Imaging-based fibrosis assessment and risk stratification in MASLD

Introduction Metabolic dysfunction-associated steatotic liver disease (MASLD) is now one of the leading causes of chronic liver disease worldwide. Fibrosis stage is the principal determinant of liver-related outcomes and overall mortality, yet liver biopsy is unsuitable for broad use because of invasiveness, sampling variability, and limited value for longitudinal assessment. Areas covered This review discusses imaging-based assessment of fibrosis in MASLD with emphasis on ultrasound elastography, magnetic resonance elastography, multiparametric MRI, and selected emerging tools. The discussion is organized around diagnostic performance, technical limitations, prognostic value, treatment monitoring, and integration with serum-based non-invasive tests. In addition, this review proposes a practical framework linking pathophysiological mechanisms, imaging biomarkers, and stepwise clinical decision-making pathways for risk stratification in MASLD. Expert opinion Imaging in MASLD now serves more than a diagnostic function. Ultrasound elastography remains the practical first-line imaging test because it can be deployed at scale and incorporated into referral algorithms. Magnetic resonance elastography offers the highest diagnostic confidence and is most useful when first-line tests are indeterminate, technically unreliable, or discordant with the clinical picture. Recent clinical pathways increasingly combine serum markers, elastography, quantitative magnetic resonance imaging (MRI), and longitudinal risk assessment rather than relying on a single modality or threshold.