Integrating Non-Invasive Liver Assessment into Screening Colonoscopy: A Prospective Cross-Sectional Study

Introduction: Steatotic liver disease is underdiagnosed despite guideline recommendations for risk-based case-finding. Colorectal cancer (CRC) screening colonoscopy engages a prevention-oriented, healthcare-seeking population in whom liver disease may go undetected. We assessed the feasibility, acceptance, and yield of non-invasive liver assessment integrated into screening colonoscopy visits. Methods: This prospective cross-sectional study enrolled adults aged ≥50 years attending screening colonoscopy. Individuals with known chronic liver disease were excluded. Participants underwent hepatic ultrasound and point shear wave elastography. Liver stiffness measurements (LSM) were interpreted using prespecified thresholds of 1.30, 1.50, and 1.70 m/s (∼5, 7, and 9 kPa, respectively). We assessed whether risk-factor–based criteria would have identified participants with elevated stiffness, and evaluated the Fibrosis-4 index (FIB-4) against LSM thresholds. Results: Of 692 adults offered participation, 610 enrolled (88.2% acceptance); one was excluded for decompensated heart failure. Reliable LSM was obtained in 578 of 609 (94.9%). Ultrasound-defined steatosis was identified in 55.5%. LSM exceeded 1.30 m/s in 25.3%; 9.0% and 5.0% met thresholds consistent with significant fibrosis (≥1.50 m/s) and compensated advanced chronic liver disease (≥1.70 m/s), respectively. Among participants with LSM ≥1.50 m/s, exposure profiles were metabolic in 63.5%, mixed metabolic–alcohol in 21.2%, and alcohol-related in 15.4%. Risk-factor criteria were met by 76.6% and captured 46/52 participants with LSM ≥1.50 m/s. At this threshold, FIB-4 showed modest discrimination (AUROC 0.682); sensitivity decreased from 0.706 using a single threshold to 0.529 using age-adjusted thresholds. Discussion: Opportunistic liver assessment integrated into screening colonoscopy was feasible, well accepted, and identified previously undetected steatosis and elevated LSM.