• non-alcoholic steatohepatitis
• biopsy

The leading article by Day (

) provides a valuable summary of the current understanding of the pathogenesis and clinical relevance of non-alcoholic steatohepatitis (NASH). The article also makes two points clear: (a) we have little ability to provide accurate prognostic information in an individual patient, even when liver histology is available, and (b) although there is the promise of new treatments, the only known effective therapy at present, for the obese patient, is weight loss. Why then should these patients be subjected to liver biopsy?

Day proposes that a subgroup of patients with suspected fatty liver should undergo biopsy, including those with alanine aminotransferase (ALT) more than twice the upper limit of normal, aspartate aminotransferase >ALT values, “moderate” central obesity, non-insulin dependent diabetes, hypertension, and hypertriglyceridaemia. Gastroenterologists are commonly referred patients fulfilling these criteria but is liver biopsy likely to affect their management? The only therapeutic option at present is weight loss and all obese patients should of course lose weight, whether they have simple steatosis, NASH, or even normal liver biochemistry.

A number of arguments may be used to justify liver biopsy in these patients; histopathology may reveal unexpected findings and the results may allow more accurate prognostic information to be given to the patient.

Sherwood and colleagues¹ identified 342 patients found on screening by their general practitioner to have liver enzymes raised above twice the normal upper limit who had not been referred to a specialist for further assessment. Of these, less than half were thought to require further investigation, approximately one third of whom had normal results on repeat testing. Following investigation of the remainder in a gastroenterology clinic, alcoholic liver disease and …