Non-Invasive Imaging Assessment of Liver Fibrosis

Chronic liver disease (CLD) is a major cause of global morbidity and mortality, with outcomes closely linked to the severity of liver fibrosis. While liver biopsy has historically been the reference standard for fibrosis staging, its invasiveness, sampling variability and limited suitability for longitudinal monitoring have driven the widespread adoption of non-invasive tests (NITs). Imaging-based biomarkers, particularly elastography, now play a central role in the clinical assessment and care pathway design. This review focuses on imaging techniques for non-invasive assessment of liver fibrosis, with emphasis on elastography techniques: vibration-controlled transient elastography (VCTE), ultrasound-based shear wave elastography (SWE) and magnetic resonance elastography (MRE). Technical principles, advantages, limitations and implementation considerations are discussed to support informed selection across clinical contexts. VCTE offers rapid point-of-care assessment with extensive validation for identifying advanced fibrosis but is limited by operator dependence, reduced repeatability and lack of anatomical information. SWE provides real-time, radiologist-controlled assessment with improved applicability in obesity and ascites, though intervendor variability and operator dependence remain challenges. MRE demonstrates the highest diagnostic accuracy, reproducibility and technical success, with assessment of larger liver volume and strong performance across etiologies, albeit with limited access due to the requirement of an MRI system. Adjunct MRI biomarkers, including proton-density fat fraction and iron-corrected T1 mapping, further enhance liver phenotyping by characterising steatosis and fibro-inflammatory activity. Understanding the strengths and limitations of each technique is essential for radiologists supporting multidisciplinary CLD management and service implementation, particularly in evolving healthcare environments such as Australia.