para>NAFLD has been reported in children as young as 2 years of age and NASH-related cirrhosis as early as 8 years of age (2).
Screening for NAFLD in overweight and obese children is controversial. Expert committee opinion recommends biannual screening with liver enzyme measurements in overweight children (2)[B].
Children with fatty liver who are very young or who are not overweight should be tested for other causes of liver disease, such as fatty acid oxidation defects, lysosomal storage diseases, peroxisomal disorders, infectious hepatitis, Wilson disease, and autoimmune diseases (2)[C].
Liver biopsy in children with suspected NAFLD should be performed if the diagnosis is unclear, when there is possibility of multiple diagnoses, or before starting therapy with potentially hepatotoxic medications (2)[B].
First-line treatment for children with NAFLD is weight loss and lifestyle modifications (2)[B].
ISSUES FOR REFERRAL
Hepatology referral may help with staging and prognosis.
SURGERY/OTHER PROCEDURES
- The lack of randomized clinical trials precludes assessment of the benefits and harms of bariatric surgery as a treatment for patients with NASH (6)[A].
- Although abdominal weight loss surgery coupled with rapid weight loss has been implicated as contributing to the development of NASH, it is not contraindicated in otherwise eligible obese patients (2)[A].
COMPLEMENTARY & ALTERNATIVE MEDICINE
- Probiotic therapies can reduce liver aminotransferases, total cholesterol, and TNF-α and improve insulin resistance in NAFLD patients (7)[A].
- Omega-3 fatty acids may be used to treat hypertriglyceridemia in patients with NAFLD (2,8)[B].
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- All patients should be tested for hepatitis A and B and vaccinated, if appropriate.
- Consider screening patients with NASH cirrhosis for hepatocellular carcinoma according to AASLD/ACG guidelines (http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/HCCUpdate2010.pdf) (2)[B].
- Current evidence does not support routinely repeating liver biopsies in patients with NAFLD or NASH (2)[C].
Patient Monitoring
Regularly assess patients with fatty liver disease for:
- Patient complaints (encephalopathy, ascites, fatigue)
- Physical exam findings (spider telangiectasia, palmar erythema, splenomegaly)
- Laboratory findings (change in liver enzyme tests, decreasing platelets, elevated bilirubin, decreasing albumin)
- Incidental imaging study findings (cirrhotic liver, splenomegaly, varices, ascites)
DIET
Restrict total calories, simple carbohydrates, and alcohol to control diabetes, weight, and lipids.
PATIENT EDUCATION
Ongoing follow-up and motivational interviewing to assess lifelong changes in diet, exercise, and alcohol use
PROGNOSIS
- 25 " 35% of NASH patients develop fibrosis; 9 " 20% develop cirrhosis (3).
- Patients with NAFLD have increased all-cause mortality.
- Half of deaths in patients with NASH are due to cardiovascular disease and malignancy.
COMPLICATIONS
Steatohepatitis may progress to cirrhosis. Complications include variceal bleeding, ascites, encephalopathy, liver failure, and hepatocellular carcinoma.
REFERENCES
11 Vernon G, Baranova A, Younossi ZM. Systematic review: the epidemiology and natural history of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis in adults. Aliment Pharmacol Ther. 2011;34(3):274 " 285.22 Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Hepatology. 2012;55(6):2005 " 2023.33 Schneider AL, Lazo M, Selvin E, et al. Racial differences in nonalcoholic fatty liver disease in the U.S. population. Obesity (Silver Spring). 2014;22(1):292 " 299.44 Ramesh S, Sanyal AJ. Evaluation and management of non-alcoholic steatohepatitis. J Hepatol. 2005;42(Suppl 1):S2 " S12.55 Rinella M. Nonalcoholic fatty liver disease: a systematic review. JAMA. 2015;313(22):2263 " 2273.66 Chavez-Tapia NC, Tellez-Avila FI, Barrientos-Gutierrez T, et al. Bariatric surgery for non-alcoholic steatohepatitis in obese patients. Cochrane Database Syst Rev. 2010;(1):CD007340.77 Ma YY, Li L, Yu CH, et al. Effects of probiotics on nonalcoholic fatty liver disease: a meta-analysis. World J Gastroenterol. 2013;19(40):6911 " 6918.88 Dasarathy S, Dasarathy J, Khiyami A, et al. Double-blind randomized placebo-controlled clinical trial of omega 3 fatty acids for the treatment of diabetic patients with nonalcoholic steatohepatitis. J Clin Gastroenterol. 2015;49(2):137 " 144.
CODES
ICD10
- K75.81 Nonalcoholic steatohepatitis (NASH)
- K76.0 Fatty (change of) liver, not elsewhere classified
ICD9
571.8 Other chronic nonalcoholic liver disease
SNOMED
- nonalcoholic steatohepatitis (disorder)
- Non-alcoholic fatty liver (disorder)
CLINICAL PEARLS
- The prevalence of NAFLD and NASH is higher in patients with metabolic syndrome or any one of its components (diabetes, obesity, hypertriglyceridemia).
- Liver biopsy is the gold standard for diagnosis.
- Lifestyle changes are central to the treatment of NAFLD.
- Vitamin E should be considered as first-line therapy in nondiabetic patients with biopsy-proven NASH.
- Consider statins in patients with NAFLD and dyslipidemia.