Non-Alcoholic Steatohepatitis (NASH)

Question 1

Define Non-Alcoholic Steatohepatitis (NASH)

Answer 1

Sub-type of Non-alcoholic fatty liver disease (NAFLD) characterised histologically by macrovesicular hepatic steatosis in those who do not consume alcohol in harmful amounts

Question 2

Aetiology fo Non-Alcoholic Steatohepatitis (NASH) and its decompensation

Answer 2

Hepatic steatosis with inflammatory changes and fibrosis

Insulin resistance -> increased tricglycerides -> steatosis -> inflammation -> Steatohepatitis

Decompensation: infection | Gi bleeds | constipation | high-protein | electrolyte imbalance | alcohol | Drugs | tumours | Portal vein thrombosis

Question 3

Risk factors for Non-Alcoholic Steatohepatitis (NASH)

Answer 3

Obesity 
Diabetes (esp. T2DM) 
Total parenteral nutrition
Short bowel syndrome
Hyperlipidaemia
Drugs e.g. amiodarone, tamoxifen

Question 4

Symptoms of Non-Alcoholic Steatohepatitis (NASH)

Answer 4

Fatigue, malaise
Obesity 
Jaundice, pruritus 
RUQ pain (Dull, aching)
Weight loss or weakness 

Hx of NO significant alcohol use

Question 5

Signs of Non-Alcoholic Steatohepatitis (NASH) on examination

Answer 5

Hepatosplenomegaly 
Jaundice 
Truncal obesity 
CLD signs 
Gynaecomastia + testicular atrophy (reduced oestrogen clearance)
Caput meduse
Cruveilhier-Baumgarten murmur 
Nails: Muehrcke's line, Terry nails and clubbing

Question 6

Investigations for Non-Alcoholic Steatohepatitis (NASH)

Answer 6

Liver biopsy: diagnostic

LFTs: ALT/AST raised (ratio <1), GGT and bilirubin raised, albumin reduced
FBC: anaemia, thrombocytopenia
Lipid: raised total cholesterol, LDL and triglyceride
Fasting insulin: insulin resistance
Hepatic function: PT/INR prolonged, ANA/SMA/AMA variable, iron studies variable

Hepatic USS: abnormal echo texture

Question 7

Management for Non-Alcoholic Steatohepatitis (NASH)

Answer 7

Conservative:
Diet and exercise
lose weight 
No alcohol
Control any hypertension 

Medical:
Weight loss: Orlistat
Diabetic: insulin sensitiser
Dyslipidaemia: statins

Surgical: Roux-en-Y gastric bypass | TIPS insertion | transplant

Question 8

Complications of Non-Alcoholic Steatohepatitis (NASH)

Answer 8

Increases risk of developing cirrhosis 
Hepatocellular carcinoma
Ascites
Portosystemic thrombosis 
haemorrhage

Question 9

Prognosis for Non-Alcoholic Steatohepatitis (NASH)

Answer 9

1/3 tend to reverse condition
1/3 stay stable
1/3 progress to cirrhosis