The Evolving Role of Liver Biopsy in Non-alcoholic Fatty Liver Disease

Evaluation patients with nonalcoholic steatohepatitis (NASH) imply the need of appropriate assessment of disease severity (i.e. the presence of nonalcoholic steatohepatitis (NASH)) as well as of the disease stage (i.e. the extent of liver fibrosis). Liver biopsy (LB) is still considered the gold standard for diagnosing NASH as well as for establishing the degree of liver fibrosis. However, due to its invasive nature and costs, use of LB should be restricted to selected patients and, according guidelines and expert opinion, indicated in the following scenarios: a) when LB will guide treatment, b) to confirm or exclude NAFLD in patients with conflicting clinical data, c) to increase patient's awareness about their disease, and improve engagement in their care and d) for inclusion in clinical trials. However, the role fo LB in NAFLD is evolving since when new and costly therapeutic agents become available, LB will be eventually necessary to make clinical decisions. The use of non-invasive tools (NITs) to assess steatosis, NASH and hepatic fibrosis is useful to triage NAFLD patients and decide in whom perform a LB.