Gastroscopy (upper gastrointestinal endoscopy) cannot detect fatty liver disease. This common misconception arises because endoscopy is a widely used diagnostic procedure, but it examines only the oesophagus, stomach, and duodenum—not the liver itself. Fatty liver disease, whether non-alcoholic (NAFLD) or alcohol-related (ARLD), requires different investigations including blood tests, ultrasound scanning, and non-invasive fibrosis assessment. Understanding which tests are appropriate for liver health ensures timely diagnosis and prevents unnecessary procedures. This article explains why endoscopy is not used for fatty liver detection and outlines the correct diagnostic pathway recommended by NICE and NHS guidance.
Summary: Endoscopy cannot detect fatty liver disease because it examines only the upper gastrointestinal tract and does not visualise liver tissue.
- Gastroscopy visualises the oesophagus, stomach, and duodenum but not the liver, which sits outside the gastrointestinal tract.
- Fatty liver disease is diagnosed using blood tests (liver function tests), abdominal ultrasound, and non-invasive fibrosis assessment tools.
- NICE recommends risk stratification using FIB-4 index or NAFLD Fibrosis Score, with Enhanced Liver Fibrosis (ELF) blood test or transient elastography for higher-risk patients.
- Endoscopy may reveal complications of advanced cirrhosis such as oesophageal varices, but these indicate late-stage liver disease rather than early fatty liver.
- Patients with risk factors including obesity, type 2 diabetes, or elevated liver enzymes should consult their GP for appropriate liver investigations.
- Early detection through correct diagnostic pathways enables lifestyle interventions that can prevent progression to cirrhosis.
Table of Contents
Am I eligible for weight loss injections?
Find out whether you might be eligible!
Answer a few quick questions to see whether you may be suitable for prescription weight loss injections (like Wegovy® or Mounjaro®).
- No commitment — just a quick suitability check
- Takes about 1 minute to complete
Can Endoscopy Detect Fatty Liver Disease?
Gastroscopy (upper gastrointestinal endoscopy) is not used to diagnose fatty liver disease. An endoscopy involves passing a flexible camera through the mouth to examine the oesophagus, stomach, and duodenum. Whilst this procedure is invaluable for investigating upper gastrointestinal symptoms such as persistent indigestion, bleeding, or swallowing difficulties, it does not provide direct visualisation of the liver.
The liver sits outside the gastrointestinal tract in the upper right abdomen, and standard endoscopic procedures do not reach or assess liver tissue. During an endoscopy, clinicians may observe indirect signs of advanced liver disease—such as oesophageal varices (enlarged veins) or portal hypertensive gastropathy—which indicate complications of cirrhosis. However, these findings reflect advanced liver disease with portal hypertension rather than early fatty liver disease.
Gastroscopy plays no role in detecting non-alcoholic fatty liver disease (NAFLD) or alcohol-related liver disease (ARLD). If your GP suspects fatty liver, they will arrange appropriate investigations such as blood tests and ultrasound rather than referring you for endoscopy. Endoscopy may be requested if you have symptoms suggesting upper gastrointestinal pathology alongside liver concerns, but it serves a different diagnostic purpose. Specialised endoscopic techniques such as endoscopic ultrasound (EUS) or ERCP are not used to diagnose fatty liver disease.
Understanding the limitations of each investigation helps patients and healthcare professionals select the most appropriate tests. If you are concerned about liver health, discussing your symptoms and risk factors with your GP will ensure you receive the correct diagnostic pathway, which does not include endoscopy as an investigation for fatty liver disease.
References: NHS Gastroscopy (endoscopy) page; NHS Non-alcoholic fatty liver disease (NAFLD) page.
How Fatty Liver Disease Is Diagnosed in the UK
Fatty liver disease diagnosis in the UK follows a structured approach combining clinical assessment, blood tests, and imaging. The condition is often identified incidentally during investigations for other health concerns, as early-stage fatty liver rarely causes symptoms. Your GP will begin with a thorough medical history, focusing on alcohol consumption, metabolic risk factors (obesity, type 2 diabetes, high cholesterol), and family history of liver disease.
Blood tests form the initial screening tool. Liver function tests (LFTs) measure enzymes such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST), which may be elevated in fatty liver disease. However, normal LFTs do not exclude the diagnosis, as many patients with significant hepatic steatosis have normal enzyme levels. Additional blood tests assess metabolic parameters including fasting glucose, HbA1c, and lipid profile. Your GP will also request tests to exclude other liver conditions such as viral hepatitis (hepatitis B surface antigen, hepatitis C antibody), autoimmune liver disease (autoantibodies), and haemochromatosis (ferritin and transferrin saturation).
