Evaluating the Role of Ultrasonography in Diagnosing Alcohol-associated Liver Disease in Low-resource Settings: A Critical Review of Current Evidence

Abstract Alcohol-associated liver disease (ALD) remains to be a significant contributor toward the global morbidity and mortality, with a predominant impact in low-resource settings (LRSs) where the latest and advanced diagnostic modalities are often inaccessible. Although liver biopsy and transient elastography are considered diagnostic benchmarks, their implementation is frequently limited by cost, accessibility, and technical constraints in such regions. In contrast, ultrasonography offers a cost-effective and widely deployable imaging modality suitable for use in resource-constrained environments. This review examines current literature published since 2015 to evaluate the diagnostic utility of ultrasonography in identifying and staging ALD within LRS. Key sonographic features – including hepatic echotexture alterations, morphologic changes, and signs suggestive of portal hypertension – were analyzed for their diagnostic performance. Ultrasonography demonstrates considerable reliability in detecting hepatic steatosis and advanced cirrhosis, with reported sensitivities approaching 89% and 88%, respectively; however, its sensitivity in identifying early-stage fibrosis remains limited. Diagnostic accuracy improves substantially when ultrasonographic findings are integrated with non-invasive serological indices such as the aspartate aminotransferase-to-Platelet Ratio Index and Fibrosis-4 scores. Factors such as operator expertise, imaging protocol consistency, and equipment quality significantly influence diagnostic yield. Despite inherent limitations, ultrasonography continues to serve as a first-line diagnostic tool for ALD in LRS. Its strategic incorporation into broader diagnostic frameworks may enhance clinical evaluation and facilitate timely management, especially in environments with limited healthcare infrastructure.