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Clinical Crossroads | Conferences With Patients and Doctors| Clinician's Corner

Management of Nonalcoholic Fatty Liver Disease:  A 60-Year-Old Man With Probable Nonalcoholic Fatty Liver Disease: Weight Reduction, Liver Biopsy, or Both?

Nezam H. Afdhal, MD
JAMA. 2012;308(6):608-616. doi:10.1001/jama.2012.8402.
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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.

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Figure 1. Mr T's Abdominal Ultrasound
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Ultrasound image showing diffuse increased echogenicity consistent with fatty liver.

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Figure 2. Assessment of Nonalcoholic Steatohepatitis (NASH) Severity in Patients With Nonalcoholic Fatty Liver Disease (NAFLD) and Examples of Histological Features
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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).

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