ORIGINALARTICLE

QUANTIFICATION OF LIVER FAT AND FIBROSIS WITH ULTRASOUND: THE EXPANDING

ROLE OF ELASTOGRAPHY

Zubair Janan Orakzai¹, Laila Khan², Hina Baig², Muhammad Sadiq³

How to cite this article

ABSTRACT

OBJECTIVES

To assess ultrasound-detected fatty liver grade and elastography-based

brosis stage among adults undergoing liver ultrasound evaluation and to

determine their association with selected clinical and metabolic risk factors.

METHODOLOGY

Janan Z, Khan L, Baig H, Sadiq M.

Quantication of Liver Fat and

Fibrosis With Ultrasound: The

Expanding Role of Elastography. J

Gandhara Med Dent Sci. 2026;13(3):

This descriptive cross-sectional observational study was conducted at the

Department of Radiology, MTI Bacha Khan Medical College and Mardan

Medical Complex, Mardan, from February 2026 to April 2026. A total of 83

adults undergoing liver ultrasound evaluation were recruited through non-

probability consecutive sampling. Demographic, clinical, laboratory,

ultrasound, and elastography ndings were recorded. Signicant brosis was

dened as brosis stage ≥F2. Data were analyzed using SPSS version 25. The

chi-square test and Cramér’s V were used to assess unadjusted associations,

while binary logistic regression was used to identify independent factors

associated with signicant brosis.

98-102.

https://doi.org/10.37762/jgmds.13-3.912

Date Submission:

Date Revised:

13-04-2026

20-05-2026

Date Acceptance: 20-05-2026

¹Associate Professor, Department of

Radiology, Bacha khan Medical

Complex, Medical Teaching Institute

of Mardan

³Tranning Medical Ocer, Department

of Radiology, Bacha khan Medical

Complex, Medical Teaching Institute

of Mardan

RESULTS

The mean age of participants was 42.1 ± 13.8 years, and 45 (54.2%) were male.

Overweight and obesity were observed in 38 (45.8%) and 22 (26.5%)

participants, respectively. Grade II fatty liver was the most common ultrasound

nding, observed in 39 (47.0%) participants. Signicant brosis ≥F2 was

present in 51 (61.4%) participants. On unadjusted analysis, BMI category,

ALT category, and fatty liver grade were signicantly associated with

signicant brosis. On multivariate logistic regression, elevated ALT was

associated with higher odds of signicant brosis (AOR = 5.85, 95% CI: 1.12 -

30.30, p = 0.036). Fatty liver grade was also independently associated with

signicant brosis (AOR = 15.87, 95% CI: 3.47 -72.64, p < 0.001). BMI,

diabetes mellitus, age group, and gender were not signicant after adjustment.

CONCLUSION

Correspondence

²Laila Khan, Assistant Professor,

Department of Radiology, Bacha khan

Medical Complex, Medical Teaching

Institute of Mardan

+92-333-7395178

lailakhan_81@hotmail.com

Signicant brosis was common in this hospital-based sample. Elevated ALT

and higher fatty liver grade were independently associated with signicant

brosis ≥F2. Ultrasound-detected fatty liver grade and elastography-based

brosis staging may support non-invasive risk stratication in patients

undergoing liver evaluation.

KEYWORDS: Elastography, Liver Fibrosis, Ultrasound, Alt, Metabolic Risk

Factors

INTRODUCTION

biopsy has traditionally been considered the reference

standard for brosis assessment; however, it is invasive,

Non-alcoholic fatty liver disease (NAFLD) is one of the costly, and associated with potential complications.

