Nonalcoholic Steatohepatitis And Gilbert’s Disease?

Over a year ago, through a routine physical, my boyfriend’s physician discovered his liver enzymes were high, and his liver was enlarged. Over a month ago he had another physical. His enzymes are still up, there are amounts of fat in his liver, and it is still enlarged. He is scheduled for an ultra-sound and will see a gastroenterologist.

My boyfriend is about 5’11” and weighs approximately 200 lbs. He is not a heavy drinker by any standards and is not diabetic. I am concerned because he has been experiencing stabbing, though sometimes dull, aching pains on his side. Would you be able to tell me if fatty liver is the same as steatohepatitis? Is this Gilbert’s disease?

Nonalcoholic steatohepatitis (NASH) is a newly recognized condition, first described in 1980, that has recently been the subject of more interest and many studies. The name means liver inflammation (hepatitis), with fat in the liver cells (steato), in someone who does not abuse alcohol. The term nonalcoholic is added here because the pathology of the liver, its appearance under a microscope, is very similar to that seen in people with alcoholic liver disease.

Hepatitis can be due to viruses (hepatitis B, C, EBV and others), bacteria (tuberculosis), non-infectious causes (sarcoid), autoimmune disease, genetic defects, and other causes. By and large these can all be distinguished on examination of tissue by a pathologist. Hepatitis from the hepatitis B and C viruses looks different from that caused by autoimmune disease, or sarcoid or alcoholism, for example. Most forms of hepatitis can lead to the death of liver cells, fibrosis (scarring), and may lead to cirrhosis which is advanced scarring and destruction of the normal appearance of the liver with interference in its function.

Fat droplets in liver cells are seen in many conditions, but fatty infiltration of liver cells appears to be fundamental to NASH. Pathologists recognize a continuum of liver changes which have simple fatty liver at one end, and cirrhosis at the other. NASH lies on this continuum, and may remain stable without progressing, may heal completely, or may progress along the continuum to cirrhosis.

NASH is seen most commonly in people who are overweight, and we may be seeing more of it as obesity increases in our country. Your boyfriend has a body-mass index (BMI) of 28, which puts him in the overweight but not yet obese category. Some studies have shown a particular connection between NASH and abdominal obesity, in which the circumference of the abdomen is greater than the circumference of the hips, known as the waist-hip ratio. This type of obesity is also common in type II diabetics, and about half of people with NASH have type II diabetes. Many also have abnormal blood fat levels, particularly high levels of triglycerides. The fat droplets seen in the liver cells in NASH are made of triglycerides.

It is not known how the fats in the blood might produce NASH. Some people with NASH who have developed cirrhosis and required a liver transplant have developed NASH in the new liver, implying that some more general disturbance of fat metabolism is at work. The natural history of the condition is also not known because large, long term, follow up studies have not yet been completed. Many people with it do not progress, and in some the condition may actually improve with weight loss. An unknown percentage can go on to more advanced liver fibrosis or cirrhosis.

There are no studies yet which have demonstrated an effective treatment for NASH. If a person with the condition is obese, then weight loss may bring about an improvement of the liver enzyme tests, but we don’t yet know if this translates into less fibrosis and cirrhosis. If the person is diabetic, good diabetic control may be helpful, since it may reduce the fat abnormalities in the blood. If someone is thin, as are a minority of people with NASH, then correcting any fat abnormalities in the blood should be attempted. A small study has shown some promise using bile salts (ursodiol) which improved the liver enzymes and the fat in the liver cells, though it did not seem to improve fibrosis.

Most people with NASH are picked up when a routine blood test shows abnormal liver enzymes, as were found in your boyfriend. The condition usually produces no symptoms, and I would doubt that his abdominal pains have any connection to his liver. Bilirubin, another product of the liver which is somewhat elevated in Gilbert’s disease, is usually not high in NASH, and there is no evidence that NASH and Gilbert’s disease are in any way related. A number of blood tests can be done to rule out other causes of elevated enzymes, but the only way to diagnose NASH with precision is to do a liver biopsy. The gastroenterologist who will be seeing your boyfriend may well suggest a biopsy if other tests don’t turn up the correct diagnosis.

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