Imaging provides direct evidence of hepatic steatosis. Ultrasound scanning is the most commonly used first-line imaging modality in UK primary and secondary care. It is non-invasive, widely available, and can identify moderate to severe fatty infiltration with reasonable accuracy. The sonographer assesses liver echogenicity (brightness) compared to the kidney, which appears characteristically increased in fatty liver. More advanced imaging techniques include transient elastography (FibroScan), which measures liver stiffness as a marker of fibrosis, and MRI-based methods used in specialist centres for precise fat quantification when indicated.
NICE guidance recommends risk stratification using validated scoring systems such as the FIB-4 index or NAFLD Fibrosis Score to identify patients who may have advanced fibrosis. If these scores are indeterminate or suggest higher risk, your GP may arrange an Enhanced Liver Fibrosis (ELF) blood test or refer you for transient elastography. Patients identified as having advanced fibrosis require specialist hepatology referral for further assessment and management.
References: NICE NG49 (Non-alcoholic fatty liver disease: assessment and management); NICE DG34 (ELF test for advanced liver fibrosis in NAFLD); BSG Guidelines on the management of abnormal liver blood tests (2017; update 2018); NHS Non-alcoholic fatty liver disease (NAFLD) page.
Recommended Tests for Detecting Fatty Liver
The diagnostic pathway for fatty liver disease involves several complementary investigations. Understanding which tests are appropriate helps patients navigate their healthcare journey and ensures timely detection of liver disease.
Liver function tests (LFTs) are typically the first investigation. These measure:
-
ALT and AST: Enzymes released when liver cells are damaged. Elevated levels suggest hepatocellular injury, though the degree of elevation does not always correlate with disease severity.
-
Alkaline phosphatase (ALP) and gamma-GT: May be mildly elevated in fatty liver disease.
-
Bilirubin and albumin: These assess synthetic liver function and are usually normal until advanced cirrhosis develops.
Prothrombin time (PT) or INR may be requested separately to assess synthetic liver function when indicated, particularly if advanced liver disease is suspected.
Abdominal ultrasound remains the cornerstone imaging investigation in UK practice. It is cost-effective, radiation-free, and readily accessible. Ultrasound can detect moderate to severe steatosis and may show features suggesting cirrhosis or portal hypertension (such as splenomegaly or portal vein changes). However, it has limited sensitivity for mild fatty infiltration and cannot reliably distinguish simple steatosis from steatohepatitis (inflammation).
Non-invasive fibrosis assessment is essential to identify patients at higher risk of progressive liver disease. NICE recommends a stepwise approach:
-
FIB-4 index or NAFLD Fibrosis Score: Calculated from routine blood tests and clinical data to stratify risk of advanced fibrosis.
-
Enhanced Liver Fibrosis (ELF) blood test: NICE-recommended second-line test when initial scores are indeterminate or suggest higher risk. The ELF test measures markers of liver fibrosis and helps identify patients who need specialist referral.
-
Transient elastography (FibroScan): Increasingly used in secondary care and some primary care settings. This specialised ultrasound technique measures liver stiffness (a surrogate marker for fibrosis) and can estimate hepatic fat content using the controlled attenuation parameter (CAP). It provides valuable prognostic information, as advanced fibrosis indicates higher risk of progression to cirrhosis.
Advanced imaging such as MRI with proton density fat fraction (MRI-PDFF) is mainly used in specialist centres for precise fat quantification when indicated, rather than being reserved solely for research.
Liver biopsy is considered the gold standard for definitive diagnosis and staging but is invasive and carries small risks. NICE recommends biopsy only when non-invasive tests are inconclusive or when distinguishing between different liver pathologies is essential for management decisions.
References: NICE NG49 (Non-alcoholic fatty liver disease: assessment and management); NICE DG34 (ELF test for advanced liver fibrosis in NAFLD); BSG Guidelines on the management of abnormal liver blood tests (2017; update 2018).
When to See Your GP About Liver Health
Early consultation with your GP is important if you have risk factors for fatty liver disease or concerning symptoms. Whilst fatty liver is often asymptomatic in early stages, certain circumstances warrant medical assessment.
