Liver cirrhosis (LC) is the end stage of various forms of chronic hepatitis of different etiologies and is a diffuse process typified by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules surrounded by annular fibrosis. It can also progress to liver cell failure and portal hypertension, which can trigger the onset of hepatocellular carcinoma. 

Liver biopsy is currently considered as the reference standard to assess both the necroinflammatory (grading) and the fibrosis (staging) components. However, it has some limitations, as it usually over- or under-estimate the degree of progression of liver disease in 1/3 cases as it samples only a small portion of the liver. In addition, liver biopsy may lead to some moderate or severe complications and mortality. 

In view of these limitations, alternative tools have been developed to replace liver biopsy when evaluating liver fibrosis. Serum markers provides  a cost-effective alternative to liver biopsy wit insignificant complications. They can be categorized into direct and indirect markers which may be used alone or in combination to generate composite scores. Hyaluronan, previously known as hyaluronic acid is an anionic, non-sulfated glycosaminoglycan extensively distributed throughout connective, epithelial, and neural tissues. It is presently regarded as one of the best direct markers of fibrosis, with sensitivity and specificity values of 86%-100% and 88% respectively in NAFLD and in fibrosis related to other etiologies.

Diagnostic imaging comprises of numerous instruments and techniques to assess liver fibrosis and cirrhosis like ultrasound (US), US Doppler, contrast enhanced US and Elastography. US is cost-effective, non-invasive, readily available and acceptable to patients. Various international guidelines recommends US for determining the large spectrum of chronic liver disease (CLD). The diagnostic tool offers data on the morphologic changes taking place in the liver along with CLD complications such as portal hypertension. In addition, it can also help in the early detection of HCC. However, US does not have the potential to evaluate progression of fibrosis, for which Elastography is more reliable.

Source: Soresi M, Giannitrapani L, Cervello M, Licata A, Montalto G. Non invasive tools for the diagnosis of liver cirrhosis. World J Gastroenterol. 2014;20(48):18131-18150.