Non-alcoholic steatohepatitis

Background

Stages of non-alcoholic fatty liver disease, progressing from healthy, to steatosis (fat accumulation), inflammation, fibrosis and cirrhosis.

Inferior view of the liver with surface showing lobes and impressions.

Liver vascular anatomy.

Bile duct and pancreas anatomy. 1. Bile ducts: 2. Intrahepatic bile ducts; 3. Left and right hepatic ducts; 4. Common hepatic duct; 5. Cystic duct; 6. Common bile duct; 7. Sphincter of Oddi; 8. Major duodenal papilla; 9. Gallbladder; 10-11. Right and left lobes of liver; 12. Spleen; 13. Esophagus; 14. Stomach; 15. Pancreas: 16. Accessory pancreatic duct; 17. Pancreatic duct; 18. Small intestine; 19. Duodenum; 20. Jejunum; 21-22: Right and left kidneys.

• Fatty liver disease due to causes other than excessive alcohol
• Associated with insulin resistance and metabolic syndrome

Clinical Features

• Often asymptomatic or with mild RUQ discomfort
• Signs of portal hypertension (e.g. ascites) if advanced fibrosis
• Hepatomegaly

Differential Diagnosis

Hepatic Dysfunction

Infectious

• Hepatitis
  • Viral hepatitis
• Malaria
• HIV (present in 50% of AIDS patients)
• EBV
• Babesiosis, leptospirosis
• Typhoid
• Hepatic abscess, amebiasis

Neoplastic

• Metastases
• Hepatocellular carcinoma
• Multiple myeloma
• Leukemia
• Lymphoma
• Myeloproliferative disorders

Metabolic

• Hemochromatosis
• Wilson's disease
• Non-alcoholic steatohepatitis
• Inborn errors of metabolism

Biliary

• Biliary cirrhosis

Drugs

• Alcoholic cirrhosis
• Alcoholic hepatitis
• Hepatotoxic drugs

Miscellaneous

• Other causes of cirrhosis
• Autoimmune hepatitis
• Veno-occlusive disease
• CHF (right heart failure)

Evaluation

• LFTs, CBC
• RUQ US
• Outpatient elastography/Fibroscan

Management

• Treat complications of portal hypertension, if present
• Counsel on weight loss, increased coffee consumption
• Vitamin E if known F2 fibrosis

Disposition

• Discharge unless complications

See Also

• Hepatomegaly