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World J Gastrointest Pathophysiol. Sep 22, 2026; 17(3): 121790
Published online Sep 22, 2026. doi: 10.4291/wjgp.121790
Accuracy of non-invasive tests for diagnosing liver fibrosis and steatosis: A systematic review
Saurin R Shukla, Mirza Amer Ali Baig, Arika Pareek, Namita Johari, Yeshika Thapa, Beulah Blessy Kumpati, Shreya Mahesh Nirmal, Ifrah Ayesha Imdad, Durnave Azid, Eniola Aina, Alisha Lakhani
Saurin R Shukla, Medicine, GMERS Medical College, Ahmedabad 382016, India
Mirza Amer Ali Baig, Medicine, Gandhi Medical College, Hyderabad 500003, Telangāna, India
Arika Pareek, Medicine, Dr. Vithalrao Vikhe Patil Foundation’s Medical College and Hospital, Mahad 414111, Mahārāshtra, India
Namita Johari, Medicine, K. J. Somaiya Medical College, Mahad 400022, Mahārāshtra, India
Yeshika Thapa, Internal Medicine, University of Central Florida, Orlando, FL 32816, United States
Beulah Blessy Kumpati, Medicine, Narayana Medical College, Hyderabad 400022, Telangāna, India
Shreya Mahesh Nirmal, Medicine, Government Medical College, Mahad 425412, Mahārāshtra, India
Ifrah Ayesha Imdad, Durnave Azid, Eniola Aina, Medicine, Research MD, Vadodara 390002, Gujarāt, India
Alisha Lakhani, Medicine, Shantabaa Medical College and General Hospital, Amreli 365601, Gujarāt, India
Co-first authors: Saurin R Shukla and Mirza Amer Ali Baig.
Author contributions: Shukla SR, Baig MAA, and Lakhani A contributed to conceptualization, manuscript drafting, and critical revision; Shukla SR and Lakhani A contributed to study design, supervision, methodology, and they contributed equally to this manuscript and are co-first authors; Shukla SR, Johari N and Lakhani A contributed to data interpretation; Baig MAA and Pareek A contributed to data extraction; Baig MAA and Pareek A contributed to literature screening; Pareek A, Thapa Y, and Ayesha Imdad I contributed to manuscript editing; Pareek A and Kumpati BB contributed to quality assessment; Pareek A, Nirmal SM, and Ayesha Imdad I contributed to literature review; Johari N contributed to methodology support; Johari N, Kumpati BB, and Azid D contributed to manuscript review; Thapa Y contributed to data collection, statistical interpretation support; Kumpati BB contributed to study selection; Nirmal SM contributed to data extraction and manuscript preparation support; Ayesha Imdad I contributed to data organization; Azid D contributed to data screening, and formatting assistance; Aina E data screening critical manuscript revision and review of scientific content. All authors contributed substantially to the work, reviewed the final manuscript, and approved it for submission.
AI contribution statement: Portions of this manuscript were edited using ChatGPT by OpenAI solely for language refinement, grammar correction, and improvement of overall readability. The authors carefully reviewed, verified, and approved all content generated or modified with AI assistance and take full responsibility for the integrity, accuracy, originality, and scientific validity of the manuscript. AI tools were not used for data analysis, interpretation of results.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Corresponding author: Alisha Lakhani, Consultant, Medicine, Shantabaa Medical College and General Hospital, Civil Hospital Campus, Lathi Road, Amreli 365601, Gujarāt, India.
alishalakhani@smcgh.edu.in
Received: April 8, 2026
Revised: May 31, 2026
Accepted: July 1, 2026
Published online: September 22, 2026
Processing time: 160 Days and 8.4 Hours
BACKGROUND
Liver fibrosis is a key determinant of prognosis and management in chronic liver diseases. Although liver biopsy is considered the gold standard for fibrosis assessment, its invasiveness, sampling variability, and associated risks have prompted increasing reliance on non-invasive tests. This systematic review evaluates the diagnostic accuracy and clinical applicability of non-invasive modalities for diagnosing liver fibrosis in adult patients with chronic liver diseases.
AIM
To systematically evaluate the diagnostic accuracy, clinical utility, and applicability of non-invasive tests for detecting and staging liver fibrosis in adult patients with chronic liver diseases, using liver biopsy as the reference standard.
METHODS
A systematic literature search was conducted using predefined search terms combining liver fibrosis, chronic liver disease, non-invasive diagnostic tests, and diagnostic accuracy measures, with liver biopsy as the reference standard. Studies were selected based on a PICO (Population, Intervention, Comparison, Outcome) framework including adults (≥ 18 years) with chronic liver diseases such as hepatitis B, hepatitis C, non-alcoholic fatty liver disease, and alcohol-related liver disease. Eligible interventions included serum biomarkers (e.g., aspartate aminotransferase-to-platelet ratio index, fibrosis-4 index, enhanced liver fibrosis), imaging-based techniques (e.g., transient elastography, acoustic radiation force impulse, magnetic resonance imaging elastography), and combined diagnostic algorithms. Diagnostic accuracy outcomes including sensitivity, specificity, positive predictive value, and negative predictive value were extracted. Two independent reviewers performed abstract and full-text screening according to predefined inclusion and exclusion criteria, with disagreements resolved by consensus or a third reviewer.
RESULTS
The included studies comprised prospective and retrospective cohort studies, randomized controlled trials, and cross-sectional studies. Elastography-based techniques consistently demonstrated high diagnostic accuracy for detecting significant and advanced fibrosis across multiple chronic liver disease etiologies. Serum biomarker panels showed variable performance but were effective as first-line screening tools due to their accessibility and cost-effectiveness. Heterogeneity was observed in study design, fibrosis staging systems, and cut-off values.
CONCLUSION
Non-invasive tests represent reliable and clinically applicable alternatives to liver biopsy for fibrosis assessment in chronic liver diseases. Elastography-based modalities, particularly transient elastography and two-dimensional shear wave elastography, demonstrated consistently high diagnostic accuracy for advanced fibrosis across included studies. Serum biomarker panels such as fibrosis-4 index and enhanced liver fibrosis showed variable performance but are effective as first-line screening tools due to their accessibility and cost-effectiveness. A sequential diagnostic approach integrating serum biomarkers followed by imaging modalities improves overall diagnostic accuracy and reduces the need for invasive procedures. However, significant heterogeneity in study design, patient populations, and cut-off values limits standardization and highlights the need for larger multicentric validation studies.
Core Tip: Non-invasive tests are increasingly replacing liver biopsy for fibrosis assessment in chronic liver diseases due to their safety and accessibility. This systematic review highlights that elastography-based modalities provide high diagnostic accuracy for detecting significant fibrosis, while serum biomarkers serve as effective first-line screening tools. Despite variability in cut-off values and study designs, a stepwise approach combining serum and imaging-based non-invasive tests improves diagnostic reliability. Integrating these modalities into clinical practice can reduce the need for invasive procedures while maintaining accurate fibrosis staging and guiding patient management.
