Alcoholic and Non-Alcoholic Fatty Liver Disease

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1 Alcoholic and Non-Alcoholic Fatty Liver Disease Thomas W. Faust, M.D., M.B.E. Professor of Clinical Medicine Division of Gastroenterology The University of Pennsylvania

2 Alcoholic Liver Disease Additional Take Home Points Spectrum of disease Steatosis, steatohepatitis, cirrhosis Risk factors Dose, duration, type, sex, ethnicity, genetics, other underlying liver diseases Histology Macrovesicular steatosis, ballooning, Mallory Bodies, perivenular and pericellular fibrosis, cirrhosis

3 Alcoholic Fatty Liver Disease Additional Take Home Points Alcoholic hepatitis prognostic factors Maddrey DF, MELD, Lille Model Alcoholic liver disease treatment Enteral nutrition Alcoholic hepatitis: steroids, pentoxifylline End stage liver disease Transplantation in carefully selected cases

4 NAFLD Additional Take Home Points Spectrum of disease Bland steatosis, ballooning, inflammation, zone 3 fibrosis, cirrhosis Pathogenesis Obesity, insulin resistance, increased free fatty acids, de novo lipogenesis Risk factors Obesity, insulin resistance, race and ethnicity, age, sex Treatment Diet and exercise, vitamin E, bariatric surgery in selected cases

5 DDSEP 6, AGA Press, Alcoholic Liver Disease Question 1 A 50 yr. old man is seen in the office for routine evaluation. He is asymptomatic. He acknowledges drinking one pint of liquor per day for many years. Physical exam reveals marked hepatomegaly without splenomegaly. Liver enzymes include AST 65 U/L and ALT 25 U/L (normal for each is < 40 U/L). CBC, coagulation studies, bilirubin, and albumin are normal. What would liver biopsy reveal in this patient?

6 Alcoholic Liver Disease Question 1 A. Microvesicular steatosis B. Macrovesicular steatosis C. Macronodular cirrhosis D. Mallory s hyaline E. Ballooning degeneration of hepatocytes with polymorphonuclear infiltrate DDSEP 6, AGA Press, 2011.

7 Alcoholic Liver Disease Question 1 A. Microvesicular steatosis B. Macrovesicular steatosis C. Macronodular cirrhosis D. Mallory s hyaline E. Ballooning degeneration of hepatocytes with polymorphonuclear infiltrate DDSEP 6, AGA Press, 2011.

8 Alcoholic Liver Disease Question 2 In a patient hospitalized for severe alcoholic hepatitis, which of the following would be an indication to treat with methylprednisolone? A. New onset of confusion and asterixis B. Massive variceal hemorrhage C. Ascites with spontaneous bacterial peritonitis D. Albumin less than 3.0 g/dl E. AST/ALT ratio greater than 2 DDSEP 6, AGA Press, 2011.

9 Alcoholic Liver Disease Question 2 In a patient hospitalized for severe alcoholic hepatitis, which of the following would be an indication to treat with methylprednisolone? A. New onset of confusion and asterixis B. Massive variceal hemorrhage C. Ascites with spontaneous bacterial peritonitis D. Albumin less than 3.0 g/dl E. AST/ALT ratio greater than 2 DDSEP 6, AGA Press, 2011.

10 DDSEP 6, AGA Press, NAFLD Question 3 A 60 yr old man is referred because of abnormal LFTs. His BMI is 36 and his cholesterol and triglycerides are managed with diet and simvastatin. He takes hydrochlorothiazide for mild hypertension and acetaminophen 1 g BID for back pain. He denies alcohol use. PE is unrevealing except for mild obesity. AST is 75 U/L, ALT is 60 U/L (normal < 40 U/L for both). The alkaline phosphatase, bilirubin, albumin, and INR are normal. Platelets are mildly low at 120,000. Fasting glucose is 160 mg/dl. Viral, autoimmune markers, and quantitative immunoglobulins are normal. Ceruloplasmin, alpha-1-antitrypsin, and iron studies are normal. Ultrasound reveals an echogenic liver. Which test is most likely to lead to the correct diagnosis?

11 NAFLD Question 3 A. Magnetic resonance imaging B. Serum protein electrophoresis C. Plasma acetaminophen level D. Liver biopsy E. Repeat liver tests following withdrawal of simvastatin DDSEP 6, AGA Press, 2011.

12 NAFLD Question 3 A. Magnetic resonance imaging B. Serum protein electrophoresis C. Plasma acetaminophen level D. Liver biopsy E. Repeat liver tests following withdrawal of simvastatin DDSEP 6, AGA Press, 2011.

13 DDSEP 6, AGA Press, NAFLD Question 4 All of the following metabolic and laboratory abnormalities are characteristic of nonalcoholic steatohepatitis except: A. Insulin resistance B. Elevated plasma cholesterol and triglycerides C. Elevated circulating levels of free fatty acids D. Elevated circulating levels of adiponectin E. Elevated circulating levels of tumor necrosis factor alpha

14 DDSEP 6, AGA Press, NAFLD Question 4 All of the following metabolic and laboratory abnormalities are characteristic of nonalcoholic steatohepatitis except: A. Insulin resistance B. Elevated plasma cholesterol and triglycerides C. Elevated circulating levels of free fatty acids D. Elevated circulating levels of adiponectin E. Elevated circulating levels of tumor necrosis factor alpha

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