Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as Nonalcoholic Fatty Liver Disease (NAFLD), has emerged as a global health concern, reflecting the growing burden of metabolic disorders worldwide. Initially characterized in 1980 as Nonalcoholic Steatohepatitis (NASH)-a liver pathology resembling alcohol-induced damage in non-drinkers-the disease was later termed NAFLD in 1986 to describe hepatic steatosis involving at least 5% of hepatocytes in the absence of significant alcohol intake [1-3]. In recognition of the strong association between hepatic steatosis and metabolic abnormalities such as insulin resistance, dyslipidemia, hypertension, obesity and type 2 diabetes mellitus, the nomenclature evolved to Metabolic-Associated Fatty Liver Disease (MAFLD) in 2020. Most recently, in 2023, an international Delphi consensus recommended adopting the term MASLD to more accurately reflect the underlying metabolic dysfunction driving the disease process [4-6].

The redefinition of this entity has emphasized phenotype-based classification, enhanced disease awareness and improved identification of at-risk individuals, including those with normal body weight but with metabolic derangements. Globally, MASLD affects nearly 38% of the population, with a significant rise observed in Asian countries. Despite the growing prevalence and its potential to progress to steatohepatitis, fibrosis, cirrhosis and hepatocellular carcinoma, MASLD remains underdiagnosed and underappreciated in routine clinical practice. Non-invasive diagnostic tools like transient elastography have significantly improved the detection of hepatic fat and fibrosis, allowing for earlier identification and intervention [7-9].

Gallstone Disease (GSD), a prevalent gastrointestinal disorder, shares several risk factors with MASLD, including obesity, diabetes, metabolic syndrome and dietary patterns influenced by urbanization and Western lifestyles. While previous studies have established a link between NAFLD and GSD, the potential relationship between GSD and MASLD-under the new diagnostic criteria-remains inadequately explored, especially in the Indian population [8-12].

Given the rising incidence of both conditions and their shared metabolic foundation, understanding the association between MASLD and gallstone disease has critical implications for preventive strategies, early diagnosis and comprehensive metabolic care. Moreover, clarifying whether the previously established link between GSD and NAFLD persists under the revised MASLD criteria is crucial for refining clinical protocols and health policies.

This study, therefore, aims to assess the prevalence of MASLD among patients with ultrasonography-confirmed cholelithiasis and to examine the relationship between MASLD severity-as determined by transient elastography-and gallstone disease. Through this, we seek to validate the metabolic continuum between hepatobiliary and metabolic pathologies in the context of evolving disease definitions.

Study Design and Setting

This prospective, observational, hospital-based study was conducted over a 12-month period from June 1, 2024, to May 31, 2025, in the Department of Surgery in collaboration with the Department of Gastroenterology at Indira Gandhi Medical College (IGMC), Shimla. The study involved adult patients from Himachal Pradesh, including both natives and immigrants, who presented with symptoms suggestive of Gallstone Disease (GSD).

Study Population and Eligibility Criteria

Patients visiting the outpatient departments of Surgery or Gastroenterology for evaluation of abdominal pain were screened for inclusion. Consecutive patients with ultrasonography-confirmed symptomatic cholelithiasis who consented to participate were enrolled in the study. Inclusion criteria were: age ≥18 years, diagnosis of gallbladder stones via ultrasonography and willingness to provide informed consent. Exclusion criteria included patients with choledocholithiasis, gallstone-induced pancreatitis, pregnancy, significant alcohol consumption, viral hepatitis (HBV or HCV), autoimmune hepatitis, Wilson’s disease, hemochromatosis, hepatobiliary malignancies, or coexisting gallbladder adenomyomatosis. Patients with any other known cause of fatty liver or cirrhosis apart from gallstones were also excluded.

Sample Size Determination

Sample size was calculated based on data from Zhao et al¹³, which reported a 33.8% prevalence of MASLD among patients with gallstone disease. Using the formula:

n = [Z(α/2)]² × P(1−P) / l²

with a 95% confidence interval (Z = 1.96), absolute error of 10% and adding a 10% non-response rate, the calculated sample size was approximately 95. However, to enhance statistical power and accommodate logistical constraints, a final sample of 131 patients was enrolled.

Study Procedure

All eligible patients underwent a structured clinical evaluation, including a detailed history and physical examination. Baseline demographic data such as age, gender, height, weight, body mass index (BMI) and waist circumference were recorded. Routine laboratory investigations included Complete Hemogram (CHG), Fasting Blood Sugar (FBS), renal function tests (RFT), serum electrolytes, Postprandial Blood Sugar (PPBS), chest X-ray and Electrocardiogram (ECG).

