This case study introduces a patient with non alcoholic steatohepatitis and related conditions, along with suggested medical calculators which can help healthcare professionals assess, diagnose and manage these conditions.
Bob is an obese 65-year-old Caucasian male with Type 2 diabetes. Several years ago his liver function enzymes were noted to be elevated on routine screening. A liver biopsy at that time showed steatohepatitis with early fibrosis. He does not drink alcohol or take medications. A diagnosis of non alcoholic steatohepatitis NASH was made.
Recently he was referred to a gastroenterologist. Because of persistently abnormal liver function tests, the gastroenterologist ordered a hepatic ultrasound scan. Two mass lesions were noted, the larger centrally located and measuring 2.5 cm in diameter. A liver biopsy of the nodule showed a well-differentiated hepatocellular carcinoma. An initial staging workup indicated that there was no evidence of spread beyond the liver. The serum alpha fetoprotein (AFP) was normal.
He was referred to the local university hospital where his management options were discussed at a tumor board.
Diabetes, the Metabolic Syndrome and Fatty Liver
With the rise of obesity in developed countries there has been a surge of patients with Type 2 diabetes. Many of these patients show features of metabolic syndrome (obesity, hypertension, abnormal lipid metabolism, abnormal glucose metabolism).
- Diabetes Risk Score for Identifying Patients in General Practice at Risk for Type 2 Diabetes Mellitus (Cambridge Risk Score)
- Criteria for Identifying a Patient at Risk for Type 2 Diabetes
- WHO Definition of the Metabolic Syndrome
- International Diabetes Foundation (IDF) Definition of the Metabolic Syndrome
One of the complications of the metabolic syndrome is fatty liver (steatosis), often with non-alcoholic steatohepatitis (NASH). Over time this can lead to increasing hepatic fibrosis and cirrhosis, similar to the progression seen with alcoholic steatohepatitis.
- Grading and Staging Scheme for Nonalcoholic Steatohepatitis
- Risk Factors for Nonalcoholic Steatohepatitis
- Predictors of Hepatic Fibrosis in Patients with Nonalcoholic Steatohepatitis
- HAIR Score for Predicting Nonalcoholic Steatohepatitis in a Severely Obese Patient
Risk of Hepatocellular Carcinoma
A patient who develops cirrhosis is at increased risk for developing a hepatocellular carcinoma (hepatoma). NASH has become an important cause for hepatocellular carcinoma in developed countries. The prognosis for a patient with a hepatocellular carcinoma depends on a number of factors such as tumor size, tumor location and resectability, vascular invasion, distant metastases, and the number of tumors.
- Prognostic System of the Cancer of the Liver Italian Program (CLIP)
- The Barcelona-Clinic Liver Cancer (BCLC) Staging Classification for Hepatocellular Carcinoma
- The French Classification for Hepatocellular Carcinoma (GETCH Score)
- Modified Japan Integrated Scoring System (JISS) for a Patient with Hepatocellular Carcinoma
Management of a hepatocellular carcinoma can be challenging and outcomes are better in centers that specialize in its care. Surgery is an important modality. If the tumor cannot be completely resected and if the patient does not have metastatic disease, then liver transplant may be considered. Various techniques of ablation can be achieved for patients who cannot have or do not want surgery. Each modality has pros and cons, and it is necessary to match benefits and risks with the patient’s preferences.
For our patient, surgical resection of the individual tumors is not an option. The patient is otherwise relatively healthy and compliant, with favorable prognostic factors and no contraindications to transplantation. The patient has been placed on the liver transplant list.
When faced with a complex clinical problem it is often possible to divide it up into smaller and more easily managed tasks. Each of these tasks can be developed into an algorithm. Executing these algorithms in the right sequence can be helpful in clinical decision-making.