showed significant positive correlation with serum bilirubin, AST and ALT, and significant negative correlation with albumin and platelet count. This suggests that higher liver stiffness was associated with hepatocellular injury, reduced synthetic function and portal hypertension. Sharma et al. (2021)[5] similarly reported that bilirubin abnormalities and reduced platelet count are commonly associated with cirrhosis and portal hypertension. The significant association of elastography with splenomegaly, ascites and increased portal vein diameter in the present study further supports its value in identifying advanced liver disease. Fibrosis staging by elastography showed F0–F1 in 19.0%, F2 in 27.0%, F3 in 31.0% and F4 in 23.0% of patients. Thus, advanced fibrosis or cirrhosis was detected in 54.0% of cases. Clinical progression and radiological progression were significantly associated with elastography findings, and elastography was considered useful for fibrosis staging in 91.0% of patients. These findings are supported by EASL guidelines, which recommend non-invasive tests, including liver stiffness measurement, for assessment of disease severity and prognosis in chronic liver disease Berzigotti et al. (2021)[6]. Cai et al. (2021)[7] also found that liver stiffness measurement was accurate for diagnosing fibrosis, particularly severe fibrosis, in alcohol-related liver disease and NAFLD. Similarly, Zhang et al. (2019)[8] highlighted the role of elastography in NAFLD patients for identifying progressive fibrosis and risk of cirrhosis.

The present study demonstrated that liver elastography is a valuable, reliable, and non-invasive tool for assessing the progression and severity of chronic liver disease. The majority of patients exhibited moderate-to-severe liver stiffness, reflecting a substantial burden of advanced fibrosis and cirrhosis. Liver stiffness measurements showed significant positive correlations with serum bilirubin, AST, and ALT levels, and significant negative correlations with serum albumin and platelet count, indicating a close relationship between elastography findings and hepatic dysfunction. Furthermore, liver stiffness was significantly associated with radiological indicators of advanced liver disease such as splenomegaly, ascites, and portal vein dilatation.

Elastography successfully identified advanced fibrosis and cirrhosis in more than half of the study population and proved useful for fibrosis staging in 91% of patients. The high rate of valid measurements and acceptable quality parameters further confirmed its feasibility in routine clinical practice. Overall, liver elastography provides an effective alternative to invasive liver biopsy for fibrosis assessment, disease monitoring, and prognostic evaluation. Its incorporation into routine clinical practice may facilitate early detection of disease progression, guide therapeutic decisions, and improve long-term management of patients with chronic liver disease.

LIMITATIONS OF STUDY

1. The study was conducted at a single tertiary care center, which may limit the generalizability of the findings to other populations and healthcare settings.
2. The sample size of 100 patients, although adequate for analysis, may not fully represent the wide spectrum of chronic liver disease etiologies.
3. The cross-sectional design assessed liver stiffness at a single point in time and did not evaluate longitudinal changes in fibrosis progression.
4. Histopathological confirmation by liver biopsy was not available for all patients; therefore, direct comparison between elastography findings and biopsy-based fibrosis staging could not be performed comprehensively.
5. Factors known to influence liver stiffness measurements, such as acute inflammation, cholestasis, hepatic congestion, and obesity, may have affected elastography values in some patients.
6. The study included patients with different etiologies of chronic liver disease, which might have introduced variability in liver stiffness measurements and fibrosis progression patterns.
7. Operator dependency and technical limitations of elastography could not be completely eliminated despite adherence to standard quality criteria.
8. Long-term clinical outcomes such as hepatic decompensation, transplantation, and mortality were not assessed.

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3. Sandrin L, Fourquet B, Hasquenoph JM, et al. Transient elastography: a new non-invasive method for assessment of hepatic fibrosis. Ultrasound Med Biol. 2003.
4. Castera L, Forns X, Alberti A. Non-invasive evaluation of liver fibrosis using transient elastography. J Hepatol. 2008.
5. Sharma P, Arora A. Value of liver function tests in cirrhosis. J Clin Exp Hepatol. 2021.
6. Berzigotti A, Tsochatzis E, Boursier J, et al. EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis. J Hepatol. 2021.
7. Cai C, Song X, Chen Y, et al. Transient elastography in alcoholic liver disease and nonalcoholic fatty liver disease. Can J Gastroenterol Hepatol. 2021.
8. Zhang X, Wong GLH, Wong VWS. Application of transient elastography in nonalcoholic fatty liver disease. Clin Mol Hepatol. 2019.