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Challenges in the diagnosis of NASH
WHO SHOULD BE SCREENED FOR NASH?
Naga Chalasani
Division of Gastroenterology & Hepatology,
Indiana University School of Medicine,
Indianapolis, IN, The United States
Email: nchalasa@iu.edu
Take home messages
• Not all patients with NAFLD will have NASH; in fact, the prevalence of NASH in unselected
consecutive NAFLD patients is suspected to be below 25%.
• When evaluating a new patient with recently diagnosed NAFLD, it is essential to obtain a careful
history of anthropometric and metabolic risk factors, co-morbidities, and signs and symptoms. Often,
one would be able to pick up many clues with regards to disease severity.
• Depending on local resources, the initial evaluation for the possible presence of NASH may consist
of applying one of many easily available risk stratification models (e.g., NAFLD Fibrosis Score,
APRI, FIB-4, BARD, etc.) and/or transient elastography.
• Patients who are deemed at high risk for NASH by bedside and non-invasive criteria should be
approached about a percutaneous liver biopsy, especially if they are suitable candidates for available
treatments or clinical trial participation.
Introduction
NAFLD encompasses the entire spectrum of fatty liver disease in individuals without significant alcohol
consumption, ranging from fatty liver to steatohepatitis and cirrhosis. NAFL is described as the presence
of hepatic steatosis with no evidence of hepatocellular injury in the form of ballooning of the hepatocytes
or no evidence of fibrosis. The risk of progression to cirrhosis and liver failure is minimal, but not non-
existent. NASH is defined as presence of hepatic steatosis and inflammation with hepatocyte injury
(ballooning) with or without fibrosis. This can progress to cirrhosis, liver failure and rarely liver cancer.
Initial evaluation of a patient with newly diagnosed NAFLD
The majority of patients with NAFLD are identified when their liver enzymes are found to be elevated
during routine blood testing. Admittedly, there are a large number of patients with normal or near
normal aminotransferases but with hepatic steatosis. These patients and their physicians are unaware of
the potential presence of NAFLD at this time. Hepatic steatosis is sometimes found incidentally when
patients undergo imaging for related (e.g., abdominal discomfort), or unrelated reasons (e.g., kidney
stone evaluation).
A key element in evaluating a new patient with NAFLD is to exclude competing and concomitant
etiologies.The former includes, among others, heavy alcohol consumption, medications (e.g., tamoxifen,
amiodarone), viral hepatitis (especially HCV genotype 3), and Wilson’s disease. Common concomitant
etiologies include hemochromatosis, autoimmune hepatitis, Wilson’s disease, etc.
16 Postgraduate Course Syllabus • Metabolic Liver Disease
WHO SHOULD BE SCREENED FOR NASH?
Naga Chalasani
Division of Gastroenterology & Hepatology,
Indiana University School of Medicine,
Indianapolis, IN, The United States
Email: nchalasa@iu.edu
Take home messages
• Not all patients with NAFLD will have NASH; in fact, the prevalence of NASH in unselected
consecutive NAFLD patients is suspected to be below 25%.
• When evaluating a new patient with recently diagnosed NAFLD, it is essential to obtain a careful
history of anthropometric and metabolic risk factors, co-morbidities, and signs and symptoms. Often,
one would be able to pick up many clues with regards to disease severity.
• Depending on local resources, the initial evaluation for the possible presence of NASH may consist
of applying one of many easily available risk stratification models (e.g., NAFLD Fibrosis Score,
APRI, FIB-4, BARD, etc.) and/or transient elastography.
• Patients who are deemed at high risk for NASH by bedside and non-invasive criteria should be
approached about a percutaneous liver biopsy, especially if they are suitable candidates for available
treatments or clinical trial participation.
Introduction
NAFLD encompasses the entire spectrum of fatty liver disease in individuals without significant alcohol
consumption, ranging from fatty liver to steatohepatitis and cirrhosis. NAFL is described as the presence
of hepatic steatosis with no evidence of hepatocellular injury in the form of ballooning of the hepatocytes
or no evidence of fibrosis. The risk of progression to cirrhosis and liver failure is minimal, but not non-
existent. NASH is defined as presence of hepatic steatosis and inflammation with hepatocyte injury
(ballooning) with or without fibrosis. This can progress to cirrhosis, liver failure and rarely liver cancer.
Initial evaluation of a patient with newly diagnosed NAFLD
The majority of patients with NAFLD are identified when their liver enzymes are found to be elevated
during routine blood testing. Admittedly, there are a large number of patients with normal or near
normal aminotransferases but with hepatic steatosis. These patients and their physicians are unaware of
the potential presence of NAFLD at this time. Hepatic steatosis is sometimes found incidentally when
patients undergo imaging for related (e.g., abdominal discomfort), or unrelated reasons (e.g., kidney
stone evaluation).
A key element in evaluating a new patient with NAFLD is to exclude competing and concomitant
etiologies.The former includes, among others, heavy alcohol consumption, medications (e.g., tamoxifen,
amiodarone), viral hepatitis (especially HCV genotype 3), and Wilson’s disease. Common concomitant
etiologies include hemochromatosis, autoimmune hepatitis, Wilson’s disease, etc.
16 Postgraduate Course Syllabus • Metabolic Liver Disease
