Nonalcoholic Steatohepatitis (NASH)

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NASH is a health condition caused by the buildup of fat in the liver, resulting in liver inflammation and damage. NASH is a further stage of nonalcoholic fatty liver disease (NAFLD). The symptoms are hardly noticed until it gets to the cirrhosis stage, but early signs may be… Treatment of the condition includes the management of obesity and others.

The name was first given by Dr. Ludwig, about 30 years ago, to describe a nonalcoholic fatty liver dysfunction, which leads to inflammation and damage of the liver. 

Healthcare providers categorize fatty liver disease into two forms: nonalcoholic fatty liver disease (NAFLD), and nonalcoholic steatohepatitis (NASH) — because of the extremity of this fatty liver disease. 

NAFLD is the most common form of chronic liver disease affecting over 20% of the population in the USA, and a 30% proximity of this class advancing to NASH, with proofs of cirrhosis and liver failure. 


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Nonalcoholic Steatohepatitis (NASH)

What is nonalcoholic steatohepatitis?

Whenever there is an excess amount of fat deposition in the cells of the liver, it results in causing fatty liver disease. Fatty liver disease is of two forms, they are:

  1. Alcoholic fatty liver disease
  2. Nonalcoholic fatty liver disease (NAFLD)– the nonalcoholic fatty liver disease is of two types:
  • Simple fatty liver disease
  • Nonalcoholic steatohepatitis.

Nonalcoholic steatohepatitis (NASH)- The term NASH was first coined by Dr. Ludwig about three decades ago. It is considered to be the most severe form of NAFLD. NAFLD is caused due to deposition of fat in the liver cells. When this fat accumulation causes inflammation and damage to the liver, then is called NASH, which can lead to scarring of the liver. The scarring of the liver is potentially a life-threatening condition causing liver cirrhosis.

Nonalcoholic Steatohepatitis
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The reason why some people have accumulated fat in the liver while others do not is not yet known. It isn’t clear why some fatty livers develop inflammation which leads to total liver collapse. 

However, NASH is believed to be associated with the following:

  • Obesity.
  • High-fat concentration in the blood.
  • Metabolic dysfunction (in which body cells resist insulin which, in turn, hinders the absorption of sugar into cells).
  • Hyperglycemia (high sugar level due to no absorption)
causes of non-alcoholic steatohepatitis
Picture Courtesy: endocrineweb

What are the risk factors of nonalcoholic steatohepatitis?

Risk Factors Of NASH
Picture Courtesy: researchgate
  • Type 2 diabetes,
  • Hypothyroidism,
  • Hypopituitarism,
  • Obesity,
  • High cholesterol levels,
  • High-fat levels (triglycerides) in the blood,
  • Sleep apnea (breathing disorder that stops and starts),
  • PCOS (enlarged ovary with small cysts), 
  • Metabolic syndrome (high blood pressure, excess fat, high blood sugar, high cholesterol levels),
  • Old age.


NASH and NAFLD do not show any signs and symptoms in their early stage. However, when they do, they may include pain in the upper right abdomen and fatigue. In its advanced stage (cirrhosis), NASH may have the following signs and symptoms:

  • Jaundice (eye and skin yellowing).
  • Reddish palms.
  • Ascites (swollen abdomen).
  • Swollen spleen.
  • General body weakness.
symptoms of non-alcoholic steatohepatitis
Picture Courtesy: verywellhealth

How is nonalcoholic steatohepatitis diagnosed?

  • Lab Tests

Blood tests are done to determine the following:

  1. Blood sugar levels (on fasting blood sugar), 
  2. Complete blood count,
  3. HbA1c (to determine the stability of the blood sugar),
  4. Lipid profile,
  5. Liver enzyme and function tests,
  6. Celiac disease screening tests,
  7. Test for hepatitis A, C, and others.

The following tests make the diagnosis of NASH. They are listed below:

  • Physical examination- During a physical examination, the doctor will examine the patient thoroughly. Will palpate (touch) the abdomen and liver to look for any signs of abnormalities.
  • Medical and family history- During this process, the doctor records the medical history of the patient, his lifestyle habitus, food habitus, and history of any surgery or medication history. The doctor also records the family history of the patient.
  • Imaging Tests- They include,  
  1. Abdominal Ultrasound, which is always the first test when NASH is suspected.
  2. Magnetic Resonance Elastography (MRE); which creates a usual map (Elastography), showing the stiffness of body tissues.
  3. Transient Elastography, which is the Ultrasound that measures liver stiffness indicated by fibrosis or scarring.
  4. CT scan, fibro scan.
  • Liver biopsy– It is considered to be the gold standard test in diagnosing NASH. A small liver sample is taken out during this test and sent for pathological study.

How is nonalcoholic steatohepatitis treated?

The first approach for treating NASH is the management of obesity. Weight loss can be managed through a combination of a healthy diet and exercise. The doctor may recommend a weight loss surgery if the patient needs a significant weight loss. 

Liver implantation remains the best option for patients who develops cirrhosis due to NASH.

Unfortunately, there’s no approved drug treatment by FDA for a nonalcoholic fatty liver disorder, up to date. Intense research is ongoing with promising results. 

