**Background:** Cirrhosis represents the common endpoint of chronic liver disease, driven by recurrent cellular damage, diffuse fibrosis, and nodular regeneration. In children, cirrhosis is rare but its incidence is increasing. Common etiologies vary by age: biliary atresia and inherited metabolic disorders predominate in neonates and young children, while autoimmune hepatitis, chronic viral hepatitis, Wilson disease, alpha-1-antitrypsin deficiency, cardiac causes, and NAFLD are more frequent in older children and adolescents. Diagnosis is often delayed due to a long silent clinical phase. Imaging plays a multifaceted role: initial detection, noninvasive fibrosis staging, monitoring disease progression, identifying complications (portal hypertension, HCC), and evaluating patients for liver transplantation.
**Methods:** This is a narrative review summarizing the role of imaging in pediatric cirrhosis. The authors discuss ultrasound (US), MRI, and CT techniques. US is the primary modality due to its availability and noninvasiveness. A multiparametric US approach includes B-mode imaging (morphology, texture, liver surface nodularity), color Doppler (hepatic vasculature, portal flow velocity, resistive index, hepatic vein waveform), and elastography (VCTE, pSWE, 2-D SWE). MRI and CT are second-line, reserved for specific questions; younger children often require sedation. MRE uses an external driver to generate shear waves and produces cross-sectional elastograms covering the entire liver. Automated texture analysis, DWI, ADC mapping, T1/T2/T1rho mapping, and quantitative fat fraction/iron measurement are discussed as advanced techniques.
**Key Results:** Morphological signs of cirrhosis include hepatomegaly in early stages, later volume loss with lobar hypertrophy (left lateral segments 2/3) and hypotrophy (right lobe, medial segment 4), nodular liver contour, capsular retraction, and textural coarseness on US. However, conventional US has relatively low sensitivity for detecting cirrhosis/high-grade fibrosis. Normal liver stiffness values in children vary by technique and vendor: VCTE 3.4–4.1 kPa (age-dependent), 2-D SWE 4.9–5.2 kPa, MRE 2.1–2.45 kPa. For staging significant fibrosis (≥F2 METAVIR): VCTE meta-analysis (723 children) reported 95% sensitivity and 90% specificity (cutoff 10.6 kPa); ARFI meta-analysis (550 children) reported 81% sensitivity and 91% specificity (2-D SWE median cutoff 9.4 kPa); MRE in children showed 88% sensitivity and 85% specificity (cutoff 2.7 kPa). In neonatal cholestasis, VCTE differentiated biliary atresia from other causes with 80% sensitivity and 97% specificity (cutoff >7.7 kPa). Spleen stiffness was the best predictor for esophageal varices in biliary atresia (2-D SWE >4.12 m/s, sensitivity 92.9%, specificity 90%). For predicting high-risk varices, spleen stiffness outperformed liver stiffness (sensitivity 77% vs. 67%, specificity both 87%). Elevated liver stiffness is not specific to fibrosis and can result from congestion (e.g., Fontan patients: median 15.6 vs. 5.5 kPa in controls), inflammation, or cellular infiltration. In autoimmune hepatitis, liver stiffness decreases after immunosuppression (delta -6.5 kPa at 12 months in one case).
**Clinical Implications:** Imaging is essential across the entire diagnostic pathway for pediatric cirrhosis. US with elastography enables noninvasive fibrosis staging, reducing the need for liver biopsy. Longitudinal stiffness measurements can monitor disease activity and treatment response (e.g., autoimmune hepatitis, Fontan-associated liver disease). Spleen stiffness measurement may improve noninvasive risk stratification for portal hypertension and variceal bleeding, though pediatric-specific thresholds require further validation. For HCC surveillance in at-risk children (e.g., biliary atresia, tyrosinemia type 1, PFIC type 2, glycogen storage disease type 1), US every 6–12 months with AFP measurement is recommended. When a focal lesion is detected, contrast-enhanced US and MRI with hepatobiliary contrast agents (LI-RADS guidelines) are recommended for characterization. CT is reserved for staging and preoperative vascular assessment. The authors emphasize that imaging findings must be interpreted in the context of the underlying disease, as stiffness can be confounded by congestion, inflammation, or steatosis.