10 NASH (non-alcoholic steatohepatitis) facts

10 NASH (non-alcoholic steatohepatitis) facts

In this article we will describe 10 facts about NASH.

1. What is the liver and what does it do?

The liver is a large organ that sits on the right side of the upper tummy and under the ribs. The liver is the processing factory of the body. Its main jobs are to:

1. Filter the blood coming from the stomach, before passing it to the rest of the body
2. Breakdown (and thus detoxify) chemicals in your body, and drugs
3. Secrete bile into the intestines
4. Make proteins important for blood clotting and other functions.

2. What is NASH?

Non-alcoholic steatohepatitis (NASH) is liver inflammation and damage caused by a build-up of fat in the liver. It is part of a group of conditions called ‘Non-alcoholic fatty liver/liver disease’ (NAFL/NAFLD). You may be told that you have a ‘fatty liver’.

Many people have a build-up of fat in the liver, and for most people it causes no symptoms and no problems. But in some people, the fat causes inflammation and damages cells in the liver. Because of the damage, the liver doesn’t work as well as it should.

NASH can get worse and cause scarring of the liver, which leads to fibrosis (which means scarring) and subsequently to cirrhosis – and eventually liver failure (which may lead to the need for a liver transplant). But the disease doesn’t always get worse.

NAFLD is usually related to conditions known as ‘metabolic conditions’. These include being overweight or obese, having high lipids in the blood, diabetes mellitus or high blood pressure. Those who drink excess alcohol can have fatty changes in the liver. The recommended alcohol limit for both men and women is 14 units per week.

But NASH also occurs in people who don’t abuse alcohol.

3. Stages

These are the three stages of NASH:

1. NALFD-NAFL (simple fat deposition) and NASH (inflammation in the liver)
2. NASH with fibrosis
3. NASH with cirrhosis.

The progression of these stages can take years.

4. Cause

The cause of NASH is not known but it has been proposed that genetic and environmental factors may play a role. NAFLD is strongly associated with metabolic conditions such as:

1. Being overweight or obese
2. Type 2 diabetes (insulin resistance)
3. High lipids including cholesterol
4. Hypertension.

NAFLD can happen in people who have none of these risk factors

Some drugs have been linked to it, e.g. amiodarone, tamoxifen, steroids (e.g. prednisolone, hydrocortisone), and synthetic oestrogens or those with polycystic ovarian syndrome (PCOS).

5. Symptoms 

Most people with NASH have no symptoms at the early stages.

As NASH progresses and liver damage gets worse, you may start to have symptoms such as:

1. Fatigue (feeling tired all the time)
2. Weight loss
3. General weakness
4. An ache in the upper right part of your belly.

It may take many years for NASH to become severe enough to cause symptoms.

6. Diagnosis

There is no single test that can diagnose NASH. But the following tests are done:

1. Blood tests – blood glucose and liver enzymes (also called liver function tests, LFTs). Increased levels of liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are characteristic
2. Other blood tests – are useful for ruling out other causes of liver disease. These usually include tests for viral hepatitis (hepatitis A, B, or C), and may include tests for less common causes of liver disease such as autoimmune and genetic conditions
3. Abdominal ultrasound
4. CT or MRI scan – in some cases.

Once you had been referred to a hospital liver specialist (hepatologist), the specialist will do a Fibroscan to assess the degree of scarring or damage within the liver. Sometimes, you will need a liver biopsy as well. In a liver biopsy, a sample of tissue is taken from your liver. Liver biopsy is most commonly used in the clinical trials for treatment of NASH.

7. Who should be referred to a liver specialist?

Unless your GP is certain, if they suspect NASH, you will usually be referred to a liver specialist (hepatologist) at your local hospital – especially if there is a high suspicion of underlying liver injury/scarring.

In some cases, the specialist may suggest medicines to control or reverse liver damage caused by NASH.

8. What is a Fibroscan?

A fibroscan is a special ultrasound scan to determine how ‘stiff’ the liver is. It can be done on the bedside in the clinic room. This stiffness can then be used to estimate how much scarring there is in the liver, and to determine if cirrhosis has developed. It is also used to monitor the progression of liver disease over the years. Where available, fibroscan is an alternative to liver biopsy for detecting liver scarring.

9. What can do I to improve my NASH?

Quite a lot actually. Treatment for NASH includes managing underlying conditions.

1. Diet and exercise – try to reach a healthy weight by adopting a healthy lifestyle. Losing between 5 and 10% of your total body weight can make a difference. With regard to diet, a Mediterranean diet has been shown benefit those with NAFLD. We recommend 15-20 minutes of physical activity (at least 3 times) per week
2. Lose weight – for those who are unable to lose weight despite changing the lifestyle, referral to specialist for weight loss treatment may be needed. This may include bariatric surgery
3. Alcohol – stop or cut back on drinking alcohol
4. Control diabetes
5. Reduce your cholesterol level.

10. Your pharmacist can help as well

Ask your pharmacist about all the medicines you are taking – as some may harm your liver.

Summary

We have described 10 NASH (non-alcoholic steatohepatitis) facts. If you follow the advice above, it can improve significantly.

Other resources

This is a doctors review article in the BMJ.
The British Liver Trust have good documents: https://britishlivertrust.org.uk/information-and-support/living-with-a-liver-condition/liver-conditions/non-alcohol-related-fatty-liver-disease/.
This NHS weight loss is useful as well: https://www.nhs.uk/better-health/lose-weight/.

Reviewed by Dr Sophia Than, Consultant Hepatologist, UHCW.