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Non-alcoholic fatty liver disease/non-alcoholic steatohepatitis (NAFLD/NASH): diagnosis and clinical course

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Non-alcoholic fatty liver disease (NAFLD) is a frequent syndrome encompassing fatty liver alone and steatohepatitis (NASH). Often asymptomatic, the suspicion arises because of abnormal aminotransferases or a bright liver on abdominal ultrasound. It should be suspected during evaluation of associated conditions as obesity, diabetes or dyslipidaemia. The diagnostic evaluation must exclude other potential causes of liver disease and may include a liver biopsy, the only method able to confirm features of necroinflammation and fibrosis that define NASH and its prognostic implications. Indeed, the presence of necroinflammation has been associated with a significant risk of progression to cirrhosis and eventually hepatocellular carcinoma. Age >45 years, obesity and diabetes have also been associated with an increased risk of liver fibrosis and progression to cirrhosis. Given the high prevalence of NAFLD, general measures of life-style changes, focusing on exercise, diet, and total alcohol abstinence, should be implemented before a liver biopsy is considered.

Section snippets

When to suspect NAFLD/NASH?

These conditions should be suspected in individuals with persistent unexplained elevation of serum ALT. They should also be considered in the presence of risk factors such as obesity, diabetes and hyperlipidaemia. In the differential diagnosis of elevated aminotransferases, secondary forms of NAFLD should be hypothesized in individuals who are receiving drugs or have clinical conditions known to be associated with hepatic steatosis with or without necroinflammation.9., 10.

Patient demographics

Table 1 summarizes

Clinical course

Few studies address long-term follow-up, thus NAFLD/NASH natural history is difficult to ascertain. Progression seems mostly dependent on the severity of histological damage.9 Within the spectrum of NAFLD/NASH, patients with pure steatosis seem to have the best prognosis, when followed up to 19 years only 1/12 patients showed progression of fibrosis5, although another study in 49 patients with fatty liver alone reported 2 (4%) who progressed to cirrhosis.22 A more recent Danish study revealed

Summary

The true prevalence of NAFLD/NASH has been underestimated; it is likely to become more frequent worldwide, given the increasing diagnosis of major insulin resistant associated metabolic disorders: type 2 diabetes/overweight/obesity. There still is a widespread dismissal of the potential importance of the diagnosis which is mostly occasional, suspected because of elevated aminotransferases, typically ALT>AST, and/or bright liver on ultrasound, during a routine work-up. NAFLD/NASH tends to be

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