most common chronic liver diseases worldwide and is These limitations have increased interest in non-invasive

closely associated with obesity, diabetes mellitus, imaging methods that can assist in the assessment of

dyslipidemia, and metabolic syndrome.¹It represents a liver fat and brosis in routine clinical practice.^5,6

spectrum of liver involvement ranging from simple Ultrasound is commonly used as a rst-line imaging

steatosis to non-alcoholic steatohepatitis, brosis, and modality because it is widely available, aordable, safe,

cirrhosis. The rising burden of NAFLD is an important and acceptable to patients. It is useful for detecting

public health concern, particularly in low- and middle- hepatic steatosis, particularly moderate-to-severe fatty

income countries where lifestyle changes, increasing liver, but its ability to quantify early steatosis and assess

brosis is limited.⁷Elastography has therefore gained

importance as a non-invasive method for measuring liver

stiness, providing additional information on brosis

stage.⁸Previous studies have shown that elastography

obesity, and metabolic disorders are becoming more

common.^2,3Accurate assessment of hepatic steatosis and

brosis is important for identifying patients who may

require closer clinical evaluation and follow-up.⁴Liver

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Quantification of Liver Fat and Fibrosis with Ultrasound

can support non-invasive assessment of clinically the sample size was calculated for estimation purposes,

signicant brosis and cirrhosis, particularly when the multivariable association analysis was considered

interpreted in conjunction with clinical and laboratory exploratory. All adult patients aged 18 years and above

ndings.⁹It is repeatable and may be useful for follow- undergoing abdominal ultrasound for suspected fatty

up assessment in selected patients. However, the liver disease or liver-related clinical evaluation were

combination

conventional

ultrasound

and included in the study. Patients with known chronic liver

elastography is already well established; therefore, the disease already under treatment, liver malignancy, prior

present study does not claim novelty in the technique hepatic

itself. Instead, its relevance lies in evaluating the interfering

surgery,

with

pregnancy,

elastography

signicant

ascites

measurement,

association between ultrasound-detected fatty liver incomplete clinical or imaging data were excluded. A

grade, elastography-based brosis stage, and metabolic structured proforma was used to collect demographic,

factors in a local tertiary-care radiology setting. Despite clinical, laboratory, ultrasound, and elastography data.

increasing international evidence, local data from Laboratory parameters were retrieved from hospital

Pakistani hospital-based radiology practice remain records and included alanine aminotransferase, aspartate

limited regarding how sonographic fatty liver grade and aminotransferase, AST/ALT ratio, serum bilirubin, and

elastography-based brosis stage are associated with platelet count. ALT was categorized as normal or

metabolic and biochemical risk factors. This local elevated using 40 U/L as the cut-o value. BMI was

evidence is important because patient proles, obesity recorded as a continuous variable and categorized as

patterns, diabetes burden, referral practices, and access normal, overweight, or obese according to standard BMI

to advanced hepatology services may dier across categories. Each participant underwent conventional

settings. Therefore, this study was conducted to assess abdominal ultrasound followed by elastography using a

ultrasound-detected fatty liver grade and elastography- standardized imaging protocol. Ultrasound was

performed to assess liver size, echotexture, and fatty

liver grade. Fatty liver was categorized as Grade 0,

Grade I, Grade II, and Grade III based on liver

echogenicity, visualization of intrahepatic vessels, and

posterior beam attenuation. Grade 0 represented normal

liver echogenicity, Grade I represented mild steatosis,

Grade II represented moderate steatosis, and Grade III

based brosis stage among adults undergoing liver

ultrasound evaluation and to determine whether fatty

liver grade and selected metabolic risk factors are

associated with signicant brosis, dened as brosis

stage ≥F2.

METHODOLOGY

represented

severe

steatosis.

Elastography

was

This was a descriptive cross-sectional observational performed using transient elastography/FibroScan-based

study designed to assess ultrasound-detected fatty liver

grade and elastography-based brosis stage among

adults undergoing liver ultrasound evaluation. The study

also aimed to determine the association of fatty liver

liver stiness measurement on a FibroScan elastography

system using the standard adult M probe. The XL probe

was used, as required, for overweight or obese

participants

obtain

reliable

measurements.

grade and selected metabolic risk factors with signicant Participants were examined in the supine position with

brosis, dened as brosis stage ≥F2. The study was the right arm elevated to improve access to the right

conducted at the Department of Radiology, MTI Bacha

Khan Medical College and Mardan Medical Complex,

Mardan, over 2 months from February 2026 to April

intercostal spaces. Liver stiness measurements were

obtained from the right hepatic lobe through an

intercostal approach, avoiding large vessels, focal

2026. Ethical approval was obtained from the lesions, ribs, and biliary structures. Liver stiness was

Institutional Ethical Review Board of Bacha Khan recorded in kilopascals (kPa). For each participant, at

Medical College, Mardan, vide reference number No. least 10 valid liver stiness measurements were

980/BKMC dated 09/02/2026. Written informed consent

was obtained from all participants prior to inclusion, and

condentiality of patient information was ensured

throughout the study. The study was reported in

accordance with relevant STROBE recommendations

obtained, and the median value was used for analysis.

