Who’s who in NASH? A medical fieldwork guide
NASH (non-alcoholic steatohepatitis) is a stage of non-alcoholic fatty liver disease (NAFLD). NAFLD patients often require a range of healthcare professionals to help them get the diagnosis and treatment they need to reduce the long-term effects of this disease.
NAFLD is a term used to describe a range of conditions caused by a buildup of fat in the liver. It is not caused by heavy alcohol consumption and it can affect anyone of any age. However, people are at greater risk of NAFLD if they smoke and are over the age of 50.
NAFLD is also more common in individuals with pre-existing health conditions such as obesity, high blood pressure, high cholesterol and type 2 diabetes.
There are four basic stages of NAFLD. These are:
- Simple fatty liver (steatosis) – where fat starts to accumulate in liver cells.
- NASH – the liver starts to become inflamed.
- Fibrosis – persistent inflammation causes scar tissue around the liver and its nearby blood vessels. However, the liver can still function normally.
- Cirrhosis – this final and most severe stage occurs after years of inflammation. The liver shrinks, is lumpy, scarred and permanently damaged. Cardiovascular disease, liver failure and liver cancer may also result.
However, it can take years for fibrosis or cirrhosis to develop. It is, therefore, important that patients receive a diagnosis at the NASH stage and make lifestyle changes in the early stages to prevent NAFLD developing.
An estimated 20% of NAFLD patients have NASH. However, diagnosis is not easy. While some patients may feel weak and tired, experience discomfort in the upper right side of the abdomen or unexplained weight loss, there are often few or no symptoms of NASH.
To diagnose NASH, doctors will assess the patient’s medical history, perform a physical exam and conduct a series of tests. These may include a blood test called a liver function test, ultrasound, CT or MRI scan, or a liver biopsy. Patients may also be asked about their diet and lifestyle choices.
There also isn’t currently any medication to treat NAFLD. However, medicines that could help manage the problems associated with the condition may be prescribed.
Weight loss (normally at least 2-5% of body weight) is normally recommended to reduce the fat content and inflammation in the liver. It’s a difficult balancing act though as rapid weight loss can make NAFLD worse. So, a gradual weight loss plan is the most effective route for the majority of patients.
Patients should also eat a healthy diet, exercise regularly and stop smoking. While NAFLD is not caused by alcohol consumption, patients are usually advised to cut down or stop drinking alcohol as well.
Who treats NASH?
Many NAFLD patients seek and benefit from the help of a range of healthcare professionals to receive a diagnosis, treatment and manage the condition. These include GPs, liver diseases specialists known as hepatologists or gastroenterologists, nutritionists or dietitians and, in many cases, cardiologists.
The first port of call for many NASH patients is their GP. A general practitioner can assess a patient for NAFLD by investigating their medical history and lifestyle choices.
They may also perform a physical examination. Here, a GP may examine the patient’s body, check their weight and height, and calculate their body mass index.
They will also look for signs of early onset NAFLD or NASH, including: an enlarged liver and signs of insulin resistance such as darkened skin patches over the patient’s knees, knuckles and elbows. They will also examine them for signs of cirrhosis or jaundice, such as the yellowing of the skin and whites of the eyes.
If NASH is suspected, the patient will likely be referred to a specialist technician to perform a range of diagnostic tests.
These typically take place in an outpatient centre or hospital and may include:
- A liver function test – where a blood sample is taken to detect for increased levels of liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Further blood tests may also be necessary to find out if a patient has other health conditions that may increase their liver enzyme levels.
- Ultrasound – where sound waves are used to create an image of the liver and its structure. However, an ultrasound cannot detect and differentiate NACLD stages and technical limitations are common in obese patients.
- Computerised Tomography (CT) scan – where a combination of X-rays and computer technology create images of the liver. This offers an alternative to ultrasound imaging.
- Magnetic Resonance Imaging (MRI) scan – where radio waves and magnets produce detailed images of organs and soft tissues, without using X-rays. It is superior in differentiating the different stages of fibrosis compared to other imaging techniques.
A radiologist will then read and report on the diagnostic images from an ultrasound, CT or MRI scan.
If NASH is suspected or further diagnosis is required, the patient will likely be referred to a liver specialist known as a hepatologist or gastroenterologist.
Hepatologists specialise in a branch of medicine which studies body parts such as the liver, biliary tree, gallbladder and pancreas. Gastroenterologists specialise in the digestive system, including liver health.
The level of experience and expertise among hepatologists and gastroenterologists in diagnosing and treating liver disease varies greatly.
For example, a hepatologist or gastroenterologist may perform a liver biopsy to further aid the diagnosis. This is the only way to detect liver inflammation and damage to diagnose NASH.
Doctors don’t recommend a liver biopsy for every NAFLD patient, but if their initial tests show signs of advanced liver disease or cirrhosis, such a test may be necessary.
Hepatologists and gastroenterologists will also advise patients on the best course of treatment, once a diagnosis is received.
A nutritionist or dietitian can help patients lose weight and provide advice on healthy eating choices. They often create diet and exercise programmes that will effectively reduce body weight for the NASH patient.
NAFLD patients are also at an increased risk of cardiovascular disease. So, a cardiologist may also be required to address and treat any heart or blood vessel problems the patient may have in addition to NAFLD.
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