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Nonalcoholic Steatohepatitis

Sunil G. Sheth, MD; Fredric D. Gordon, MD; and Sanjiv Chopra, MD
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From Beth Israel Deaconess Medical Center, Boston, Massachusetts Acknowledgments: The authors thank Donald Antonioli, MD, (Beth Israel Deaconess Medical Center, Boston, Massachusetts) for providing (Figure 1). Current Author Addresses: Dr. Sheth: Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1997;126(2):137-145. doi:10.7326/0003-4819-126-2-199701150-00008
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Objective: To determine the clinical relevance of nonalcoholic steatohepatitis (NASH) and to review the available literature on the epidemiology, clinical features, histology, pathogenesis, clinical course, and management of this condition.

Data Sources: Pertinent articles in English identified through a MEDLINE search (1966 to the present) and the bibliographies of relevant articles.

Study Selection: All studies, including case reports, evaluating the salient features and clinical profile of NASH.

Data Extraction: Data were selected from all articles that fit the study selection criteria.

Data Synthesis: Nonalcoholic steatohepatitis is a distinct clinical entity characterized by elevated plasma liver enzyme levels and liver biopsy findings that are identical to those seen in alcoholic hepatitis; patients with NASH, however, do not consume alcohol in quantities known to cause liver injury. Patients with NASH are typically obese, middle-aged women with asymptomatic hepatomegaly who are diabetic or hyperlipidemic and present with an unrelated medical problem. Analysis of liver biopsy specimens is the cornerstone of diagnosis; hepatic morphologic findings range from mild fatty degeneration and inflammation to cell degeneration, fibrosis, and cirrhosis with or without the presence of Mallory hyaline bodies. Elevated levels of free fatty acids in the liver are thought to be responsible for the development of steatohepatitis. Although NASH is most often a benign disease with an indolent course, patients with this condition occasionally develop cirrhosis, portal hypertension, and hepatic failure. In some cases, NASH may be reversed with weight reduction.

Conclusion: Nonalcoholic steatohepatitis is an important differential diagnosis for asymptomatic patients with chronically elevated plasma liver enzyme levels, especially if obesity, diabetes, or hyperlipidemia are present. Analysis of liver biopsy specimens is necessary for diagnosis and must be done in all patients with unexplained abnormal liver function and negative results on a noninvasive workup. Prognosis is good in most patients. The precise role of weight reduction and ursodeoxycholic acid therapy in the favorable alteration of the natural history of this disorder needs to be addressed in large, well-controlled studies.


Grahic Jump Location
Figure 1.
Nonalcoholic steatohepatitis.

Macrovesicular fatty changes, cytoplasmic hyaline in hepatocytes, and a mixed inflammatory sinusoidal infiltrate can be seen. (Hematoxylin and eosin; original magnification, x200.).

Grahic Jump Location




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