Measurements were considered reliable when the

interquartile range-to-median ratio was ≤30%. Fibrosis

staging was categorized as F0, F1, F2, F3, and F4

according to liver stiness values. For this study, brosis

staging was dened as follows: F0–F1 ≤ 7.4 kPa; F2 =

7.5–10.0 kPa; F3 = 10.1–14.0 kPa; and F4 > 14.0 kPa.

Signicant brosis was dened as brosis stage ≥F2. All

imaging procedures were performed or supervised by

trained radiologists using standardized criteria. Where

more than one operator was involved, radiologists with

comparable experience performed scans, and doubtful

cases were reviewed by a senior radiologist to maintain

for cross-sectional observational studies.

non-

probability consecutive sampling technique was

employed to recruit participants presenting for liver

ultrasound evaluation. The sample size was calculated

using the WHO formula, with a 95% condence level, P

assumed to be 50% due to variability in reported

prevalence across previous studies, and a 10% margin of

error (d), yielding a sample size of 83 participants.¹⁰As

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Quantification of Liver Fat and Fibrosis with Ultrasound

Table 4: Association of Selected Variables with Signicant

consistency. Interobserver reliability was not formally

calculated, and this was acknowledged as a study

limitation. Data were entered and analyzed using SPSS

version 25. A p-value ≤0.05 was considered statistically

signicant.

Fibrosis ≥F2 (n = 83)

Variable

Category

Fibrosis

Cramér

's V

-value

≥F2 n <F2 n

(%)

(30.4

(69.6

BMI

Category

Normal

0.49

<0.001

RESULTS

Overweig 23(60.5 15 (39.5

Obese

Table 1: Demographic and Clinical Characteristics of

Participants (n = 83)

21(95.5 1(4.5%)

Variable

Category

18-30 years

31-50 years

>50 years

Male

Frequency (%age)

23 (27.7%)

36 (43.4%)

24 (28.9%)

45 (54.2%)

38 (45.8%)

23 (27.7%)

38 (45.8%)

22 (26.5%)

33 (39.8%)

50 (60.2%)

38 (45.8%)

45 (54.2%)

22 (26.5%)

61 (73.5%)

5 (6.0%)

Diabetes

Mellitus

Yes

23 (69.7 10 (30.3 0.14

%) %)

28 (56.0 22 (44.0

%) %)

8 (28.6 20(71.4 0.48

43(78.2 12(21.8

%) %)

0.210

Age Group

Gender

ALT

Category

≤40 U/L

<0.001

(Normal) %)

Female

Normal

Overweight

Obese

Yes

BMI Category

>40 U/L

(Elevated)

Grade 0

Fatty

Liver

Grade

(0.0%) 12(100.0 0.72

Diabetes

Mellitus

Hypertension

Grade I

4 (25.0 12 (75.0

%) %)

31(79.5 8 (20.5

%) %)

16(100. 0 (0.0%)

0%)

Yes

Grade II

Grade III

Dyslipidemia

Hepatitis B

Hepatitis C

Symptoms

Yes

78 (94.0%)

11 (13.3%)

72 (86.7%)

37 (44.6%)

26 (31.3%)

20 (24.1%)

