Fat can sometimes accumulate in the liver. Most commonly it is due to obesity. Fatty liver can also occur in people with diabetes, high cholesterol or high triglycerides and in people who take certain drugs. Sometimes fat accumulates in the liver without causing injury; this is called hepatic steatosis or non-alcoholic fatty liver disease (NAFLD). In some patients, however, the fat damages the liver, causing inflammation and scarring. This is called NASH (non-alcoholic steatohepatitis). Researchers are still trying to figure out why this liver damage occurs. It can lead to cirrhosis, even in children.

Causes

The underlying cause of NASH is unknown. While obesity, diabetes, high cholesterol and high triglycerides are risk factors, these conditions do not always result in a person having NASH. Likewise, a person with NASH may not have any of these risk factors. Research indicates that insulin resistance (body doesn't respond to insulin) may be an underlying factor. The NASH affects between 2 and 5 percent of the population.

Symptoms

People with fatty liver may not experience any symptoms. Sometimes routine blood work will show elevated levels of certain liver enzymes and further tests will reveal fat accumulation in the liver. Some patients with NASH have right upper abdominal pain. Weight loss, fatigue and weakness only occur once the disease is more advanced or cirrhosis develops.

Exams and Tests

Routine blood tests that include liver panels may reveal certain liver enzymes to be elevated. Your child's pediatric GI specialist may suspect NASH but will need to do a liver biopsy to confirm the diagnosis.

Liver Biopsy

Your child will receive sedation medications or a general anesthetic before the biopsy. These medications will prevent your child from feeling pain or anxiety or remembering the procedure. An area on the right side of your child's abdomen or mid-upper abdomen will be cleansed with an antibacterial soap. The biopsy site will then be numbed with an injection of lidocaine (numbing medicine). The doctor will insert a needle through the skin and into the liver to obtain a very small piece of liver tissue. The sample will be sent to a lab and analyzed. The doctor will apply a small pressure dressing (bandage) to the site.

After the biopsy your child will stay in or return to his/her room for four hours, when a repeat blood count is checked. (Children less than one year are observed overnight.) He or she should lie on the right side or back, depending on the biopsy site, for two hours. Being in bed will reduce the chance of bleeding after the biopsy. Once your child is awake and alert, he/she will be allowed to drink fluids. If fluids are tolerated, a regular diet can be restarted. For the remainder of the day, your child will need to participate in quiet activity. The results of the liver biopsy are usually available two weeks after the procedure.

Treatment

There is no specific treatment for NASH. Your child's pediatric gastroenterologist may make the following recommendations, depending on your child's situation:

• reduce weight (if obese or overweight)
• follow a balanced and healthy diet
• increase physical activity

Research

Pediatric Gastroenterology/Hepatology/Nutrition participates in a multi-center research study investigating nonalcoholic steatohepatitis. We encourage you to ask questions in order to make an informed decision about participation.

Points to Remember

• Fat accumulation in the liver is abnormal but may not cause severe disease.
• Sometimes fatty liver results in liver inflammation and scarring (NASH) and may progress to cirrhosis.
• People with fatty liver may not have any symptoms until the condition worsens and develops into NASH. Symptoms may include weight loss, fatigue and weakness.
• There is no specific treatment for NASH, but your child's doctor may recommend things to help improve or lessen the progression of the disease.

For More Information

American Liver Foundation - liverfoundation.org

Clinical Research Network in Nonalcoholic Steatohepatitis - jhucct.com/nash/default.asp

National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health - digestive.niddk.nih.gov/ddiseases/pubs/nash/

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition - NASPGHAN.org