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Diagnosis
NAFLD/NASH in children is generally asymptomatic and, therefore, the diagnosis is commonly made
during a supplementary evaluation for elevated aminotransferases or hyperechogenic liver found during
a routine check-up [4]. In obese children, NAFLD should always be suspected and many centres
have adopted a screening program for NAFLD in high-risk individuals, particularly those presenting
with features of the MetS (Fig. 1). The position paper by the ESPGHAN Hepatology Committee has
recently delineated diagnostic criteria for pediatric NAFLD [5]. Elevated aminotransferase levels and
liver hyperechogenicity deserve further evaluation and the exclusion of other causes of liver disease,
because of the poor sensitivity of these tests in overweight/obese children [5]. Liver biopsy remains
the gold standard for diagnosing NAFLD, distinguishing between NASH and simple steatosis and
estimating the severity of liver damage, especially fibrosis.
NAFLD in children displays the same basic morphological lesions observed in adults, but the pattern of
distribution of these lesions is frequently different. Hepatocellular ballooning degeneration and MDBs
are only sporadically observed and portal-based chronic inflammation is predominant [6]. Based on the
distinctive histological pattern of disease in children, a specific histological score (Pediatric NAFLD
Histological Score - PNHS), has been validated for a better classification of children with/without
NASH [7].
Non-invasive markers and imaging techniques are the first diagnostic step. Predictors of fibrosis (e.g.
TE, ARFI) and serum biomarkers (e.g. ELF panel and CK18) could be adopted to reduce the need for
liver biopsy [8].
Figure 1. Management algorithm for children affected by NAFLD. Adapted from Alisi et al. [4].
32 Postgraduate Course Syllabus • Metabolic Liver Disease
NAFLD/NASH in children is generally asymptomatic and, therefore, the diagnosis is commonly made
during a supplementary evaluation for elevated aminotransferases or hyperechogenic liver found during
a routine check-up [4]. In obese children, NAFLD should always be suspected and many centres
have adopted a screening program for NAFLD in high-risk individuals, particularly those presenting
with features of the MetS (Fig. 1). The position paper by the ESPGHAN Hepatology Committee has
recently delineated diagnostic criteria for pediatric NAFLD [5]. Elevated aminotransferase levels and
liver hyperechogenicity deserve further evaluation and the exclusion of other causes of liver disease,
because of the poor sensitivity of these tests in overweight/obese children [5]. Liver biopsy remains
the gold standard for diagnosing NAFLD, distinguishing between NASH and simple steatosis and
estimating the severity of liver damage, especially fibrosis.
NAFLD in children displays the same basic morphological lesions observed in adults, but the pattern of
distribution of these lesions is frequently different. Hepatocellular ballooning degeneration and MDBs
are only sporadically observed and portal-based chronic inflammation is predominant [6]. Based on the
distinctive histological pattern of disease in children, a specific histological score (Pediatric NAFLD
Histological Score - PNHS), has been validated for a better classification of children with/without
NASH [7].
Non-invasive markers and imaging techniques are the first diagnostic step. Predictors of fibrosis (e.g.
TE, ARFI) and serum biomarkers (e.g. ELF panel and CK18) could be adopted to reduce the need for
liver biopsy [8].
Figure 1. Management algorithm for children affected by NAFLD. Adapted from Alisi et al. [4].
32 Postgraduate Course Syllabus • Metabolic Liver Disease
