Fatty Liver
NASH stands for non-alcoholic steatohepatitis
It is a new identity introduced to medical literature on 1980 by ledwig et al.,
It covers spectrum of liver disease, ranging from benign fatty liver, to Nash which is inflammatory process that may lead eventually to fibrosis in the absence of alcohol history.
Now it is believed that it is the most common cause of abnormal function tests in the US.
Causes of NASH are either primary or secondary, where primary NASH happens in association with metabolic syndrome, in other words it happens more in fatty people.
Secondary causes include drugs, like methotrexate, steroids, isoniazid, NSAID and others, other causes of NASH include toxins and metabolic disturbances mainly genetic, It was also reported in people with sudden weight loss and jujenoileal by pass operations.
Histology findings are similar to that found in Alcohol, with accumulation of Fat inside the liver cells and inflammatory infiltrates and fibrosis.
Pathophysiology process has not been confirmed but all happens mainly due to insulin resistance. Insulin resistance cause more lipolysis, more FFA entry to liver cells and increased FFA inside liver cells. Impaired beta oxidation inside liver cells causes the release of oxygen free radicals causing the inflammation.
Symptoms and Signs
Most of patients are asymptomatic, or complain of mild symptoms such as fatigue and right hypochondrial pain; however Hepatomegaly is the most common clinical findings.
30% of patients with fatty liver will progress to has liver fibrosis and cirrhosis and those may present with more advanced liver failure signs.
Investigations
ALT normal or raised up to four folds
AST normal or raised up to four folds
AST/ALT ratio is less than one where it is more than one in alcoholic liver disease
Low Albumin, impaired coagulation profile and low platelet are all features of chronic liver disease that may present in patients with NASH
Don’t forget that Nash is a diagnosis of exclusion and s copper, -ve autoimmune studies and no alcohol history is mandatory to diagnose NASH.
S ferritin is sometimes raised and it may be a challenge to differentiate it from haemochormatosis.
U/S is easy and cheap but not accurate, as it doesn’t detect less fat when it is less than 30%, It is also challenging to perform it with good result in the obese population.
Liver biopsy is the gold standard and it helps not only to diagnose NASH but also to stage the degree of fibrosis.
Treatment is to treat obesity; weight loss was proven to be beneficial and to decrease the degree of inflammation inside the liver.
Drugs to increase insulin sensitivity like metformin and glitazones are also helpful.
Other modules of management are lipid lowering drugs like statins.
NASH stands for non-alcoholic steatohepatitis
It is a new identity introduced to medical literature on 1980 by ledwig et al.,
It covers spectrum of liver disease, ranging from benign fatty liver, to Nash which is inflammatory process that may lead eventually to fibrosis in the absence of alcohol history.
Now it is believed that it is the most common cause of abnormal function tests in the US.
Causes of NASH are either primary or secondary, where primary NASH happens in association with metabolic syndrome, in other words it happens more in fatty people.
Secondary causes include drugs, like methotrexate, steroids, isoniazid, NSAID and others, other causes of NASH include toxins and metabolic disturbances mainly genetic, It was also reported in people with sudden weight loss and jujenoileal by pass operations.
Histology findings are similar to that found in Alcohol, with accumulation of Fat inside the liver cells and inflammatory infiltrates and fibrosis.
Pathophysiology process has not been confirmed but all happens mainly due to insulin resistance. Insulin resistance cause more lipolysis, more FFA entry to liver cells and increased FFA inside liver cells. Impaired beta oxidation inside liver cells causes the release of oxygen free radicals causing the inflammation.
Symptoms and Signs
Most of patients are asymptomatic, or complain of mild symptoms such as fatigue and right hypochondrial pain; however Hepatomegaly is the most common clinical findings.
30% of patients with fatty liver will progress to has liver fibrosis and cirrhosis and those may present with more advanced liver failure signs.
Investigations
ALT normal or raised up to four folds
AST normal or raised up to four folds
AST/ALT ratio is less than one where it is more than one in alcoholic liver disease
Low Albumin, impaired coagulation profile and low platelet are all features of chronic liver disease that may present in patients with NASH
Don’t forget that Nash is a diagnosis of exclusion and s copper, -ve autoimmune studies and no alcohol history is mandatory to diagnose NASH.
S ferritin is sometimes raised and it may be a challenge to differentiate it from haemochormatosis.
U/S is easy and cheap but not accurate, as it doesn’t detect less fat when it is less than 30%, It is also challenging to perform it with good result in the obese population.
Liver biopsy is the gold standard and it helps not only to diagnose NASH but also to stage the degree of fibrosis.
Treatment is to treat obesity; weight loss was proven to be beneficial and to decrease the degree of inflammation inside the liver.
Drugs to increase insulin sensitivity like metformin and glitazones are also helpful.
Other modules of management are lipid lowering drugs like statins.
great work doc, keep it up !
ReplyDeleteconcise, up to the mark and right on target !
ReplyDelete