Study-specific investigations included liver function tests (LFT), glycated hemoglobin (HbA1c), lipid profile, Thyroid Function Tests (TFT), quantitative C-reactive protein (qCRP) and viral markers for hepatitis B and C. All patients underwent abdominal ultrasonography to confirm gallstone disease and assess hepatic steatosis. Those diagnosed with GSD subsequently underwent transient elastography (FibroScan) to evaluate liver steatosis and stiffness.

Transient Elastography Protocol

FibroScan was performed after overnight fasting using a 50 MHz ultrasound probe equipped with a transducer to assess liver stiffness by measuring the velocity of shear waves through hepatic tissue. The Controlled Attenuation Parameter (CAP) was used to quantify liver steatosis, while Liver Stiffness Measurement (LSM) assessed hepatic fibrosis. CAP values were reported in decibels per meter (dB/m) and LSM in kilopascals (kPa). CAP thresholds for grading steatosis were: ≥248 dB/m for mild (S1), ≥268 dB/m for moderate (S2) and ≥280 dB/m for severe (S3) steatosis.

Statistical Analysis

Data were compiled in spreadsheets and verified for completeness and accuracy. Statistical analyses were performed using IBM SPSS version 26.0. Descriptive statistics included means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Comparative analyses were conducted using the independent t-test or Mann–Whitney U test for continuous variables and the chi-square test for categorical variables. A p-value <0.05 was considered statistically significant. Results were summarized and presented using tables and illustrative diagrams.

The study population consisted of 161 patients with ultrasonography-confirmed gallstone disease. The mean age was 44.52±13.75 years, with the majority (58.4%) aged between 41 and 60 years, followed by 40.4% aged 18–40 years and only 1.2% above 60 years. A strong female predominance was observed, with 77.6% of the cohort being women, aligning with global trends in gallstone disease epidemiology. Among comorbidities, hypertension and thyroid disorders were the most common (each 9.9%), followed by diabetes mellitus (8.7%) and cerebrovascular accident (1.9%). Dyslipidemia and coronary artery disease were rare, each accounting for 0.6% of patients. Substance use was minimal, with alcohol use reported in 1.9% and tobacco use in 0.6%, indicating a largely non-alcoholic cohort consistent with MASLD diagnostic criteria (Table 1).

Table 1: Baseline Demographics and Comorbidities of the Study Population (N = 161)

Anthropometric analysis revealed a mean BMI of 25.66±4.33 kg/m² and a waist circumference of 85.35±11.95 cm, suggesting that a significant proportion of patients were overweight or centrally obese. Blood pressure readings were within normal limits on average (SBP 122.52±15.80 mmHg; DBP 77.99±9.67 mmHg). Biochemically, the mean fasting blood sugar was 100.98±13.94 mg/dL and HbA1c was 5.63±1.06%, indicating borderline glycemic control in many participants. Lipid profile data revealed elevated mean triglyceride levels (159.32±116.24 mg/dL) and suboptimal HDL levels (48.58±11.34 mg/dL), further reflecting a high prevalence of metabolic derangement. Inflammatory burden, assessed via qCRP, was modestly elevated (mean 3.63±4.27 mg/L), consistent with low-grade systemic inflammation characteristic of metabolic syndrome and MASLD (Table 2).

Table 2: Physical and Biochemical Characteristics of the Study Population (N = 161)

Ultrasound-based grading identified hepatic steatosis in 23% of the study population, with Grade 1 seen in 19.3% and Grade 2 in 3.7%, while the majority (77%) had normal hepatic echotexture. In contrast, FibroScan-based CAP scores provided a more sensitive detection of steatosis: 40.9% of patients had values above the diagnostic threshold (≥248 dB/m), with 11.8% falling into mild (S1), 8.1% into moderate (S2) and20.5% into severe (S3) categories. The mean CAP was 235.61±56.40 dB/m, LSM was 5.47±1.88 kPa and IQR was 7.99±8.87 kPa. These values suggest that although steatosis was present in a sizable proportion, advanced fibrosis was generally absent, as LSM values remained within early disease thresholds (Table 3).