Yes

Table 5: Multivariate Logistic Regression Analysis for

Independent Factors Associated with Signicant Fibrosis ≥F2

Asymptomatic

Fatigue

RUQ Pain

Variable

Adjusted OR 95% CI

1.12–30.30 0.036

3.47–72.64 <0.001

0.84–1.32 0.681

p-value

Elevated ALT >40 U/L 5.85

Fatty liver grade

BMI

Diabetes mellitus

Male gender

Age group

15.87

1.05

2.40

1.09

0.47–12.20 0.295

0.25–4.65

Table 2: Components of Continuum of Maternal Care Across

Included Studies

0.909

0.979

Parameter

Mean ± SD (Min–Max)

48.9 ± 14.8 (18.9–83.4)

41.6 ± 11.1 (18.3–64.3)

0.92 ± 0.36 (0.39–2.36)

1.32 ± 0.39 (0.60–2.25)

196.6 ± 46.6 (80–297)

Note: Signicant brosis was dened as brosis stage ≥F2. The

model was adjusted for age group, BMI, ALTcategory, gender,

diabetes mellitus, and fatty liver grade. Fatty liver grade was entered

as an ordinal variable.

ALT (U/L)

AST (U/L)

AST/ALT Ratio

Serum Bilirubin (mg/dL)

Platelet Count (×10⁹/L)

DISCUSSION

Table 3: Determinants and Barriers Aecting Continuum of

Maternal Care

This study evaluated fatty liver grade and brosis stage

using ultrasound and elastography in adults undergoing

liver ultrasound, correlating these with metabolic and

biochemical factors. The predominantly middle-aged,

overweight/obese cohort reects the established

Variable

Category

Normal

Frequency(%)

19 (22.9%)

64 (77.1%)

23 (27.7%)

60 (72.3%)

12 (14.5%)

Ultrasound

Findings:

Fatty Liver

Grading

Liver Size

Enlarged

Normal

Coarse

Echotexture

connections

between

NAFLD,

obesity,

insulin

Fatty Liver

Grade

Grade 0

resistance, and metabolic risk factors. Consistent with

the current literature, our results indicate a strong

association between NAFLD and components of

metabolic syndrome, particularly elevated body weight

and impaired glucose metabolism, which promote

hepatic steatosis and brosis.¹⁰The ultrasound ndings

demonstrated that fatty liver was common in the study

population, with Grade II steatosis being the most

frequent category. Similar distributions have been

reported in other hospital-based studies.¹¹While

ultrasound is a common rst-line modality due to its

availability, aordability, and safety, its ability to assess

(Normal)

Grade I (Mild)

Grade II

(Moderate)

16 (19.3%)

39 (47.0%)

(Severe)

Grade III

16 (19.3%)

Elastography Fibrosis

F0 (No brosis) 14 (16.9%)

Findings:

Fibrosis

Staging

Stage

F1 (Mild)

18 (21.7%)

24 (28.9%)

22 (26.5%)

5 (6.0%)

F2 (Moderate)

F3 (Severe)

F4 (Cirrhosis)

Liver Stiness Mean ±SD

(kPa)

8.74 ± 2.87

(3.00-15.13)

(Min–Max)

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Quantification of Liver Fat and Fibrosis with Ultrasound

brosis is limited. Elastography, used in conjunction brosis through its association with fatty liver severity

and other metabolic factors. However, the modest

sample size may also have limited the precision of

adjusted estimates.¹⁵Diabetes mellitus was not

signicantly associated with brosis in this study, either

in the unadjusted analysis or after adjustment. This

nding diers from several studies that have reported

diabetes as an important risk factor for advanced brosis

in NAFLD. The dierence may be due to variation in

sample size, diabetes duration, glycemic control,

treatment status, or the hospital-based nature of the

sample.¹⁶Therefore, the non-signicant association

observed in this study should not be interpreted as

absence of a relationship between diabetes and brosis.

