Steatosis

Question 1

What’s the difference between non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH) and cryptogenic cirrhosis?

Answer 1

NAFLD: hepatic steatosis associated with metabolic syndrome. Technically includes NAFL, NASH and NASH cirrhosis.

NASH: inflammation of the liver associated with NAFLD

Cryptogenic cirrhosis: cirrhosis from an unknown aetiology, often from “burnt out” NAFLD

Question 2

Define hepatic steatosis (fatty liver)

Answer 2

Histologically, defined as >5% hepatocyte fat accumulation (they start to look like adiopocytes)

Question 3

What are the 2 most common aetiologies of hepatic steatosis?

Answer 3

NAFLD

Alcohol

Question 4

Why is NASH dangerous?

Answer 4

A significant number of them will develop hepatic fibrosis and cirrhosis

Question 5

Initial workup for NAFLD

Answer 5

1) Ask about alcohol use 
2)
FBC, LFTs
Hep C ab
Hep B core antigen and surface antigen
Alpha 1 anti-trypsin 
Ferritin +/- Tf sat 
If AST and ALT >5x ULN: autoimmune hepatitis labs

Question 6

What are 2 good scoring systems to estimate the risk of fibrosis in NAFLD?

Answer 6

Fibrosis-4 score (FIB-4) = AgexAST/(PLTxALT)
FIB-4 <1.3 is reassuring

NAFLD fibrosis score (NFS)

• Uses age, BMI, impaired fasting glucose (Y/N), AST/ALT, platelet and albumin
• NFS

Question 7

List 3 adverse outcomes associated with NASH and fibrosis

Answer 7

1) CV mortality
2) Liver morbidity and mortality
3) Malignancy (HCC and others)

Question 8

Are statins safe in chronic liver disease?

Answer 8

YES unless ALT or AST are >3 times the ULN and if evidence of cholestasis is present

Question 9

Rx fatty liver disease

Answer 9

Weight loss +/- bariatric surgery (10% weight loss can improve/resolve NASH)

Stop ETOH (regardless of the aetiology)

Vitamin E: NASH without DM (PIVENS trial)

Pioglitazone: NASH. Watch for weight gain SE.

Liraglutide GLP-1 agonist: NASH +/- DM (LEAN trial)

Question 10

How to evaluate for liver fibrosis?

Answer 10

FIB-4: <1.3 = reassuring
NFS score = VCTE vs biopsy
Vibration elastography (VCTE): ≥F2 = consider biopsy

Question 11

Can you distinguish NASH and alcohol related steatohepatitis on histology?

Answer 11

No

And both can be present simultaneously

Question 12

How to differentiate NAFLD from alcohol-related liver disease?

Answer 12

Alcoholic liver disease/nonalcoholic fatty liver disease index (ANI)

Question 13

What’s vibration-controlled transient elstography (VCTE)?

Answer 13

VCTE measures how fast the deep shear waves conduct through the liver.
The velocity of the shear wave is reported as liver stiffness measurement (LSM) in kPA, which correlates with fibrosis (F1-F4 scoring).

F2 or greater, consider biopsy

False positive can occur in obesity, recent oral intake, liver congestion and inflammation.

Question 14

When do you screen for HCC in fatty liver?

Answer 14

Only in cirrhosis. Although you can still get HCC in NAFLD without cirrhosis, this is less common.

US screening every 6 months