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Updated: Dec 11 2021

Nonalcoholic Steatohepatitis (NASH)

  • 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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