Rather, it indicates that diabetes was not an independent

predictor in this particular dataset after adjustment for

other variables.¹⁷The ndings support the use of

combining conventional ultrasound and elastography as

a practical, non-invasive approach for assessing fatty

liver grade and liver stiness in routine radiology

practice. Recent developments in shear wave

with conventional ultrasound provides additional

noninvasive information on liver stiness. In this study,

elastography revealed signicant brosis (≥F2 stage) in

a considerable proportion of participants, indicating a

clinically relevant burden of brosis within this hospital-

based sample.¹²However, because liver biopsy or an

external reference standard was not performed, these

ndings should be considered elastography-based

staging rather than diagnostic conrmation. Prior

research suggests that elastography is valuable for non-

invasive brosis assessment, particularly in identifying

patients with elevated liver stiness who may need

further evaluation or follow-up.¹²In the present study,

elastography was not evaluated for diagnostic accuracy;

therefore, claims regarding accuracy, validation, or

superiority over biopsy are avoided.¹¹

strong

unadjusted association was observed between fatty liver

grade and signicant brosis, with Cramér’s V = 0.72

and p < 0.001. After adjustment in a binary logistic

regression

model,

fatty

liver

grade

remained

elastography,

transient

elastography,

quantitative

independently associated with signicant brosis. Each

increase in fatty liver grade was associated with higher

odds of signicant brosis (AOR = 15.87, 95% CI: 3.47–

72.64, p < 0.001). This nding suggests that increasing

sonographic fatty liver severity was associated with

greater elastography-based liver stiness in this study

population. Similar ndings have been reported in

studies showing that higher steatosis grades are

associated with increased liver stiness values on

elastography.^11,13Due to the cross-sectional design, the

observed association between steatosis and brosis

cannot be interpreted as causation or evidence of

sequential development from fatty liver. Elevated ALT

levels were signicantly associated with signicant

brosis. Unadjusted analysis showed a moderate

association, and after multivariate adjustment, elevated

ALT was associated with approximately 5.85 times

greater odds of signicant brosis, consistent with ALT

reflecting hepatocellular injury and brosis risk in fatty

liver disease.¹⁴However, ALT alone is insucient to

exclude clinically relevant brosis, as normal liver

enzymes can occur with brosis. Biochemical markers

should therefore be interpreted alongside imaging and

ultrasound, and articial intelligence-based ultrasound

models have improved non-invasive liver assessment

and may further support risk stratication in liver

disease.¹⁸However, the present study was not designed

as a diagnostic accuracy or validation study. Therefore,

the ndings should be understood as associations

between ultrasound/elastography ndings and clinical

variables, rather than proof of diagnostic performance.¹⁹

CONFLICT OF INTEREST: None

FUNDING SOURCES: None

LIMITATIONS

This study cannot establish a causal relationship between

metabolic factors and brosis. Generalizability is limited

by non-probability sampling. The absence of a reference

standard, like liver biopsy, precludes assessing

elastography's diagnostic accuracy. Although trained

radiologists performed or supervised examinations using

a standardized protocol, interobserver reliability was not

formally assessed.

clinical risk factors. BMI showed

signicant

association with brosis in the unadjusted analysis, but

this association was not independent after adjustment,

likely due to overlap with fatty liver grade, ALT levels,

and other metabolic variables. While obesity is a

CONCLUSION

recognized contributor to the burden of NAFLD and In adults undergoing liver ultrasound in this hospital-

liver stiness and has been associated with hepatic

inflammation, oxidative stress, and brotic changes, its

independent predictive value in this study was limited.¹⁴

In the present study, the loss of statistical signicance

based sample, signicant brosis (≥F2) was common.

Elevated ALT and higher fatty liver grade were

independently associated with signicant brosis, even

after adjusting for age, BMI, gender, diabetes, and fatty

after adjustment suggests that BMI may be related to liver grade. These ndings suggest ultrasound-detected

July - September 2026

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Quantification of Liver Fat and Fibrosis with Ultrasound

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diagnostic accuracy, or eectiveness. Larger prospective

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AUTHORS CONTRIBUTION

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Zubair Janan - Concept & Design; Data Acquisition; Data

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Final Approval

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One.

2022;17(1):e0262291.

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Hina Baig - Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Drafting Manuscript; Critical Revision;

Final Approval

Muhammad Sadiq - Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Drafting Manuscript; Final Approval

10. Shabbir A, Abbas Z, Khatoon A, Mirza TJA. Role of alanine

transaminase and transient elastography in categorising non-

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