Non Alcoholic Steatohepatitis
Non alcoholic steatohepatitis is an entity characterized by the presence of an association of steatosis with inflammation and fibrosis that occurs in people who do not consume alcohol. Histological lesions are very similar to those of alcoholic hepatitis.
Non alcoholic steatohepatitis main causes of are:
- Diabetes mellitus;
- Jejuno-ileal bypass for obesity;
- Prolonged parenteral nutrition;
- Some drugs (amiodarone, diltiazem, tamoxifen);
- Occupational exposure to solvents.
In clinical practice most frequent factors in the development of non alcoholic steatohepatitis are obesity, diabetes mellitus and hypertriglyceridaemia.
- Obesity is a major problem recognized worldwide. In a few countries, such as USA up to 25% of the population is obese. A body mass index greater than 30kg/m² predispose to the emergence of non alcoholic steatohepatitis. Meanwhile, not all patients with non alcoholic steatohepatitis are obese, some of them are normal weight.
- Type 2 diabetes is often associated with obesity and hypertriglyceridemia, all generating causes of non alcoholic steatohepatitis.
Most often patients with non alcoholic steatohepatitis are asymptomatic and the disease is discovered accidentally during a medical exam. In some cases, patients with non alcoholic steatohepatitis may experience fatigue, pain in right upper quadrant and in advanced stages of illness, cirrhosis may occur with typical signs such as jaundice or ascites.
Clinical examination revealed a patient often obese, sometimes with diabetes mellitus and dyslipidemia, a patient who presents a large liver with a high consistency, the spleen may also be increased in advanced stages of disease.
To remember is that most often patients with non alcoholic steatohepatitis are completely asymptomatic and the disease is discovered incidentally.
Laboratory tests that can be modified are:
- Fasting blood glucose increased, relevant for diabetes;
- Elevated transaminases (ALT, AST) typically increase by 1.5 to 3 times their normal value. ALT is more increased than AST;
- May be a slight increase in alkaline phosphatase;
- Gamma-glutamyl-transpeptidase is normal, which differentiate non alcoholic steatohepatitis from the alcoholic steatohepatitis.
Liver ultrasound is the simplest method that can diagnose fatty liver. If is an advance stage of non alcoholic steatohepatitis which can lead to cirrhosis, ultrasound can demonstrate specific signs of the disease, such as ascites, splenomegaly, signs of portal hypertension.
CT can estimate semiquantitatively the liver fat content;
Liver biopsy is the best method (gold standard) that allows a accurate staging of non alcoholic steatohepatitis. However, routine use of liver biopsy in patients with non alcoholic statoheaptitis is questionable because of high frequency of this disease, relatively good prognosis of these patients, but also because biopsy result does not change therapy. May be useful for staging of the disease and determining the exact prognosis.
Non alcoholic steatohepatitis treatment will have a dietary component and a medication component.
- On diet in obese patients weight loss is recommended as a first stage of therapy. Weight loss should be done gradually and physical activity is essential, because both reduce insulin resistance. Often reaching a normal weight will resolve the liver disease. Is very important in diabetic patients a tight glucose control in the long run. In case of hypertriglyceridemia, a low-fat diet is mandatory.
- Drug treatment includes multiple medications that can be used:
- Metformin, which decreases insulin resistance, may be administered in people who are not suffering from diabetes;
- Ursodeoxycholic acid;
- Vitamin E as antioxidant;
None of the above drugs has proven a clear efficiency in non alcoholic steatohepatitis. Simple medication without solving causal factors (obesity, dyslipidemia) will not lead to an improvement in liver function. In conclusion, diet is essential in the treatment of non alcoholic steatohepatitis.
Non alcoholic steatohepatitis has a good prognosis in cases of mild steatosis, and in case of cirrhosis, the prognosis is reserved. Progressive weight loss, along with physical activity, control of diabetes and of hypertriglyceridemia are solutions to improve the liver function.
Non alcoholic steatohepatitis evolution depends primarily on the causal factors, their importance (severity of obesity) and solving of the causal factors (weight loss, total control of diabetes or of hypertriglyceridemia). Fibrosis lesions of the liver, show that the disease is irreversible.