Jessica Davis, MD, transplant hepatologist and director of liver transplant at the DC VA Medical Center with academic appointments at Georgetown University, explains how MASLD is diagnosed and evaluated, highlighting key tests and procedures.

So most patients first hear about MASLD, or metabolic-associated steatotic liver disease, at their primary care office. And then some of those patients may be referred to see a specialist in gastroenterology or even a subspecialist in hepatology.

As far as the initial tests and screenings, most of the time the patient is diagnosed initially with blood work. So you may have for example, elevated liver enzyme tests on routine blood work from your primary care doctor.

Other times, patients come to me after they’ve had an ultrasound, for another reason, of their liver, and the ultrasound may show some evidence of fat in the liver as well.

Once the patient has findings on blood work or ultrasound that are concerning for MASLD, then the next step usually is to look and see if there’s any evidence of scar in the liver already. Generally, to begin with, we do some calculations based off the basic blood work that you have, and those may give us an idea: If your score looks really well based off some of those calculations, for example, the FIB-4 test, then you may not need any further testing or screening.

If the Fib-4 test or another test that’s looking for evidence of scar based off blood work shows that you potentially have scar, then generally, you’ll be referred to get some kind of further testing for scar itself.

Those tests fall into two categories: noninvasive or invasive testing. The noninvasive test, the most common one, would be transient elastography, or FibroScan test, which is an ultrasound-based test that looks specifically at scar in the liver. And then the most common invasive test would be actually, a liver biopsy, where they take a small sample of the liver itself to look underneath the microscope.

As far as what to expect when you go to get transient elastography or FibroScan tests, you go in — this is done in the clinic, it’s nothing that requires sedation — it’s similar to a regular ultrasound in a sense that you have a probe over your abdomen where the liver is, with some jelly.

The technology is interesting. It’s actually based off of sound wave. So the ultrasound probe itself gives you a little flick; it feels like you’re getting flicked. And then the sound waves travel through the liver and bounce back to the probe. Based off how quickly they return to the probe, we can calculate how stiff the liver is, which shows us how much scar is there.

If you end up being referred for a liver biopsy, those are outpatient — they are procedures. In general, most people get local anesthesia for the area where the needle is gonna go, which is just under your rib cage on your right side, and then some light sedation. But most people are not put fully to sleep. The needle goes in and takes a small sample of the liver.

I used to do liver biopsies, I had some people say, “Oh, that’s it,” and it would be over before they even had it. And then other people may have some pain during the procedure and just after the procedure that requires pain medication. But I never had to send anyone home on pain medication.