Table 3: Hepatic Steatosis Grading and Transient Elastography Findings (N = 161)

All patients enrolled had gallstone disease, as per the study’s inclusion criteria. Among them, 66 (41%) met the diagnostic criteria for MASLD and a substantial 74.5% had MASLD coexisting with at least one Cardiometabolic Risk Factor (CMRF). The overall burden of CMRFs was notably high-90.1% of patients had one or more CMRFs. The most common clustering was of 3 CMRFs (27.3%), followed by 2 (25.4%) and 1 (18.0%). Notably, 7.5% of patients had all five assessed CMRFs, underlining a heavy metabolic load in this gallstone population. This supports the hypothesis that gallstone disease and MASLD share a common metabolic foundation, justifying integrated screening (Table 4).

Table 4: Prevalence of Gallstone Disease, MASLD and Cardiometabolic Risk Factors (CMRFs) in the Study Population (N = 161)

Comparative analysis of transient elastography metrics revealed that CAP values were significantly higher in patients with MASLD (289.77±32.10 dB/m) compared to non-MASLD individuals (197.99±34.82 dB/m, p<0.001), confirming increased hepatic steatosis in the MASLD subgroup. However, LSM and IQR values did not differ significantly between MASLD and non-MASLD groups (p = 0.490 and 0.252, respectively), again suggesting minimal fibrosis. Similarly, patients with CMRFs exhibited higher CAP values (238.23±56.62 dB/m) than those without (211.88±49.89 dB/m), though this difference did not reach statistical significance (p = 0.076). Most notably, individuals with both MASLD and CMRFs had significantly higher CAP scores (250.50±54.41 dB/m) than those with CMRFs but no MASLD (192.05±36.17 dB/m, p<0.001). Yet again, LSM and IQR did not differ meaningfully. These findings underscore the value of CAP in detecting early-stage steatosis, while also illustrating that fibrosis progression may not be prominent in such high-risk metabolic groups at the time of diagnosis (Table 5).

Table 5: Association of MASLD and Cardiometabolic Risk Factors (CMRFs) with Transient Elastography Parameters (N = 161)

This prospective study investigated the prevalence of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) among patients with Gallstone Disease (GSD) and analyzed its association with transient elastography parameters. Among the 161 patients with ultrasonography-confirmed cholelithiasis, MASLD was identified in 41% of individuals. This finding closely mirrors the 33.8% MASLD prevalence in newly diagnosed GSD patients reported by Zhao et al¹³, indicating that a substantial proportion of GSD patients harbor hepatic steatosis as defined by modern metabolic criteria. The average age of participants was 44.52±13.75 years, with the majority (58.4%) in the 41–60-year age range. A marked female predominance (77.6%) was observed, which aligns with global epidemiological trends attributing higher GSD prevalence among women to hormonal factors such as estrogen-induced bile cholesterol saturation [11,12].

Cardiometabolic Risk Factors (CMRFs) were highly prevalent in the study cohort, with 90.1% of patients having at least one metabolic risk factor and 74.5% presenting with both MASLD and CMRFs. Hypertension and thyroid dysfunction were each present in 9.9% of patients, while diabetes mellitus was noted in 8.7%. These findings are in agreement with those of Lin et al.  [14] and Ahmed et al.  [15], who described a strong correlation between gallstones, obesity, insulin resistance and dyslipidemia. The clustering of these risk factors reinforces the understanding that MASLD is not an isolated liver disorder, but rather the hepatic component of systemic metabolic syndrome. Furthermore, it highlights the necessity of comprehensive cardiometabolic assessment in patients presenting with GSD.

Ultrasound examination revealed fatty liver in 23% of the cohort, including Grade 1 steatosis in 19.3% and Grade 2 in 3.7%, while no patients showed Grade 3 changes. However, Transient Elastography (TE) using Fibroscan revealed a markedly higher prevalence of hepatic steatosis based on Controlled Attenuation Parameter (CAP) values, with 40.9% of patients exceeding the diagnostic threshold. CAP scores were significantly higher in MASLD patients (289.77±32.10 dB/m) compared to those without MASLD (197.99±34.82 dB/m, p<0.001), confirming TE as a more sensitive tool for detecting liver fat. In contrast, Liver Stiffness Measurement (LSM) did not differ significantly between MASLD and non-MASLD groups (5.59±1.77 vs. 5.38±1.96 kPa, p = 0.490), suggesting that the majority of MASLD cases represented early-stage disease without substantial fibrosis. These results support observations by Roesch-Dietlen et al. [16], who reported limited sensitivity of ultrasound and improved diagnostic performance of elastography-based techniques in detecting hepatic steatosis.

