The Use of Ultrasound-Based Elastography Techniques in Liver Fibrosis: A Narrative Review

Liver fibrosis staging plays a key role in the prognosis and management of chronic liver disease. Liver biopsy remains the reference standard for fibrosis assessment but is limited by its invasiveness and risk of complications, while magnetic resonance elastography, though also considered a gold standard, is constrained by cost and limited availability. Ultrasound-based elastography techniques-vibration-controlled transient elastography (VCTE), point shear wave elastography (pSWE), and two-dimensional shear wave elastography (2D SWE)-have emerged as accessible non-invasive alternatives. This narrative review aimed to summarize the principles, diagnostic performance, advantages, and limitations of these three techniques across a range of etiologies. A comprehensive literature search was conducted across Scopus, PubMed, Embase, CINAHL, the Cochrane Library, Informit, and the JBI Database of Systematic Reviews and Implementation Reports, covering January 2015 to February 2026. Search terms included "vibration-controlled transient elastography", "point shear wave elastography", "two-dimensional shear wave elastography", "liver stiffness measurement", "non-invasive assessment" and "chronic liver disease". International guidelines, systematic reviews and meta-analyses, large observational cohort studies, and narrative reviews were included in the synthesis. VCTE, pSWE, and 2D SWE all demonstrated good diagnostic performance for detecting advanced fibrosis and cirrhosis across multiple etiologies. VCTE was the most extensively validated technique, with standardized cut-offs endorsed by major international guidelines. pSWE and 2D SWE showed comparable diagnostic accuracy and can be integrated into conventional ultrasound systems, enabling simultaneous structural and stiffness assessment, although validated cut-off values for these two techniques are not yet established in current guidelines, and absolute stiffness values are not directly interchangeable across techniques, manufacturers, or software versions. Obesity, inflammation, steatosis and recent food intake were identified as factors affecting measurement accuracy across all three techniques. Ultrasound-based elastography techniques offer effective, non-invasive alternatives to liver biopsy for fibrosis assessment. VCTE remains the most validated option despite cost and availability constraints, while pSWE and 2D SWE offer comparable accuracy with practical integration advantages. Future research should focus on standardizing cut-off values, addressing confounding factors, and combining elastography with biomarkers and AI-driven models.