Updated: 10/9/2019

Nonalcoholic Steatohepatitis (NASH)

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Snapshot
  • A 40-year-old obese woman with a history of diabetes presents to her primary care physician for a routine visit. She denies having any complaints. On physical exam, her physician notices mild hepatomegaly without tenderness to palpation. To address this, a liver enzyme panel is sent and reveals elevated transaminases. She is sent for a hepatic ultrasound to evaluate for nonalcoholic fatty liver disease or steatohepatitis.
Introduction
  • Overview
    • nonalcoholic fatty liver disease (NAFLD) is characterized by fatty changes in the liver in patients without a history of alcoholism
      • this may lead to inflammation and lobular hepatitis or nonalcoholic steatohepatitis (NASH)
      • causes chronic hepatitis
  • Epidemiology
    • incidence
      • common
    • demographics
      • can affect adults and adolescents
    • risk factors
      • obesity
      • hyperlipidemia
      • hypertriglyceridemia
      • diabetes or insulin resistance
  • Pathogenesis
    • mechanism
      • high levels of lipids or triglycerides, insulin resistance, and increased body weight cause fat to accumulate within the hepatic cells, resulting in decreased rate of metabolizing and excreting fat
      • this results in inflammation and eventually fibrosis of the liver
Presentation
  • Symptoms
    • often asymptomatic
    • common symptoms
      • vague abdominal discomfort
  • Physical exam
    • inspection
      • hepatomegaly
Imaging
  • Ultrasound of the liver
    • indications
      • all patients
    • findings
      • steatohepatitis
        • increased echogenicity
        • coarsened echotexture of the liver
      • cirrhosis
        • nodular surface
Studies
  • Serum labs
    • liver function panel
      • elevated AST and ALT
      • elevated alkaline phosphatase
    • viral hepatitis panel
      • to exclude viral cause of chronic hepatitis
  • Invasive studies
    • liver biopsy
      • findings
        • macrovesicular steatosis
        • lobular inflammation with lymphocytes and Kupffer cells
        • ballooned hepatocytes (liver damage)
        • pericellular/perivenular or “chicken wire” fibrosis
Differential
  • Autoimmune hepatitis
    • key distinguishing factors
      • autoimmune hepatitis presents with flares of jaundice, abdominal pain, pruritus, and may progress to encephalopathy
      • positive anti-smooth muscle antibodies
Treatment
  • Lifestyle
    • weight loss
    • alcohol cessation
    • good control of diabetes
    • low-fat diet and good control of dyslipidemia
Complications
  • NASH-associated cirrhosis
  • Hepatocellular carcinoma
 

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