Pearls and pitfalls in nonalcoholic fatty liver disease: tricky results are common

Interpretation of diagnostic and surveillance laboratory results and imaging in liver disease is fraught with misinterpretation and/or uncertainty. Nonalcoholic fatty liver disease (NAFLD) represents an ever-growing proportion of liver disease cases but presents unique challenges for the clinician. Given the necessity of excluding other etiologies of liver disease, NAFLD can at times represent a challenging diagnosis as non-invasive assessment and biopsy are imperfect tests with important limitations. Similarly, cautious review of laboratory reports is necessary to avoid missing abnormal pathophysiology. The presence of lab values within the standard reference range may be concerning in the setting of chronic liver disease ("abnormally normal") and conversely results flagged as abnormal may not necessarily be of great concern ("normally abnormal"). This review provides a framework for the clinician to review common diagnostic challenges in NAFLD and enhance patient care.