Non-Alcoholic Fatty Liver Disease

A 52-year-old woman is diagnosed with non-alcoholic steatohepatitis following a liver biopsy. What is the single most important step to help prevent the progression of her disease?

A. Stop smoking
B. Start statin therapy
C. Eat more omega-3 fatty acids
D. Start sulfonylurea therapy
E. Weight loss

Answer:
E. Weight loss

Discussion:
Non-Alcoholic Fatty Liver Disease 
Non-alcoholic fatty liver disease (NAFLD) is now the most common cause of liver disease in the developed world.
It is largely caused by obesity and describes a spectrum of disease ranging from:
 steatosis - fat in the liver
 steatohepatitis - fat with inflammation, non-alcoholic steatohepatitis (NASH),
 progressive disease may cause fibrosis and liver cirrhosis

NAFLD is thought to represent the hepatic manifestation of the metabolic syndrome and hence insulin resistance is thought to be the key mechanism leading to steatosis

Non-alcoholic steatohepatitis (NASH) is a term used to describe liver changes similar to those seen in alcoholic hepatitis in the absence of a history of alcohol abuse. It is relatively common and though to affect around 3-4% of the general population. The progression of disease in patients with NASH may be responsible for a proportion of patients previously labelled as cryptogenic cirrhosis

Associated factors
 obesity
 hyperlipidaemia
 type 2 diabetes mellitus
 jejunoileal bypass
 sudden weight loss/starvation

Clinical Features
 usually asymptomatic
 hepatomegaly
 ALT is typically greater than AST
 increased echogenicity on ultrasound

Management
 the mainstay of treatment is lifestyle changes (particularly weight loss) and monitoring
 there is ongoing research into the role of gastric banding and insulin-sensitising drugs (e.g. Metformin)