Hepatic Elastography in the Intensive Care Unit: Are We Ready to Use It as a Window into Critical Illness?

Background:The liver is highly susceptible to hemodynamic and inflammatory insults in critical illness, yet conventional biomarkers often detect injury only after it is established.Two-dimensional shear wave elastography (2D-SWE) is a noninvasive bedside tool that quantifies liver stiffness and may offer real-time insights into hepatic congestion and perfusion.Aim: This viewpoint evaluates the current evidence, practical applications, and limitations of integrating 2D-SWE into routine intensive care unit (ICU) practice.Main findings: Emerging data suggest that 2D-SWE can detect hepatic congestion secondary to right heart dysfunction and may identify early sepsis-related liver injury before biochemical changes manifest.It also holds potential for monitoring hepatosplanchnic perfusion in patients on vasopressors.However, widespread adoption is hindered by significant physiological confounders in the ICU (e.g., positive pressure ventilation, edema), a lack of randomized outcome trials, and operational challenges.Currently, its most pragmatic role lies in serial, trend-based monitoring as an adjunct to clinical assessment.Conclusion: While 2D-SWE is a promising physiological tool that can enrich our understanding of shock and organ dysfunction, it is not yet ready to dictate management.High-quality, context-specific research-particularly in high-burden settings like India-is required to transition this technology from hypothesis-generating to practice-changing.