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NASH
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(NAFLD)
Acronym for Non-Alcoholic Steato Hepatitis
Steatotic liver disease similar to that described in obese adults.
The main clinical features are:
- hypertriglyceridemia,
- an elevation of hepatic enzymes up to less than 4 times the upper normal values (and ALAT >> ASAT), as well as GGT
- vague abdominal pain
- and lack of hepatic involvement of other origin: viral, autoimmune, toxic (valproate), genetic (Wilson disease, mitochondrial cytopathy) or chronc alcoholic consumption
Liver biopsy shows steatosis with lesions of hepatitis that evolves in some cases (genetic predisposition ?) to fibrosis or even cirrhosis ('cryptogetic'), and favors the development of hepato-cellular carcinoma.
Histologically, there are two types of NASH:
- type 1 that corresponds to the typical image of the adult form: steatosis, with ballonisation in some hepatocytes and/or peri-sinusoid fibrosis but without peri-portal involvement;
- type 2: steatosis with peri-portal inflammation without ballonisation of hepatocytes nor peri-sinusoid involvement
The physiopathology is complex and probably multifactorial: insulin resistance produces accumulation of free fatty acids in hepatocytes leading to different reactions. Risk factors are: a BMI > 25, central adiposity, hyperglycemia, hypertriglyceridemia and a low HDL-cholesterol level.
The only treatment, at the stage of steatosis or steatotic hepatitis, is weight loss that must not, however, exceed 500 g a week because a too rapid weight loss may aggravate the steatosis. A treatment with metformin is useful.
Anesthetic implications:
check liver function and absence of cirrhosis; avoid hypoxemia and hepatotoxic agents.
References :
- Marion AW, Baker AJ, Dhawan A.
Fatty liver disease in children.
Arch Dis Child 2004; 89 : 648-52.
- Pardee PE, Lavine JE, Schwimmer JB.
Diagnosis and treatment of pediatric nonalcoholic steatohepatitis and the implications for bariatric surgery.
J Pediatr Surg 2009; 18:144-51
Updated: October 2016