Nonalcoholic Fatty Liver Disease--The Clinician's Perspective

Non alcoholic fatty liver (NAFLD) is a common cause of liver disease worldwide with prevalence ranging from 10-30%. It encompasses a spectrum ranging from simple steatosis to non-alcoholic steatohepatitis (NASH) which can progress to cirrhosis and hepatocellular carcinoma (HCC) in some patients. The diagnosis of hepatic steatosis can be made reliably by imaging. Differentiating simple steatosis from NASH usually requires liver biopsy although various non-invasive methods are under evaluation. Similarly, liver biopsy is the gold standard for staging of fibrosis but NAFLD fibrosis score and transient elastography are now validated for non-invasive assessment of fibrosis in patients with NAFLD. Liver biopsy should be reserved for patients at high risk of having NASH or advanced fibrosis, those needing evaluation of competing diagnoses or those enrolled in therapeutic trials. Treatment can be directed against various pathophysiological aspects of NAFLD and includes management of obesity, insulin resistance, hyperlipidemia and oxidative stress, suppression of inflammation and modulation of gut bacteria. Lifestyle modification with diet, exercise and weight loss is the cornerstone of therapy. Pharmacological treatment of NAFLD is still evolving with vitamin E and pioglitazone being the only approved drugs as of now. Bariatric surgery can lead to improvement in NASH in morbidly obese patients. Optimal therapy of NAFLD includes a multidisciplinary approach involving management of metabolic syndrome and cardiovascular disease. Management of NASH related cirrhosis and HCC is like that of other etiologies. Indications and outcomes of liver transplantation in patients with NASH are same as for other etiologies of liver disease.