Nonalcoholic fatty liver disease: multimodal treatment options for a pathogenetically multiple-hit disease

Therapeutic approach of hepatic sarcoidosis

PURPOSE OF REVIEW

Surveillance of hepatic involvement in sarcoidosis has not been standardized. Therefore, management of hepatic involvement is a clinical challenge. This review analyses published data on the pharmacological treatment of hepatic sarcoidosis.

RECENT FINDINGS

Only 5-30% of patients with hepatic sarcoidosis display symptoms. Occasionally, it has a rapid progressive course with serious complications, stressing an appropriate and carefully timed therapeutic approach. Because symptomatic hepatic sarcoidosis is uncommon, therapeutic studies are scarce. Answers to the questions when to initiate which treatment are lacking. Case reports describe beneficial effects of prednisone and the augmentation of cytotoxic and anti-tumor necrotic factor-α (TNF-α) therapy. However, because of small sample sizes, no meaningful conclusions could be drawn. In symptomatic hepatic sarcoidosis patients, it is recommended to start to treat the sarcoidosis with prednisone, preceded by ursodeoxycholic acid when signs of cholestasis are present. In refractory cases or when prednisone weaning is impossible, cytotoxic drugs or anti-TNF-α therapy should be considered.

SUMMARY

This review illustrates the importance of an appropriate therapeutic approach of sarcoidosis patients with hepatic involvement. It emphasizes the need for future studies to evaluate treatment options to avoid disease progression and hepatic complications.

Review article: is non-alcoholic fatty liver disease a spectrum, or are steatosis and non-alcoholic steatohepatitis distinct conditions?

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is currently conceptualised as a clinical spectrum that results from a ‘multiple-hit’ process which begins with simple steatosis and subsequently renders the hepatocytes susceptible to a variety of insults. Ultimately, more serious liver injuries like non-alcoholic steatohepatitis (NASH) and cirrhosis may develop. Although the metabolic syndrome is considered the crucial player in the pathogenesis of NAFLD, recent studies have highlighted novel pathophysiological mechanisms in this clinical entity.

AIM

To discuss the pathophysiology of NAFLD based on the hypothesis that simple steatosis and NASH are discrete entities rather than two points on a spectrum.

METHODS

A literature search was conducted in August 2012 on PubMed, Ovid Embase, Ovid Medline and Scopus using the following search terms: steatosis, non-alcoholic steatohepatitis, pathophysiology, fatty liver, natural history and genetics.

RESULTS

Simple steatosis and NASH appear as two distinct pathophysiological entities and progression from pure fatty liver to NASH appears to be so rare as to warrant publication. The possible pathogenetic pathways specifically related to NASH are highlighted.

CONCLUSIONS

Although simple steatosis and non-alcoholic steatohepatitis are currently viewed as two histological subtypes of the unique spectrum of non-alcoholic fatty liver disease, the two conditions are likely distinct not only from a histological but also from a pathophysiological standpoint. Efforts to distinguish simple steatosis from non-alcoholic steatohepatitis using non-invasive modalities should be informed by the current pathophysiology of these two clinical entities.