At least one third of Australian adults have Steatotic liver disease (SLD), i.e. fatty liver. B-mode ultrasound is the first-line diagnostic test for SLD in Australia, however the reporting is often subjective and it is inadequate for grading and associated fibrosis assessment. SLD is no longer considered a benign entity with low morbidity. In contrast, it has now been identified as a key element in estimation of cardiometabolic disease risk, the development of HCC and/or cirrhosis and ultimately hepatic failure.
In parallel with the development of numerous ‘liquid’ biomarkers and algorithms that combine anthropometric and laboratory parameters, innovative hepatic imaging techniques have increasingly been developed to attempt to overcome the need for biopsy, both in diagnosis, staging and in the follow-up of SLD.
Today’s lecture addresses the strengths and weaknesses of these imaging techniques, as well as the appropriate role of these technologies.

Hepatocellular carcinoma (HCC) remains a major global health challenge, particularly among patients with chronic liver disease and cirrhosis. Early detection through systematic screening and surveillance is critical for improving patient outcomes. Ultrasound (US) is the primary imaging modality for HCC surveillance, but variability in interpretation and reporting can impact diagnostic accuracy and clinical decision-making.

The Liver Imaging Reporting and Data System (LI-RADS) for ultrasound (US LI-RADS) was developed to standardise HCC surveillance reporting, improve diagnostic confidence, and enhance communication between sonographers, radiologists, and clinicians. However, successful implementation requires training, workflow integration, and an understanding of its clinical implications.

This talk will cover:
The rationale for HCC surveillance and the role of ultrasound in high-risk populations.
US LI-RADS categories (US-1 to US-3) and their clinical significance.
Challenges in real-world implementation, including operator variability and lesion characterisation limitations.
Strategies for integrating US LI-RADS into routine practice, including structured reporting, quality assurance, and multidisciplinary collaboration.

By standardising HCC surveillance with US LI-RADS, we can enhance early detection, optimise patient management, and improve outcomes for at-risk populations.

Chronic liver disease encompasses a large number of conditions that result in impaired liver function, the most common in Australia being chronic viral hepatitis and alcoholic liver disease, but more recently with non-alcoholic fatty liver disease becoming the most predominant cause for concern. The stage and progression of both hepatosteatosis and fibrosis has important clinical implications and impacts management of these patients with chronic liver disease.

The use of shearwave has grown rapidly over the last 15 years and has become readily accepted by referrers as an accurate method of fibrosis scoring for patients with chronic liver disease. This increased confidence in its ability to score liver fibrosis has led to a reduced number of liver biopsies being performed.

We have been utilising elastography at Royal Melbourne Hospital since 2012 and it is an important technology in our every-day ultrasound Liver imaging. With the increasing demand for management of these patients, it is now a tool found in many radiology practices, whether they be in the public or private sectors.

Elastography accuracy can be very operator dependant, and it isn’t an examination that you can attempt without training, and this is a crucial factor in improving interobserver reproducibility. Before sonographers begin using elastography it is important to be educated and learn from colleagues who are experienced, or by engaging in webinars or workshops to understand the technology and the protocols required.

This presentation will describe the scanning requirements that are necessary to help in diagnosis of fibrosis utilising liver elastography.

This session explores the challenges and nuances of assessing pancreatic lesions using ultrasound through a case-based format. Given the pancreas’s deep location and the limitations of ultrasound, accurate evaluation requires optimised technique and an understanding of key imaging features. Using real-world cases, this talk will cover the differentiation of cystic and solid pancreatic lesions. Discussion will focus on when ultrasound findings warrant further evaluation with CT, MRI, or EUS, providing practical insights to enhance diagnostic confidence and clinical decision-making.

Introduction: Hepatic steatosis, commonly known as fatty liver disease, is a rapidly emerging health issue linked to cardiometabolic conditions such as obesity and type 2 diabetes. Recent nomenclature and classification changes aim to reflect its aetiology and reduce stigma. This presentation addresses these updates and ultrasound’s role in diagnosing and monitoring steatosis.
Methods: A comprehensive review of current literature examines recent guidelines, nomenclature updates and their clinical significance for sonographers. The technologies used to assess hepatic fat are examined, with an emphasis on ultrasound technology.
Results: The transition in terminology from non-alcoholic fatty liver disease (NAFLD) to metabolic dysfunction-associated steatotic liver disease (MASLD) and the introduction of steatotic liver disease (SLD) classifications have expanded diagnostic criteria. Advancements in quantitative ultrasound techniques, including attenuation coefficient (AC) and backscatter coefficient (BSC) measurements, provide more objective and precise assessments than traditional B-mode ultrasound. Incorporating liver fat evaluation into routine ultrasound examinations can enhance diagnostic accuracy, improve monitoring, and reduce healthcare costs.
Conclusion: The increasing prevalence of metabolic syndrome and steatotic liver disease poses huge economic and health implications. Updates in classification systems and ultrasound technology significantly impact sonography practice, with sonographers playing a crucial role in detection and monitoring.
Take home message: Sonographers must stay informed about classification updates and ultrasound advancements, as their role in diagnosing and monitoring hepatic steatosis is expected to expand.

Introduction: Hepatic steatosis is a growing global health concern, requiring accurate, non-invasive methods for diagnosis and management. Magnetic resonance imaging proton density fat fraction (MRI-PDFF) is an established reference standard for non-invasive liver fat quantification, but its utility is limited by accessibility and cost. Advances in ultrasound-based methods, such as ultrasound-derived fat fraction (UDFF), offer a potential, cost-effective alternative. This study evaluates the accuracy and reproducibility of UDFF compared to MRI-PDFF and examines factors influencing reliability.
Methods: This ongoing study involves adult patients with liver steatosis and Fibroscan scores <8 kPa. Same-day MRI-PDFF imaging (3T Siemens Magnetom Prisma) and UDFF measurements (Siemens ACUSON Sequoia) were acquired using standardised protocols. Repeated acquisitions were acquired at various depths by multiple operators, where possible, to assess inter- and intra-operator variability. Patient demographics and clinical data were also collected to evaluate trends.
Results: Preliminary findings demonstrate strong agreement between UDFF and MRI-PDFF, particularly at lower fat levels, with intra- and inter-operator variability coefficients of variation below 15% and intraclass correlation coefficients exceeding 0.85. Agreement appears to decrease with higher fat levels, suggesting a potential threshold for reliability.
Conclusion: UDFF demonstrates substantial potential as a reliable, non-invasive technique for liver fat quantification, particularly in patients with lower fat levels.
Take Home Message: UDFF is a promising tool for assessment of hepatic steatosis. Further research with larger cohorts is required to refine protocols and evaluate clinical impact.