Non Alcoholic Fatty Liver Disease (NAFLD) is a spectrum of disorders seen in people without consumption of alcohol in amounts known to be toxic to the liver and characterized by pathological appearance of  predominant macro-vesicular hepatic steatosis. Non-Alcoholic Steato-Hepatitis (NASH) is a metabolic liver disease in which fatty change i.e  steatosis is accompanied  with lobular inflammation, hepatocyte injury and/or hepatic fibrosis. NASH can be defined pathologically as significant steato-hepatitis not resulting from alcohol, drugs, toxins, infectious agents or other identifiable exogenous causes. Abnormal liver function tests secondary to NASH/NAFLD has become the most common liver disease worldwide. 

This study was planned to evaluate the clinical and biochemical profile of 85 diabetic -out-patients and in- patients attending, the Department of Medicine, Government T.D.Medical College, Alappuzha. The study concluded that NASH prevalence is strongly associated with Female gender, hypertension, dyslipidemia and family history. Further, the occurrence of NASH was higher in those with longer duration of Type 2 Diabetes, uncontrolled Diabetes, higher waist-hip ratio and higher BMI. Presence of combination of low serum albumin levels, low-normal platelet counts, acanthosis nigricans and non-tender hepatomegaly was found to be a strongly predictive of NASH in diabetics.

