Imaging to Monitor Hepatic Steatosis

First-Line Monitoring

The European Association for the Study of the Liver (EASL) recommends conventional ultrasound as the first-line modality for monitoring hepatic steatosis in clinical practice, despite its limitations 1
Conventional ultrasound is practical for serial assessments due to its universal availability and real-time capability 1
Ultrasound can evaluate the entire hepatobiliary system beyond just steatosis 2
Ultrasound is relatively low-cost compared to advanced imaging and has no radiation exposure 2

Ultrasound lacks accuracy for grading steatosis severity, with children having "mild" steatosis by ultrasound showing moderate steatosis by histology in approximately 50% of cases 3, 4, 5
Ultrasound sensitivity drops significantly when steatosis is less than 30% 2
Ultrasound performance is poor in obese patients 2
Ultrasound cannot distinguish non-alcoholic steatohepatitis (NASH) from simple steatosis 2

CAP can be used as a monitoring tool for hepatic steatosis and can be examined simultaneously with transient elastography 2, 7
The EASL guidelines note CAP is promising for rapid, standardized detection but cannot yet be recommended as first-line due to limited availability and lack of head-to-head studies versus ultrasound 1
CAP values above 275 dB/m show over 90% sensitivity to detect steatosis 1
The area under the curve (AUC) for mild, moderate, and severe steatosis using CAP are 0.96, 0.82, and 0.70 respectively 7

MRI-PDFF is the most accurate non-invasive method for detecting and quantifying steatosis, but it is not recommended as a first-line tool given its cost and limited availability 1
MRI-PDFF is the most precise imaging tool for evaluating non-alcoholic fatty liver disease (NAFLD) 2, 7
MRI-PDFF can map the entire liver for degree of steatosis 7
MRI-PDFF is accurate and reproducible across different scanners and field strengths 3, 4, 5

The available data do not support ultrasound for grading hepatic steatosis in children for clinical care or research 6
MRI shows promise but evidence is insufficient to make firm recommendations for clinical use in pediatric populations at this time 6

Do not rely on ultrasound grading (mild/moderate/severe) for treatment decisions due to the high misclassification rate 3, 6, 4, 5
Do not use CT for routine monitoring due to radiation concerns and suboptimal sensitivity for mild steatosis 2, 7
Do not use conventional MRI without proper confounding factor correction, as results may be inaccurate and non-reproducible 3, 4, 5