A 40-year old obese female presents with fullness of right upper quadrant of abdomen. Her medical history is significant for Type 2 diabetes mellitus and hyperlipidemia. Liver biopsy is most likely suggestive of which of the following diagnoses?
Correct Answer: Non-alcoholic steatohepatitis
Description: Ans. a. Non-alcoholic steatohepatitis (Ref: Harrison 19/e p2054-2057, 18/e p2604-2605A 40-year-old obese female presents with fullness of right upper quadrant of abdomen. Her medical history is significant for Type 2 diabetes mellitus and hyperlipidemia. Liver biopsy is most likely suggestive of Non-alcoholic steatohepatitis."NASH is frequently seen in conjunction with other components of the metabolic syndrome (hypertension, diabetes mellitus, elevated lipids, and obesity), with NAFLD being considered the hepatic manifestation of this syndrome."- Harrison 18/e p2604Non-Alcoholic Fatty Liver Disease (NAFLD)The spectrum of NAFLD includes simple hepatic steatosis, which, over time, can progress to Non-Alcoholic SteatoHepatitis (NASH), with the subsequent development of fibrosis and cirrhosisQ.Clinical Features:Most patients who come to medical attention with NAFLD are identified as a result of incidentally discovered elevated liver enzymesQ (ALT, AST).When patients are symptomatic, symptoms include fatigue or a vague right upper quadrant discomfort.ALT is generally higher than ASTQ, and aminotransferases are only mildly (1.5-2 times the upper limit of normal) elevated.NASH is frequently seen in conjunction with other components of the metabolic syndrome (hypertension, diabetes mellitus, elevated lipids, and obesity ), with NAFLD being considered the hepatic manifestation of this syndromeQ.Insulin resistance is the underlying link between these various disorders and numerous studies have shown that virtually all patients with NASH have insulin resistanceQ.Abnormal ferritin values are seen in ~ 50% of patients with NASH, and an elevated ferritin level may be a marker of insulin resistance in NASHQ.Diagnosis:The diagnosis of NAFLD requires a careful history to determine the amount of alcohol usedQ.Imaging studies can show characteristic features of a fatty liver, but the ultimate diagnosis of either hepatic steatosis or NASH requires liver biopsyQ.Liver biopsy shows characteristic macrovesicular steatosis with occasional microvesicular fat being identifiedQ.The histologic features of NASH are very similar to those seen in alcoholic liver diseaseQMallory's hyaline can be seen in both disorders, although the number of hepatocytes containing Mallory's hyaline and the size of the deposits are frequently greater in alcoholic liver disease than in NASHQ.The fibrosis that occurs in NASH has a characteristic perivenular and perisinusoidal distributionQ.Treatment:The mainstay of treatment of fatty liver disease is weight loss and exerciseQAs an aid to weight loss, orlistat, which is a reversible inhibitor of gastric and pancreatic lipase, has been shown to result in a small decrease in body weight and is usually fairly well tolerated.At present, efforts should be directed to encouraging patients with NAFLD to lose weight and exerciseQ.
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