NAFLD - NASH, NALD

Question 1

Can ultrasound differentiate non-alcoholic fatty liver (NAFL) from Non-alcoholic steatohepatitis (NASH)?

Answer 1

No, do a liver biopsy

Question 2

What points towards NASH instead of NAFL?

Answer 2

Elevated serum transaminase levels greater than 2 times the upper limit of normal + presence of metabolic syndrome (Hyperlipidaemia, insulin resistance, obesity, hypertension, etc) points towards NASH.

Question 3

In liver biopsy, NASH is characterised by?

Answer 3

Fat, Mallory bodies, Neutrophil infiltration and pericellular fibrosis.

Question 4

Steatohepatitis can progress into?

Answer 4

1. Liver failure (jaundice, coagulopathy, encephalopathy)
2. Portal hypertension (ascites, varices, spontaneous bacterial peritonitis)
3. Hepatocellular carcinoma

Question 5

What is the most probable cause of NAFLD?

Which condition is highly associated with NAFLD?

Answer 5

Insulin resistance. 
Most patients with NAFLD have metabolic syndrome, which is defined as having 3 of the following 5:
- Diabetes (insulin resistance)
- Obesity
- Hypertension
- Hyperlipidaemia
- Hypertriglyceridemia

Question 6

What are causes of secondary NAFLD?

Answer 6

Secondary NAFLD can be caused by drugs, such as Amiodarone or Tamoxifen, Hepatitis C virus, and endocrine conditions such as Polycystic Ovary Syndrome

Question 7

What is the most common cause of death in patients with NAFLD?

Answer 7

Cardiovascular diseases, such as MI, AF and ischaemic stroke.

Question 8

What are the direct liver complications of NAFLD?

Answer 8

• Portal hypertension
• Variceal haemorrhage
• Liver failure
• HCC
• Sepsis: The liver has a major role in producing host-defense mechanisms and systemic response to infection.

Question 9

When should NAFLD be suspected?

Answer 9

Suspect NAFLD if patient has:

• Risk factors suggestive of metabolic syndrome or risk factors for NAFLD
• Persistent elevation of LFTs for 3 months or more - typically alanine aminotransferase (ALT) levels are raised up to 3 times the upper limit of normal and exceed aspartate aminotransferase (AST) levels
• Upper abdominal USS findings consistent with fatty liver changes (increased hepatic echogeneicity)

Question 10

How does levels of ALT and AST change as fibrosis develops and worsens into cirrhosis?

Answer 10

ALT falls while AST remains or rises in value.