In the LITMUS imaging study, we assessed non-invasive alternatives to liver biopsy histopathology in metabolic dysfunction-associated steatotic liver disease (MASLD). Elastography and elastography-based composite scores had sufficient diagnostic accuracy to replace liver biopsy histopathology in evaluating advanced fibrosis and cirrhosis, but no markers were accurate enough for diagnosing metabolic dysfunction-associated steatohepatitis (MASH).