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Steatohepatitis: Causes, Symptoms and Treatment

Steatohepatitis is a liver inflammation caused by fat deposits in the liver. It can progress to liver cirrhosis and liver failure if left untreated.

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Things worth knowing about "Steatohepatitis"

Steatohepatitis is a liver inflammation caused by fat deposits in the liver. It can progress to liver cirrhosis and liver failure if left untreated.

What Is Steatohepatitis?

Steatohepatitis is a liver condition characterised by the combination of fat accumulation in liver cells (steatosis) and inflammation of the liver tissue (hepatitis). Unlike simple fatty liver disease, steatohepatitis carries a significantly higher risk of progressive liver damage, including liver fibrosis, cirrhosis, and hepatocellular carcinoma (liver cancer).

Two main forms are distinguished:

NASH (Non-Alcoholic Steatohepatitis): Occurs without significant alcohol consumption and is closely linked to metabolic disorders such as obesity, type 2 diabetes, and metabolic syndrome. It is also referred to as MASH (Metabolic dysfunction-Associated Steatohepatitis) in current nomenclature.
ASH (Alcoholic Steatohepatitis): Caused by chronic or excessive alcohol consumption.

Causes

The causes of steatohepatitis differ depending on the type:

Non-Alcoholic Steatohepatitis (NASH / MASH)

Obesity and visceral fat accumulation
Insulin resistance and type 2 diabetes mellitus
Elevated blood lipid levels (dyslipidaemia)
Metabolic syndrome
Genetic predisposition (e.g., variants in the PNPLA3 gene)
Certain medications (e.g., corticosteroids, tamoxifen)

Alcoholic Steatohepatitis (ASH)

Chronic or heavy alcohol use
Malnutrition
Genetic factors influencing alcohol metabolism

Symptoms

Steatohepatitis is often asymptomatic in its early stages or presents with non-specific complaints. Possible symptoms include:

Fatigue and general weakness
Dull pressure or discomfort in the upper right abdomen
Mild nausea
Unintentional weight loss (in advanced stages)
In later stages: jaundice (icterus), fluid accumulation in the abdomen (ascites), and other signs of liver dysfunction

Because the disease often causes no clear symptoms for a long time, it is frequently discovered incidentally during blood tests or abdominal ultrasound examinations.

Diagnosis

The diagnosis of steatohepatitis is based on a combination of investigations:

Blood tests: Elevated liver enzymes (ALT, AST, GGT) may indicate liver inflammation.
Ultrasound (sonography): Imaging of the liver to detect fat deposits and structural changes.
Liver elastography (FibroScan): A non-invasive method to measure liver stiffness and estimate the degree of fibrosis.
MRI or CT scan: Advanced imaging when further evaluation is required.
Liver biopsy: The gold standard for definitive diagnosis; a tissue sample is examined microscopically for fat accumulation, inflammation, and signs of fibrosis.

Treatment

Treatment strategies vary depending on the type and stage of steatohepatitis:

General Measures

Weight loss: In NASH, a body weight reduction of 7–10 % can significantly improve liver inflammation.
Dietary changes: A Mediterranean-style diet with reduced sugar and saturated fat intake is recommended.
Regular physical activity
Abstaining from alcohol (essential for ASH; also strongly recommended for NASH)
Management of co-existing conditions such as diabetes and high blood pressure

Pharmacological Therapy

Resmetirom (approved in the USA in 2024) is the first specifically approved medication for NASH/MASH.
GLP-1 receptor agonists (e.g., semaglutide) have shown promising results in reducing liver inflammation in clinical studies.
In severe cases of alcoholic steatohepatitis, corticosteroids may be used.

Liver Transplantation

In end-stage disease with severe cirrhosis or liver failure, a liver transplantation may be necessary.

Prognosis and Outlook

The course of steatohepatitis is variable. While some individuals maintain a stable condition, others progress to cirrhosis or liver cancer. Early diagnosis and consistent lifestyle modifications are key to a favourable prognosis.

References

European Association for the Study of the Liver (EASL), European Association for the Study of Diabetes (EASD), European Association for the Study of Obesity (EASO): EASL-EASD-EASO Clinical Practice Guidelines for the Management of Non-Alcoholic Fatty Liver Disease. Journal of Hepatology, 2016.
Younossi Z.M. et al.: Global epidemiology of nonalcoholic fatty liver disease – Meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology, 2016.
Rinella M.E. et al.: A multisociety Delphi consensus statement on new fatty liver disease nomenclature. Hepatology, 2023.

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