With all clinical trials in place, doctors have resorted to this disease by educating their patients on good lifestyles and home remedies. Prominent among these are:

  1. Weight Loss Management: Reduce calories daily through food choice and physical activities.
  2. Cholesterol Reduction: Through healthy plant-based foods, exercise regularly, and medications.
  3. Taking Healthy Diets: Diets rich in vegetables, fruits, and whole grains. Eggs, fish, and seafood, as well as lean meats, should form the meals.
  4. Be More Active: Exercise, take walks and jog in the early morning hours. Also, increase household activities.
  5. Control the Blood Sugar: Fight diabetic conditions via medications and sugar intake.
  6. Avoid alcohol and all alcoholic beverages.
  7. Protect the Liver: Seek the doctor’s advice on any drug (herbal or orthodox) the patient takes, and follow all instructions on any over-the-counter drug medication.
  8. Antioxidants Intake: Vitamin E and other vitamins (antioxidants) can reduce or neutralize the damage caused by inflammation. Seek the doctor’s advice.


  • Weight Loss Surgery

Bariatric surgery affects weight loss by restricting the amount of food in the stomach of obese people. It’s a long-term care procedure achieved mainly by altering gut hormone levels that control hunger and satiety. 

Bariatric surgery is expensive ($20000–$25000) and may take up to 6 weeks.

This is the surgery that replaces a non-functional liver with a healthy one. The healthy liver may be from a deceased donor or a portion of a healthy liver from a living donor. 

What are the complications associated with nonalcoholic steatohepatitis?

As the disease advances, more complications ensue and need medical attention. It can lead to cirrhosis and liver cancer. The chances of dying from liver-related issues are high in these patients. For example, the disease progresses into cirrhosis, leading to liver failure, which results in death, except by a timely intervention of a liver transplant. 

Some complications following NASH include:

  • Inflammation of the liver,
  • Fibrosis (scarring),
  • Cirrhosis,
  • Ascites,
  • Esophageal varices (vein swelling, later rapture, and esophagus bleeding),
  • Hepatic encephalopathy (drowsiness and slurred speech),
  • Liver cancer,
  • Liver dysfunction/failure.

What is the mortality rate of nonalcoholic steatohepatitis disease?

A study presented by the American Drug Administration (ADA) revealed that patients with diabetes and NASH/NAFLD have an overall mortality rate of 25.1%. The survival rate of patients with cirrhosis over 5 years was 75.2%. Cirrhosis is the 9th leading cause of death in the USA, accounting for about 1.2% of all US deaths. About 35000 die each year in the USA of cirrhosis.


Is NASH reversible?

There’s no medication to reverse the fat build-up in the liver. While in some cases, the liver damage may correct itself, in others, it continues to progress to cirrhosis and liver failure. If a person is diagnosed with NASH, then the patient should control any condition that may contribute to fatty deposits in the liver. Avoid high calorie and high cholesterol diets.

How do I cleanse my liver?

a)      Eat more probiotics; yogurt, kimchi, sauerkraut, miso, kombucha, tempeh, bananas, etc.
b)      Eat antioxidant-rich foods.
c)      Reduce the sugar intake.
d)     Eat less processed and canned foods.
e)      Reduce the amount of salt in the diet.
f)       Reduce alcohol or alcoholic beverage intake. 
g)      Drink a lot of water and fluids.
h)      Have enough sleep.
i) Be more active and exercise

Is coffee intake good with fatty liver?

Coffee is a rich source of disease-fighting antioxidants. It is one of the best beverages the person can drink to improve moods, stop headaches, reduce the risk of liver cancer, cirrhosis of the liver, type 2 diabetes, etc. Taking two or more cups of coffee a day may influence liver damage.

What foods should form my meals with NASH, and what should not?

Foods to take:
a)      Low-glycemic index foods (most fruits, vegetables, whole grains, and olive oil).
b)      Fruits, like berries, grapefruits, grapes, prickly pear, and bananas.
c)      Probiotics; yogurt, kimchi, sauerkraut, miso, kombucha, tempeh, bananas, etc.
d)     Nuts.
e)      Fatty fish, seafood, lean meats, honey, eggs.
f)       Coffee, tea, and other antioxidant-rich foods.
g)      Much water and fluids.

Foods not to take: 
a)      Alcohol and alcoholic beverages.
b)      High-calorie foods; fried foods, fats, and oils.
c)      Sugary foods.
d)     Much salt.
e)      Red meat.
f)       White bread.
g)      Rice and pasta.

Who are the high-risk groups for nonalcoholic steatohepatitis?

The following groups have a high risk of developing the condition:
1)       The elderly.
2)       Diabetic patients.
3)       Alcoholics and drug addicts.
4)       Obesity.
5)       Sleep apnea (breathing disorder) patients.
6)       Underactive thyroid patients.
7)       Underactive pituitary gland patients.
8)       People with high cholesterol and fat levels.
9)       People with high blood pressure and high blood glucose.
10)   Patients with polycystic ovary syndrome (PCOS).

Can nonalcoholic steatohepatitis cause liver cancer?

Yes, there is a possibility that NASH can cause liver cancer if we leave the disease untreated.

Is nonalcoholic steatohepatitis hereditary?

Over time, there is an increased risk of passing NASH from generation to generation, but the inheritance pattern is not known.