You should arrange a GP appointment if you:
-
Have persistent fatigue or unexplained tiredness that affects daily activities
-
Experience discomfort or a sensation of fullness in the upper right abdomen
-
Notice unexplained weight loss or loss of appetite
-
Have risk factors including obesity (BMI >30 kg/m²), type 2 diabetes, high cholesterol, or metabolic syndrome
-
Regularly drink more than 14 units of alcohol per week (the UK Chief Medical Officers' low-risk drinking guideline for both men and women)
-
Have a family history of liver disease
-
Have been told you have abnormal liver blood tests
Seek urgent medical attention if you develop:
-
Yellowing of the skin or eyes (jaundice)
-
Severe abdominal pain or swelling
-
Vomiting blood or passing black, tarry stools—call 999 immediately
-
Confusion, severe drowsiness, or altered consciousness—call 999 immediately
-
Easy bruising or bleeding
These symptoms may indicate advanced liver disease or acute liver failure requiring immediate specialist assessment. If you are unsure whether your symptoms require emergency care, contact NHS 111 for urgent advice.
Your GP will conduct a comprehensive assessment including medical history, physical examination, and appropriate blood tests. They may calculate your risk of advanced liver disease using validated tools such as the FIB-4 index or NAFLD Fibrosis Score. If these suggest higher risk, your GP may arrange an Enhanced Liver Fibrosis (ELF) blood test or transient elastography, and determine whether specialist referral to hepatology services is necessary. Early detection of fatty liver disease allows implementation of lifestyle interventions—including weight loss, dietary modification, increased physical activity, and management of metabolic risk factors—which can prevent progression to more serious liver damage.
Regular monitoring is essential for patients diagnosed with fatty liver disease. Your GP will arrange follow-up appointments and repeat investigations to assess disease progression and response to lifestyle modifications, ensuring optimal long-term liver health outcomes.
References: NHS Non-alcoholic fatty liver disease (NAFLD) page; UK Chief Medical Officers' low-risk drinking guidelines; NHS: When to call 999 and when to go to A&E NICE NG49 (Non-alcoholic fatty liver disease: assessment and management).
Frequently Asked Questions
Why can't an endoscopy see fatty liver?
An endoscopy examines only the inside of the oesophagus, stomach, and duodenum using a flexible camera passed through the mouth. The liver sits outside the gastrointestinal tract in the upper right abdomen, so standard endoscopic procedures cannot reach or visualise liver tissue to detect fatty infiltration.
What test should I ask my GP for if I'm worried about fatty liver?
Your GP will typically arrange liver function tests (blood tests measuring ALT, AST, and other enzymes) and an abdominal ultrasound scan as first-line investigations. If these suggest fatty liver disease, your GP may calculate your fibrosis risk using the FIB-4 index or arrange an Enhanced Liver Fibrosis (ELF) blood test to assess whether specialist referral is needed.
Can endoscopy detect any signs of liver problems at all?
Endoscopy can reveal complications of advanced cirrhosis such as oesophageal varices (enlarged veins in the gullet) or portal hypertensive gastropathy, which indicate severe liver disease with portal hypertension. However, these findings reflect late-stage liver damage rather than early fatty liver disease, and endoscopy is not used as a screening or diagnostic tool for fatty liver itself.
What's the difference between an ultrasound and a FibroScan for fatty liver?
A standard abdominal ultrasound detects moderate to severe fatty infiltration by assessing liver brightness but cannot measure fibrosis (scarring). A FibroScan (transient elastography) is a specialised ultrasound that measures liver stiffness as a marker of fibrosis and can estimate fat content using the controlled attenuation parameter (CAP), providing more detailed prognostic information about disease progression risk.
How do I get a referral to a liver specialist if I have fatty liver disease?
Your GP will refer you to a hepatologist (liver specialist) if non-invasive fibrosis tests such as the FIB-4 index, NAFLD Fibrosis Score, Enhanced Liver Fibrosis (ELF) blood test, or FibroScan suggest you have advanced fibrosis or cirrhosis. Patients with indeterminate results or additional concerning features may also be referred for specialist assessment and management.
Can fatty liver be detected if my liver blood tests come back normal?
Yes, many patients with significant fatty liver disease have normal liver function tests, as enzyme levels do not always correlate with the degree of fat accumulation. If your GP suspects fatty liver based on risk factors such as obesity or type 2 diabetes, they will arrange an abdominal ultrasound even if blood tests are normal, as imaging provides direct evidence of hepatic steatosis.
The health-related content published on this site is based on credible scientific sources and is periodically reviewed to ensure accuracy and relevance. Although we aim to reflect the most current medical knowledge, the material is meant for general education and awareness only.
The information on this site is not a substitute for professional medical advice. For any health concerns, please speak with a qualified medical professional. By using this information, you acknowledge responsibility for any decisions made and understand we are not liable for any consequences that may result.
Heading 1
Heading 2
Heading 3
Heading 4
Heading 5
Heading 6
Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur.
Block quote
Ordered list
- Item 1
- Item 2
- Item 3
Unordered list
- Item A
- Item B
- Item C
Bold text
Emphasis
Superscript
Subscript
