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Dealing with NASH Dealing with NASH mildly abnormal LFTs” mildly abnormal LFTs”

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Dealing with NASH. “mildly abnormal LFTs”. Liver disease is a national epidemic. Contribution of alcoholic liver disease to overall liver deaths. and a local disaster. Liverpool S.Tyne Knowsley Blackpool - PowerPoint PPT Presentation

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Page 1: Dealing with NASH

Dealing with NASHDealing with NASH

““mildly abnormal LFTs”mildly abnormal LFTs”

Page 2: Dealing with NASH

Liver disease is a national epidemicLiver disease is a national epidemic

Page 3: Dealing with NASH
Page 4: Dealing with NASH

Contribution of alcoholic liver disease to Contribution of alcoholic liver disease to overall liver deathsoverall liver deaths

Page 5: Dealing with NASH

and a local disasterand a local disaster

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Page 6: Dealing with NASH

Hep C notifications by English Region 1995-2010

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Page 7: Dealing with NASH

Liverpool S.Tyne Knowsley Blackpool Manchester Wirral Gateshead Sunderland Sefton Newcastle Heywood Hartlepool Halton Blackburn Bolton Salford Oldham

The North of England cluster hashigher rates of Thiamine prescribing

than the other SHA clusters

Page 8: Dealing with NASH

Are LFTs a useful Are LFTs a useful test ?test ?

Page 9: Dealing with NASH

How are LFTs ranges How are LFTs ranges decideddecided

►LFT values a continuumLFT values a continuum

►Abnormal are the extreme 2.5% endsAbnormal are the extreme 2.5% ends

►““Normal” is shifting Normal” is shifting 8% of Americans have high LFTs8% of Americans have high LFTs

(Clark AJG 2003)(Clark AJG 2003)

►““Normal” may not represent “healthy”Normal” may not represent “healthy”

Page 10: Dealing with NASH

Normal LFTsNormal LFTs► High “normal” LFTs High “normal” LFTs

assoc. with assoc. with increased liver increased liver mortalitymortality

(Kim BMJ 2004) (Kim BMJ 2004)

► 20% of HCV will 20% of HCV will have “normal” ALThave “normal” ALT

(Kelly MJA 2002)(Kelly MJA 2002)

► 58% abn LFTs never 58% abn LFTs never investigated in investigated in primary careprimary care

(Sherwood BMJ 2001)(Sherwood BMJ 2001)

ALTALT RR liver deathRR liver death

MM FF

<20<20 1.01.0 1.01.0

20-20-2929

2.92.9 3.83.8

30-30-3939

9.59.5 6.66.6

Page 11: Dealing with NASH

How good are we at How good are we at investigating abnormal LFTs ?investigating abnormal LFTs ?

►Retrospective audit of primary careRetrospective audit of primary care NottinghamNottingham Jan - Jun 1995Jan - Jun 1995

►342 consecutive abnormal LFTs342 consecutive abnormal LFTs►157 suitable for FU (not normalised, 157 suitable for FU (not normalised,

RIP or moved)RIP or moved)

91 (58%)91 (58%) no further investigationno further investigation 97 (62%) 97 (62%) significant pathologysignificant pathology

Page 12: Dealing with NASH

What are the What are the commonest causes of commonest causes of

LFT abnormalities LFT abnormalities

Page 13: Dealing with NASH

Causes of abnormal LFTsCauses of abnormal LFTs42 Alcoholic liver disease (23 with

cirrhosis)26 Fatty liver / NASH (11 fibrotic on

biopsy)12 PBC / AIH / PSC6 Haemochromatosis2 Hepatitis B6 Hepatitis C3 Common bile duct stones1 α1-antitrypsin deficiency6 Cryptogenic hepatitis

(Sherwood BMJ 2001)

Page 14: Dealing with NASH

Basics of NASHBasics of NASH

►NASH is commonNASH is common►Most NASH is undetectedMost NASH is undetected

UntestedUntested Normal LFTsNormal LFTs

►NASH is “metabolic syndrome in the NASH is “metabolic syndrome in the liver”liver” Associated with obesity / DMAssociated with obesity / DM

►Most patients with NASH don’t die of Most patients with NASH don’t die of liver diseaseliver disease

Page 15: Dealing with NASH

ButBut

►Obesity / NASH potent cofactor for Obesity / NASH potent cofactor for fibrosisfibrosis

►NASH cirrhosisNASH cirrhosis Poor prognosisPoor prognosis High risk of HCCHigh risk of HCC

Page 16: Dealing with NASH

Cumulative risk of HCC in Cumulative risk of HCC in 820,000 male veterans in 820,000 male veterans in

hospital ’85-90hospital ’85-90

El-Serag 2004

Page 17: Dealing with NASH

Practical management Practical management

►Exclude other disease – aetiological Exclude other disease – aetiological screenscreen Diagnosis other than NASHDiagnosis other than NASH Other synergistic pathologiesOther synergistic pathologies

►Assess severityAssess severity►Treat cofactorsTreat cofactors►Weight and lifestyle management Weight and lifestyle management ►(Specific therapy) (Specific therapy)

Page 18: Dealing with NASH

Liver aetiological screenLiver aetiological screen

► Hep B S-AgHep B S-Ag► Hep C antibodiesHep C antibodies► Ferritin / Iron studiesFerritin / Iron studies

► AutoantibodiesAutoantibodies

► Coeliac diseaseCoeliac disease► A1-ATA1-AT► Copper studiesCopper studies

Page 19: Dealing with NASH

Assessment of severityAssessment of severity

►LFTs - virtually useless !!!LFTs - virtually useless !!!

►FBC (platelets)FBC (platelets)

►US screenUS screen

Page 20: Dealing with NASH

Specific assessmentSpecific assessment

►FibroscanFibroscan

►FibrotestFibrotest

►Traffic lightsTraffic lights

►Other indicesOther indices

Page 21: Dealing with NASH

Southampton Traffic light Southampton Traffic light testtest

►HA >30HA >30μμg/l or P3NP >5.5g/l or P3NP >5.5μμg/lg/l +1+1►HA >75HA >75μμg/lg/l +2+2►Platelets <150Platelets <150 +1+1

► Score Score 00 GreenGreen 0% risk liver death0% risk liver death

11 AmberAmber 3% risk liver death3% risk liver death

2+2+ RedRed 18% risk liver death18% risk liver death

Page 22: Dealing with NASH

ManagementManagement

►Refer if evidence of Refer if evidence of Advanced fibrosisAdvanced fibrosis Other diseaseOther disease

►Lifestyle adviceLifestyle advice WeightWeight DiabetesDiabetes AlcoholAlcohol

►Lipid RLipid Rxx

►Specific RxSpecific Rx

Page 23: Dealing with NASH

Thank youThank you

Page 24: Dealing with NASH

►NASH is 2-3% of population.NASH is 2-3% of population.►10-30% of NASH has the potential of 10-30% of NASH has the potential of

developing into cirrhosis within 10 years. developing into cirrhosis within 10 years. ►The emergence of significant fibrotic The emergence of significant fibrotic

disease in developing countries, even in disease in developing countries, even in patients of normal weight or who are patients of normal weight or who are underweight is particularly concerning.underweight is particularly concerning.

►More HCC in patients with Childs A More HCC in patients with Childs A undiagnosed NASH.undiagnosed NASH.