How can liver fibrosis be assessed without a biopsy? The role of noninvasive tests and controlled-vibration pulse elastography

A major public health challenge

Liver fibrosis is a key determinant of the progression of chronic liver diseases. Its assessment helps identify patients at risk, guide therapeutic decisions, and prevent complications, particularly cirrhosis and portal hypertension.

For many years, liver biopsy was considered the reference method. However, its invasive nature, cost, associated risks, and inter-observer variability have led scientific societies to recommend the use of non-invasive tests for the majority of patients.¹
In this context, Vibration-Controlled Transient Elastography has become a reference technology, validated by a very extensive body of scientific evidence.
More than 6,270 publications in peer-reviewed journals and 250 international recommendations recommend the use of the FibroScan^® device as the reference non-invasive solution for liver fibrosis assessment.

Why move away from liver biopsy?

Although it remains useful in complex situations, liver biopsy has several limitations²:

– Invasive, with a risk of complications (pain, bleeding).
– Limited sampling: a fragment representing 1/50,000 of the liver.
– Inter-observer variability in interpretation.
– High cost and complex logistics.
– Low patient acceptance, limiting longitudinal follow-up.

International recommendations (EASL, AASLD, AGA…)²⁻⁴ now converge:
Non-invasive tests should be used as a first-line approach to assess fibrosis in most chronic liver diseases. foie.

Non-invasive tests: to be used as first-line approach

Several technologies are available, but Vibration-Controlled Transient Elastography (VCTE^®) is the most clinically validated, the most standardized, and also the most cited in the recommendations of scientific societies (EASL, AGA, AASLD, Baveno…).

LSM by VCTE^®: the reference for non-invasive fibrosis assessment

The LSM by VCTE^® (Liver Stiffness Measurement) marker from FibroScan^® enables the measurement of liver stiffness, expressed in kilopascals (kPa). It is a quantitative, reproducible biomarker validated in most chronic liver diseases:
– Metabolic liver diseases (MASLD / MASH)
– Viral hepatitis (B, C, Delta)
– ALD / MetALD
– Autoimmune diseases
– Cirrhosis

LSM by VCTE^® is also supported by international scientific validation, with more than 5,540 publications on the clinical value of liver stiffness measurement (LSM by VCTE^®).

LSM by VCTE^® in clinical practice: a decision-making tool

1. Identify patients at riske

In patients with metabolic risk factors (diabetes, obesity, metabolic syndrome), a high LSM by VCTE^® value helps rapidly identify those requiring specialized care.

2. Reduce the need for liver biopsy

International recommendations¹ support the use of non-invasive tests to:
– Exclude the presence of advanced fibrosis (low LSM by VCTE^® + low blood test result).
– Confirm the presence of advanced fibrosis (high LSM by VCTE^® + high blood test result).

Liver biopsy is reserved only for discordant or complex cases.

3. Monitor disease progression

– The non-invasive nature of the examination with VCTE^®.
– Assessment of therapeutic response⁵.
– Monitoring of patients with MASLD/MASH⁵.
– Detection of cirrhosis and assessment of spleen stiffness in a clinical setting⁶.

Liver fibrosis assessment no longer relies solely on liver biopsy. Non-invasive examinations, and particularly LSM by VCTE^®, are now the preferred method for identifying, stratifying, and monitoring patients with chronic liver diseases.

1. European Association for the Study of the Liver (EASL) et al. “EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD).” Journal of hepatology vol. 81,3 (2024): 492-542.
2. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis – 2021 update. Journal of Hepatology. 2021;75(3):659-689.
3. Rinella, Mary E et al. “AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease.” Hepatology (Baltimore, Md.) vol. 77,5 (2023): 1797-1835
4. Bril, Fernando. “Metabolic liver disease: A summary of major guidelines and identifying opportunities to improve future guidelines.” Diabetes, obesity & metabolism vol. 28 Suppl 2,Suppl 2 (2026): 63-80.
5. Bansal, Meena B et al. “Semaglutide therapy for metabolic dysfunction-associated steatohepatitis: November 2025 updates to AASLD Practice Guidance.” Hepatology (Baltimore, Md.) vol. 83,5 (2026): 1326-1340.
6. de Franchis, Roberto et al. “Baveno VII – Renewing consensus in portal hypertension.” Journal of hepatology vol. 76,4 (2022): 959-974.

Products in the FibroScan range are class IIa medical devices according to Rule 10 of ANNEX VIII of Regulation EU 2017/745 (CE 0459) and are manufactured by Echosens. FibroScan devices are intended to provide: Liver stiffness measurements at a shear wave frequency of 50 Hz, liver ultrasound attenuation measurements (CAP: Controlled Attenuation Parameter) at 3.5 MHz and spleen stiffness measurements at a shear wave frequency of 100 Hz (FibroScan 630 Expert only). These non-invasive devices are intended to aid clinical management, diagnosis, and monitoring of patients with confirmed or suspected chronic liver disease, as part of an overall assessment of the liver. FibroScan devices may aid the healthcare professionals in the assessment of liver fibrosis, steatosis, and in determining the likelihood of cirrhosis, and its complications (FibroScan 630 Expert only). They are used, in conjunction with other clinical and laboratory data, during liver assessment in patients with confirmed or suspected chronic liver disease. Examinations with FibroScan devices shall be performed by an operator who has been certified by the manufacturer or its approved local representative. Operators are expressly recommended to carefully read the instructions given in the user manual and on the labelling of these products. Check cost defrayal conditions with paying bodies.