Patients with both MASLD and CMRFs demonstrated significantly higher CAP scores (250.50±54.41 dB/m) compared to those without MASLD/CMRF (192.05±36.17 dB/m, p<0.001), underscoring a cumulative impact of metabolic burden on liver fat deposition. However, no statistically significant differences were noted in LSM Or Interquartile Range (IQR) across groups, indicating minimal fibrotic progression. These findings are consistent with the revised MASLD diagnostic framework, which places metabolic risk at the center of disease pathogenesis [3-5]. Eslam et al. [2] emphasized the clinical relevance of identifying steatotic liver disease based on phenotypic metabolic criteria rather than exclusion-based definitions and our results reaffirm the utility of this approach in capturing at-risk patients.

The high co-prevalence of MASLD and CMRFs among GSD patients in this study reinforces the importance of integrated metabolic screening in patients presenting with gallstones. Given the rising incidence of metabolic syndrome in India, driven by sedentary lifestyles and dietary westernization, the dual burden of MASLD and GSD is likely to intensify. From a clinical perspective, this warrants the adoption of proactive strategies, including the use of Fibroscan for routine screening in GSD patients with metabolic risk factors, early initiation of lifestyle modifications and consideration of pharmacological or surgical interventions-such as GLP-1 receptor agonists or bariatric surgery-for those with significant steatosis and comorbidities.

Our findings are in strong concordance with the existing body of literature. Loria et al. [17] and Koller et al.  [18] demonstrated an elevated prevalence of gallstones in patients with NAFLD, highlighting a shared pathophysiological basis. Sogabe et al. [19] further elucidated that steatosis severity correlates with gallstone formation, particularly in patients over the age of 50, a trend also reflected in our study’s older age group. The new MASLD nomenclature and diagnostic guidelines proposed by the Delphi consensus appear to offer improved clinical sensitivity, enabling better stratification of patients with overlapping metabolic and hepatobiliary risk profiles [3].

Strengths and Limitations

A major strength of this study is its prospective design and systematic use of transient elastography in a well-defined population. The use of the most recent MASLD criteria also strengthens the clinical relevance of the findings. Nonetheless, limitations include its single-center scope, which may limit generalizability and the absence of liver biopsy for histological confirmation. Moreover, while exclusion of patients with alcohol use and viral hepatitis ensured diagnostic clarity, it may have narrowed the spectrum of steatotic liver disease captured. Future studies with multicenter collaboration, longitudinal follow-up and incorporation of histopathology would offer deeper insights into the natural history of MASLD in GSD populations.

Future Research Directions

There is a need for long-term follow-up studies to assess the progression of hepatic steatosis and potential fibrotic evolution in MASLD patients with GSD. Inclusion of liver biopsy, advanced imaging and molecular markers-including genetic susceptibility and gut microbiome analysis-may help to delineate high-risk phenotypes and guide personalized treatment strategies. Additionally, evaluating the efficacy of early interventions targeting metabolic risk in preventing both gallstones and hepatic complications should be prioritized in future research agendas.

In conclusion, this prospective observational study establishes a significant association between metabolic dysfunction-Associated Steatotic Liver Disease (MASLD) and Gallstone Disease (GSD), revealing that 41% of cholelithiasis patients also fulfilled MASLD criteria, with the majority exhibiting one or more Cardiometabolic Risk Factors (CMRFs). The strong correlation between elevated Controlled Attenuation Parameter (CAP) values and MASLD underscores the utility of transient elastography as a non-invasive, sensitive tool for early steatosis detection. Importantly, the absence of significant differences in Liver Stiffness Measurement (LSM) and Interquartile Range (IQR) across groups suggests that most MASLD cases were in early, potentially reversible stages. These findings highlight the shared pathophysiological underpinnings of MASLD and GSD particularly insulin resistance, obesity and dyslipidaemia and emphasize the urgent need for integrated metabolic screening in patients with gallstones. Adopting the updated MASLD framework enhances clinical identification of at-risk individuals and supports a paradigm shift toward preventive hepatobiliary care. Routine Fibroscan screening, along with early lifestyle and pharmacologic interventions in GSD patients with metabolic risk, may offer a strategic window to mitigate progression to advanced liver disease, reduce the dual disease burden and improve long-term outcomes in the Indian population and beyond.

Ethical Approval

Ethical approval was obtained prior to study initiation. Informed written consent was secured from all participants in their native language after explaining the study purpose and procedures. Participation was voluntary and patients were free to withdraw at any time without affecting their clinical care. No financial burden was imposed on participants for any part of the study. Data confidentiality was strictly maintained throughout data collection, storage and publication processes.

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