Nonalcoholic fatty liver disease (NAFLD) is one of the most common hepatic disorders in the United States, but uncertainty remains as to the optimal way to manage it. Using the case of Mr T, a 60-year-old man with obesity, diabetes mellitus, and increased serum transaminase levels, an evidence-based approach to diagnosis and treatment is discussed. Diagnosis of NAFLD is based on patient clinical profile and risk factors for metabolic syndrome, the exclusion of other liver diseases, radiologic imaging and sometimes biopsy. At this point in Mr T's disease, the most important step is differentiation between simple steatosis and nonalcoholic steatohepatitis (NASH). Simple steatosis has a benign natural history, but NASH is progressive and may lead to cirrhosis, liver failure, and liver cancer. An evidence-based approach to treatment is limited by lack of large randomized trials, particularly of combinations of therapies, but weight loss, exercise, and medical therapies targeted at the mechanism of liver injury in NASH are recommended. Improved noninvasive diagnostic tests, a clearer understanding of the natural history of NAFLD, and large, well-designed clinical trials are needed.
Ultrasound image showing diffuse increased echogenicity consistent with fatty liver.
Right, The severity of NASH is estimated by the NAFLD Activity Score.28 Left, A, Low-power view showing extensive macrovesicular steatosis throughout liver (hematoxylin-eosin; original magnification ×50). B, High-power view showing macrovesicular fat and balloon degeneration consistent with NASH (hematoxylin-eosin; original magnification ×200). C, High-power view showing macrovesicular fat and lobular inflammation with neutrophils and lymphocytes consistent with NASH (hematoxylin-eosin; original magnification ×200). D, Liver showing steatosis and fine perisinusoidal fibrosis around hepatocytes (blue) consistent with NASH (trichrome stain; original magnification ×100).
Thank you for submitting a comment on this article. It will be reviewed by JAMA editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 5
Customize your page view by dragging & repositioning the boxes below.
More Listings atJAMACareerCenter.com >
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.