NASH Flashcards
def nash
clinico-histopathological entity that includes a spectrum of conditions characterised histologically by macrovesicular hepatic steatosis in those who do not consume alcohol in amounts generally considered harmful to the liver
If inflammation is also present (high LFT, typically high ALT) = non-alcoholic steatohepatitis (NASH)
non-alcohol related accumulation of fat in liver cells, with chronic inflammation and damage of liver cells
aetiology nash
obestity and/or T2dm (metabolic syndrome) - primary NAFLD
secondary NAFLD
- med - amiodarone, glucocorticoids, oestrogen, antiretroviral drugs
- total parenteral nutrition - after resection of the SI and other GI interventions
rf nash
- med
- surgical procedures
- TPN
- obesity
- insulin resistance/dm
- dyslipidaemia
- HTN
- metabolic syndrome
- rapid weight loss
- hepatotoxic med
path nash
insulin resistance = accumulation of excessive TG accumulation
Once steatosis is present, some have proposed a second hit or additional oxidative injury, which is required to manifest the necro-inflammatory component seen in steatohepatitis.
Antioxidant deficiencies; hepatic iron; fat-derived hormones, including leptin, adiponectin, and resistin; and intestinal bacteria have all been implicated as potential oxidative stressors.
Hence, NASH is a subset of NAFLD
epi nash
NAFLD affects 20-40% of the western world - commonest liver disorder in W
40-60yrs
increasingly prevalent in paeds
affect sexes equally
Hispanic people more affected than white people. There is some evidence to suggest that African-Americans are less susceptible to the progressive form of the disease.
sx nash
absence of excessive alcohol use
fatigue and malaise
truncal obesity
RUQ abdo pain
sign nash
hepatosplenomegaly
ix nash
AST and ALT raised
BR raised
alkphos - raised
GGT raised
FBC - anaemia/thrombocytopenia
metabolic panel
- mild hyponaturaemia if cirrhosis (increased levels of ADH)
- creatinine and urea raised
- raised glucose
elevated total cholesterol, LDL, triglyceride, and low HDL
raised PT and INR
low albumuin
US - visualise steatosis (fat in hepatocytes)
biospy/elastography may be needed because progression to cirrhosis can occur
mx nash
control RF including obesity (bariatric surgery)
address CVS risk - commonest cause of death
avoid alcohol
no drug is beneficial
vit E may improve histology fibrosis (eg 400IU/d—higher doses associated with excess mortality).
monitor for complications
if cirrhotic - screen for HCC with US and AFP twice yearly
complications nash
- cirrhosis
- DM
- hepatocellular carcinoma
- ascites
- variceal haemorrhage
- portosystemic encephalopathy
- hepatocellular carcninoma (HCC)
- hepatorenal syndrome
- hepatopulmonary syndrome
- death
px nash
The overall prognosis in patients with bland steatosis (fatty liver without evidence of active inflammation) is considered to be good and a majority of patients will remain stable throughout their lifetime.
The same cannot be said of non-alcoholic steatohepatitis (NASH), which is considered the progressive form of NAFLD
ndependent predictors of fibrosis progression included diabetes mellitus, a low initial fibrosis stage, and a higher body mass index.
At a mean follow-up of 14 years, NASH is associated with increased overall mortality, which was primarily a result of cardiovascular disease and to a lesser extent liver-related causes
Patients who have NASH progress to cirrhosis 9% to 20% of the time. Up to one third of these patients will die from complications from liver failure or require liver transplantation
