Non Alcoholic Steatohepatits

Question 1

define NASH?

Answer 1

term used to describe range of conditions caused by build up of fat in liver due to causes other than excessive alcohol use

Question 2

Describe the aetiology of NASH?

Answer 2

If fat persists in liver-> causes inflammation and fibrosis ( steatohepatitis)

NASH is a fatty change with lobular hepatitis in absence of history of alcoholism

first hit of imbalance of fatty acid metabolism-> leads to hepatic triglyceride accumulation and second hit of dysregulated cytokine production due to effort to compensate for altered lipid homeostasis

-> thought to be associated with lipid homeostasis

Question 3

what does NASH increase the risk of?

Answer 3

Diabetes mellitus

MI

stroke

Question 4

What are the risk factors for NASH?

Answer 4

• Obesity
• Type 2 diabetes mellitus
• Hypertension
• Hypercholesterolaemia
• Age > 50 yrs
• Smoking

Question 5

briefly describe the spectrium of NAFLD?

Answer 5

Fatty liver- fat accumulates in the liver

NASH- fat plus inflammation and scarring

Cirrhosis- scar tissue replaces liver cells

Question 6

summarise the epidemiology of NASH?

Answer 6

• MOST COMMON liver disorder in developed countries

1/3 people in the UK have the early stages of NASH

Question 7

what are the presenting symptoms of NASH?

Answer 7

• Usually NO SYMPTOMS in the early stages
• Usually found as an incidental finding

Occasional symptoms include:

• Dull or aching RUQ pain
• Fatigue
• Unexplained weight loss
• Weakness
• Pruritus

Symptoms of cirrhosis will be experienced in the most advanced stages of NASH

Question 8

what are the signs of NASH on physical examination?

Answer 8

• RUQ pain/tenderness

Signs of cirrhosis (e.g. jaundice, ascites, pruritus, spider angioma - in advanced stages of NASH)

Question 9

summarise the prognosis for patients with NASH?

Answer 9

20% of NASH will develop cirrhosis

Question 10

What are the appropriate investigations for NASH?

Answer 10

1. LFTs - showing elevated AST and ALT
2. Bilirubin - high
3. ALP - high
4. GGT – high
5. Lipid panel – high total chol, LDL, TAG and low HDL (part of metabolic syndrome)
6. FBC – may see anaemia or thrombocytopenia due to hypersplenism which usually develops after cirrhosis and portal HT

Met panel: mild hyponatreaemia with cirrhosis (kidneys can also start declining so high creatinine and urea maybe)

Question 11

What investigation should you consider?

Answer 11

○ Fasting insulin (should be measured in all non-diabetic patients with NASH, it will be high)

○ Homeostatic model assessment calc

Alpha fetoprotein (typically norm (elevated with hepatocellular carcinoma))

○ Serum ammonia

○ Liver Ultrasound - may show steatosis
Liver Biopsy –if more than 5% fat content in liver biopsy = abnormal

Question 12

outline a management plan for NASH?

Answer 12

• Conservative - controlling risk factors:
○ Blood pressure 
○ Diabetes 
○ Cholesterol 
○ Lose weight 
○ Stop smoking 
○ Improve diet
○ Exercise regularly 
○ Reduce alcohol consumption (although it is NOT caused by excessive alcohol, drinking can make it worse) 

End stage => liver transplant or transjugular intrahepatic portosystemic shunt

Question 13

What is TIPS?

Answer 13

A TIPS procedure may be done by a radiologist, who places a small wire-mesh coil (stent) into a liver vein. The stent is then expanded using a small inflatable balloon (angioplasty). The stent forms a channel, or shunt, that bypasses the liver. This channel reduces pressure in the portal vein.

Question 14

What are the complications of NASH?

Answer 14

• CIRRHOSIS
○ Ascites
○ Oesophageal varices
○ Hepatic encephalopathy

Hepatocellular carcinoma
End-stage liver failure