Background:Non-alcoholic fatty liver disease (NAFLD) is a growing global health concern, affecting approximately25% of adults worldwide (WHO). The disease spectrum ranges from simple steatosis to non-alcoholicsteatohepatitis (NASH), which can progress to fibrosis, cirrhosis, and liver cancer. Complications such asportal hypertension and esophageal varices pose diagnostic challenges due to the limitations of traditionalinvasive methods like hepatic venous pressure gradient (HVPG) measurement and endoscopy, which arecostly, not widely accessible, and carry inherent risks.Objectives:This review aims to evaluate the effectiveness of non-invasive techniques for diagnosing portalhypertension and variceal bleeding in patients with NAFLD cirrhosis. It seeks to identify the most reliableand accurate non-invasive diagnostic methods and compare them with invasive techniques such as HVPG and esophagogastroduodenoscopy (EGD).Search Methods:A comprehensive and systematic literature search was conducted across databases including PubMed, Cochrane Library, Google Scholar, and ScienceDirect.Selection Criteria: Studies were selected based on predefined eligibility criteria, focusing on adult participants with confirmed NAFLD cirrhosis and the evaluation of non-invasive diagnostic techniques for portal hypertension and variceal bleeding.Data Collection and Analysis:Data extraction covered study characteristics, participant demographics, and diagnostic accuracy metrics such as sensitivity, specificity, PPV, NPV, and DOR. Two independent reviewers performed the extraction, resolving discrepancies through discussion. The quality of included studies was assessed using theQUADAS-2 tool, focusing on bias risk and applicability.Main Results:The review identified 11 studies with a total of 2,707 patients. Liver stiffness measurement (LSM) using transient elastography demonstrated high sensitivity (85%) and specificity (79%) for diagnosing clinically significant portal hypertension (CSPH) at a cutoff value of 20 kPa. For severe portal hypertension (SPH), LSM had a sensitivity of 81% and specificity of 85% at a threshold of 25 kPa. The combination of LSM and platelet count showed high sensitivity (97-98%) for detecting esophageal varices (EV) and high-risk esophageal varices (HREV), but lower specificity (32-74%). Spleen stiffness measurement (SSM)exhibited good diagnostic performance, with a sensitivity of 89% and specificity of 75% for CSPH at acutoff of 40 kPa. Real-time tissue elastography (RTE) showed a sensitivity of 90% and specificity of 51%for CSPH. The Liver Stiffness-Spleen Diameter to Platelet Ratio Score (LSPS) demonstrated a sensitivityof 89% and specificity of 75% for diagnosing HREV.Authors' Conclusions:Non-invasive tests, particularly LSM and SSM, have shown promising diagnostic accuracy for identifying portal hypertension and variceal bleeding complications in NAFLD patients. The high sensitivity of thesetests, especially when used in combination, supports their role in ruling out these conditions in clinicalsettings. The specificity of LSM at higher thresholds underscores its utility in confirming diagnoses of CSPH, SPH, and HREV. Further research is needed to address variability in test performance, standardize protocols, and explore the integration of novel biomarkers and imaging modalities to enhance diagnostic precision and clinical applicability. The value of NITs in reducing the need for invasive diagnostics and improving patient management is significant, making them a valuable addition to clinical practice.Keywords:Non-alcoholic fatty liver disease (NAFLD), Portal hypertension, Variceal bleeding, Non-invasive tests, Liver stiffness measurement (LSM), Transient elastography, Spleen stiffness measurement (SSM), Diagnostic accuracy, Sensitivity, Specificity, Cirrhosis, Esophageal varices, High-risk esophageal varices, Hepatic venous pressure gradient (HVPG), Esophagogastroduodenoscopy (EGD), Chronic liver disease.