NASH

One of my favourite disease abbreviations. That’s NASH, like the start of Nashville.


Non-Alcoholic Steatohepatitis (NASH)

Image result for NASH LIVERDefinition: an advanced form of non-alcoholic fatty liver disease (NAFLD). NASH is characterised by increased fat in hepatocytes (steatosis) + inflammation (steatohepatitis), associated with various degrees of hepatocellular injury, inflammation and fibrosis that can progress to cirrhosis and hepatocellular carcinoma. There is no background of significant alcohol intake.

NASH is a diagnosis of exclusion.

 

Aetiology/risk factors:

Risk factors: obesity, diabetes, hypertension, hyperlipidaemia, parenteral feeding, jejuno-ileal bypass (short bowel syndromes), Wilson’s disease, drugs (amiodarone, methotrexate, tetracycline, tamoxifen)

Typically occurs in middle-aged obese

Epidemiology: up to 30% of the population have some degree of non-alcoholic fatty liver disease

Symptoms:

-Most patients with NAFLD are asymptomatic

May have:

-RUQ abdominal discomfort

-As liver disease progresses towards NASH and cirrhosis, signs and symptoms of chronic liver disease become apparent

Signs:

-hepatosplenomegaly (liver size may decrease as cirrhosis develops)

-truncal obesity

-signs of chronic liver disease

Investigations:

LFTs- raised ALT and AST (AST:ALT <1/ >2 in alcoholic liver disease, ratio reverses as disease progresses towards cirrhosis)

Lipid panel- elevated total cholesterol, LDL, triglyceride, low HDL

Ultrasound/CT/MRI- fatty liver. U/S shows a bright liver because of diffuse fatty infiltration. CT and MRI can show fatty liver but the findings are non-specific.

Liver biopsy- Mallory bodies +/- neutrophil infiltrate (can be indistinguishable from alcoholic liver disease), cirrhosis (bridging fibrosis + regenerative nodules)

Image result for NASH LIVER BIOPSY mallory bodies

Management:

-control risk factors: diet and exercise, weight loss, treat diabetes

-bariatric surgery helps

-transplantation may be needed in end-stage disease

Complications:

liver cirrhosis

-liver failure

-hepatocellular carcinoma

Prognosis:

-Patients with NASH progress 9-20% of the time to cirrhosis, and up to 1/3 of these patients will die from complications of liver failure or require liver transplantation.

References: Cheese & Onion, Kumar & Clarke’s, BMJ Best Practice
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