1. IR, Lentz JS. Fatty liver hepatitis (steatohepatitis) and obesity: an autopsy study with analysis of risk factors. Hepatology 1990; 12: 1106–10.
2. Powell EE, Cooksley WGE, Hanson R et al. The natural history of non-alcoholic steatohepatitis: a follow-up study of 42 patients for up to 21 years. Hepatology 1990; 11: 74–80.
3. Neuschwander-Tetri BA, Caldwell SH. Non-alcoholic steatohepatitis: summary of an AASLD single topic conference. Hepatology 2003; 37: 1202–19
4. Angulo P. Non-alcoholic fatty liver disease. N Engl J Med 2002; 16: 1221–31.
5. Seth SG, Gordon FD, Chopra S. Non-alcoholic steatohepatitis. Ann Intern Med 1997; 126: 137–45.
6. Marchesini G, Forlani G. NASH: From liver diseases to metabolic disorders and back to clinical hepatology. Hepatology 2002; 35: 497–9.
7. Bacon BR, Farahvash MJ, Janney CG, Neuschwander- Tetri BA. Non-alcoholic steatohepatitis: an expanded clinical entity. Gastroenterology 1994; 107: 1103–9
8. Matteoni CA, Younossi ZM, Gramlich T et al. Nonalcoholic fatty liver disease: a spectrum of clinical and pathological severity. gastroenterology 1999 ; 116: 1413–9.
9. Angulo P, Keach JC, Batts KP, Lindor KD. Independent predictors of liver fibrosis in patients with non-alcoholic steatohepatitis. Hepatology 1999; 30: 1356–62.
10. Erby JR, Silberman C, Lydick E. Prevalence of abnormal serum alanine aminotransferase levels in obese patients and patients with type 2 diabetes. Am J Med 2000; 109: 588–90.
11. Dixon JB, Bhathal PS, O’Brien PE. Non-alcoholic fatty liver disease: predictors of non-alcoholic steatohepatitis and liver fibrosis in the severely obese. Gastroenterology 2001; 121: 91–100
12. Hui JM, Kench JG, Chitturi S et al. Long-term outcomes of cirrhosis in NASH compared to hepatitis C: same mortality, less cancer. Hepatology 2003; 38: 420–7.
13. Clark JM, Brancati FL, Diehl AM. Non-alcoholic fatty liver disease. Gastroenterology 2002; 122: 1649–57.
14. Ruhl CE, Everhardt JE. Determinants of the association of overweight with elevated serum alanine aminotransferase activity in the United States. Gastroenterology 2003; 124: 71–9.
15. Bellentani S, Sacoccio G, Masutti F et al. Prevalence and risk factors for hepatic steatosis in northern Italy. Ann Intern Med 2000; 132: 112–7.
16. Hasan I, Gani RA, Machmud R et al. Prevalence and risk factors for non-alcoholic fatty liver in Indonesia. J Gastroenterol Hepatol 2002; 17 (Suppl): A154.
17. Caldwell SH, Oelsner DH, Iezzoni JC et al. Cryptogenic cirrhosis: clinical characterization and risk factors for underlying disease. Hepatology 1999; 29: 664–9.
18. Ratziu V, Giral P, Charlotte F et al. Liver fibrosis in overweight patients. Gastroenterology 2000; 118: 1117–23.
19. Marchesini G, Brizi M, Morselli-Labate AM et al. Association of non-alcoholic fatty liver disease with insulin resistance. Am J Med 1999; 107: 450 -5.
20. Marceau P, Biron S, Hould FS et al. Liver pathology and the metabolic syndrome X in severe obesity. J Clin Endocrinol Metab 1999; 84: 1513–7.
21. Sanyal AJ, Campbell-Sargent C, Mirshahi F et al. Nonalcoholic steatohepatitis: association of insulin resistance and mitochondrial abnormalities. Gastroenterology 2001; 120: 1183–92.
22. Chitturi S, Abeygunasekera S, Farrell GC et al. NASH and insulin resistance: insulin hypersecretion and specific association with the insulin resistance syndrome. Hepatology 2002; 35: 373–8.
23. Pagano G, Pacini G, Musso G et al. Non-alcoholic steatohepatitis, insulin resistance and metabolic syndrome: further evidence for an etiologic association. Hepatology 2002; 35: 367–72.
24. Daniel M, Rowley KG, McDermott R, O’Dea K. Diabetes and impaired glucose tolerance in Aboriginal Australians: prevalence and risk. Diabetes Res Clin Pract 2002; 57: 23–33.
25. Zimmet P, Alberti KG, Shaw J. Global and societal implications of the diabetes epidemic. Nature 2001; 414: 782–7.
26. Omagari KH, Kadokawa Y, Masuda J et al. Fatty liver in non-alcoholic non-overweight Japanese adults: incidence and clinical characteristics. J Gastroenterol Hepatol 2002; 17: 1089–105.
27. Poonawala A, Nair SP, Thuluvath PJ. Prevalence of obesity and diabetes in patients with cryptogenic cirrhosis: a case study. Hepatology 2000; 32: 689–92.
28. Caldwell SH, Hespenheide EE. Subacute liver failure in obese women. Am J Gastroenterol 2002; 97: 2058–62.
29. Falck-Ytter Y, Younossi ZM, Marchesini G, McCullough AJ. Clinical features and natural history of non-alcoholic steatosis syndromes. Semin Liver Dis 2001; 21: 17–26.
30. Hourigan LF, Macdonald GA, Purdie D et al. Fibrosis in chronic hepatitis C correlates with body mass index and steatosis. Hepatology 1999; 29: 1215–9.
31. Hwang SJ, Luo JC, Chu CW et al. Hepatic steatosis in chronic hepatitis C virus infection: prevalence and clinical correlation. J Gastroenterol Hepatol 2001; 16: 190–5.
32. Naveau S, Giraud V, Borotto E et al. Excess weight risk factor for alcoholic liver disease. Hepatology 1997; 25: 108–11.
33. Struben VMD, Hespenheide EE, Caldwell SH. Nonalcoholic steatohepatitis and cryptogenic cirrhosis within kindreds. Am J Med 2000; 108: 9–13.
34. Angulo P, Hui JM, Marchesini G et al. The NAFLD fibrosis score: a non-invasive system that identifies liver fibrosis in patients with NAFLD. Hepatology 2007; 45: 846–54.
35. Ioannou GN, Morrow OB, Connole ML, Lee SP. Association between dietary nutrient composition and the incidence of cirrhosis or liver cancer in the United States population. Hepatology 2009; 50: 175–84.
36. Fan J-G, Farrell GC. VAT fat is bad for the liver, SAT fat is not! Gastroenterol. Hepatol. 2008; 23: 823–32.
37. Koonen DP, Jacobs RL, Febbraio M et al. Increased hepatic CD36 expression contributes to dyslipidemia associated with diet-induced obesity. Diabetes 2007; 56: 2863–71.
38. Manchanayake MMJH, Chitturi S, Nolan C, Farrell GC. The value of glucose tolerance testing in patients with nonalcoholic fatty liver disease. Gastroenterol. Hepatol. 2009; 24 (Suppl. 2): A306.
39. Palekar NA, Naus R, Larson SP, et al. Clinical model for distinguishing nonalcoholic steatohepatitis from simple steatosis in patients with nonalcoholic fatty liver disease. Liver Int 2005;26: 151–156.
40. Angulo P, Hui JM, Marchesini G, et al. The NAFLD fibrosis score: a noninvasive system that identifies liver fibrosis in patient with NAFLD. Hepatology 2007;45:846–854.

Dr Rashmi KP

Govt TD Medical College Alappuzha