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. 2025 Apr;45(4):e16127.
doi: 10.1111/liv.16127. Epub 2024 Oct 14.

Accuracy of Non-Invasive Imaging Techniques for the Diagnosis of MASH in Patients With MASLD: A Systematic Review

Jennifer Cathcart  1   2 , Rachael Barrett  1 , James S Bowness  3   4 , Ashis Mukhopadhya  2 , Ruairi Lynch  1 , John F Dillon  1
Affiliations

Accuracy of Non-Invasive Imaging Techniques for the Diagnosis of MASH in Patients With MASLD: A Systematic Review

Jennifer Cathcart et al. Liver Int. 2025 Apr.

Abstract

Background and aims: Metabolic dysfunction-associated steatotic liver disease (MASLD) is a growing public health problem. The secondary stage in MASLD is steatohepatitis (MASH), the co-existence of steatosis and inflammation, a leading cause of progression to fibrosis and mortality. MASH resolution alone improves survival. Currently, MASH diagnosis is via liver biopsy. This study sought to evaluate the accuracy of imaging-based tests for MASH diagnosis, which offer a non-invasive method of diagnosis.

Methods: Eight academic literature databases were searched and references of previous systematic reviews and included papers were checked for additional papers. Liver biopsy was used for reference standard.

Results: We report on 69 imaging-based studies. There were 31 studies on MRI, 27 on ultrasound, five on CT, 13 on transient elastography, eight on controlled attenuation parameter (CAP) and two on scintigraphy. The pathological definition of MASH was inconsistent, making it difficult to compare studies. 55/69 studies (79.71%) were deemed high-risk of bias as they had no preset thresholds and no validation. The two largest groups of imaging papers were on MRI and ultrasound. AUROCs were up to 0.93 for MRE, 0.90 for MRI, 1.0 for magnetic resonance spectroscopy (MRS) and 0.94 for ultrasound-based studies.

Conclusions: Our study found that the most promising imaging tools are MRI techniques or ultrasound-based scores and confirmed there is potential to utilise these for MASH diagnosis. However, many publications are single studies without independent prospective validation. Without this, there is no clear imaging tool or score currently available that is reliably tested to diagnose MASH.

Keywords: MASH; MASLD; biopsy; imaging; non‐invasive.

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Conflict of interest statement

J.S.B. reports honoraria and research funding by Intelligent Ultrasound (IU) Company. J.C. reports funding of her Medicine Doctorate by Intelligent Ultrasound Company. J.F.D. reports receiving consulting fees from IU and honoraria from GE ultrasound. IU and GE had no involvement in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. R.B., R.L. and A.M. declare no conflicts of interest.

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