Intraoperative liver biopsy reveals a high burden of occult metabolic-associated fatty liver disease in patients undergoing laparoscopic cholecystectomy

Introduction Conventional B-mode ultrasonography (US) is the most widely used imaging modality for detecting hepatic steatosis but has limited ability to assess steatohepatitis and fibrosis. This study evaluated the correlation between qualitative sonographic findings and histopathological features in patients undergoing laparoscopic cholecystectomy with intraoperative liver biopsy. Methods In this prospective observational study, 603 consecutive adults undergoing elective laparoscopic cholecystectomy with intraoperative wedge liver biopsy were included. Preoperative B-mode US was used to qualitatively grade hepatic steatosis, which was compared with histopathological findings using the NAFLD Activity Score and fibrosis staging. Diagnostic performance of US was assessed using histopathology as the reference standard. Multivariable logistic regression identified predictors of definite non-alcoholic steatohepatitis (NASH) and clinically significant fibrosis (stage ≥2). Results Of the 603 patients (mean age 43.8 ± 12.9 years; 65.5% female), 442 (73.3%) had sonographic steatosis and 161 (26.7%) had normal US findings. Sonographic steatosis grade showed significant but weak correlations with histological steatosis (ρ=0.308), lobular inflammation (ρ=0.231), hepatocyte ballooning (ρ=0.201), and fibrosis stage (ρ=0.149) (all p<0.001). Histological steatosis was identified in 19.9% of patients with normal US, while 23.6% had lobular inflammation, 62.7% had hepatocyte ballooning, and 47.5% had clinically significant fibrosis. Ultrasonography demonstrated a sensitivity of 85.7%, specificity of 34.0%, positive predictive value of 43.4%, negative predictive value of 80.1%, and Cohen's κ of 0.165 for detecting histological steatosis. Sonographic steatosis grade modestly improved fibrosis prediction but overall discrimination remained limited (AUROC 0.599). Conclusions Conventional B-mode ultrasonography is sensitive for detecting hepatic steatosis but has poor specificity and limited ability to identify steatohepatitis or clinically significant fibrosis. Significant histological liver disease may be present despite normal sonographic findings, supporting the use of complementary non-invasive fibrosis assessment and selective liver biopsy for comprehensive disease staging.