Question 1: Initial NAFLD Diagnosis & Care Coordination
Assessment: Calculate FIB-4 [(age×AST)/(platelets×√ALT)] to stratify fibrosis risk (≤1.30 rules out advanced fibrosis, ≥2.67 suggests advanced fibrosis); order VCTE with CAP for combined fibrosis and steatosis quantification.
Management: Coordinate care team; initiate pioglitazone (30–45 mg/day) to improve insulin sensitivity and histology in diabetic NASH; prescribe vitamin E 800 IU/day if non-diabetic; reinforce intensive lifestyle changes; monitor LFTs every 3–6 months and reassess elastography annually.
Assessment: Evaluate transplant candidacy factors—comorbid cardiovascular disease, renal function, nutritional status; perform echocardiography if indicated.
Management: Educate on end-stage risks; establish surveillance plan for decompensation; pre-emptively optimize diabetes and blood pressure; schedule quarterly multidisciplinary reviews.
Assessment: Confirm eligibility (BMI ≥35 with comorbidities); review past weight-loss efforts; evaluate psychosocial readiness.
Management: Discuss sleeve gastrectomy vs gastric bypass; coordinate preoperative hepatology clearance; oversee postoperative nutritional follow-up and monitor liver enzymes.
Assessment: Optimize glycemic control to HbA1c <7%; review for insulin resistance; assess lipid profile and blood pressure.
Management: Introduce GLP-1 agonist (e.g., semaglutide) or SGLT2 inhibitor to aid weight loss and hepatic benefit; adjust insulin regimens; provide structured diabetes education.
Assessment: Perform FibroScan using M and XL probes as needed; measure CAP for steatosis; consider 2D-SWE if VCTE fails.
Management: Report kPa and CAP values; recommend repeat imaging intervals based on fibrosis stage (every 6–12 months for F2–F3).
Question 2: Pediatric NAFLD Management
Assessment: Exclude Wilson’s, A1AT deficiency; use ALT cutoffs <22 U/L for boys; assess growth parameters.
Management: Lead family-centered lifestyle program involving dietitian and psychologist; track BMI z-score; avoid medications unless biopsy-proven NASH with fibrosis.
Assessment: Consult on severe or biopsy-proven cases; prepare transition plan for adolescence.
Management: Coordinate with pediatric team; ensure continuity of elastography monitoring into adulthood.
Assessment: Screen for insulin resistance (HOMA-IR), dyslipidemia.
Management: Implement metformin if IR severe; teach family about glycemic load and activity goals.
Assessment: Use ultrasound elastography (S-probe) for liver stiffness; avoid MRI for claustrophobic children.
Management: Provide child-friendly setting; repeat every 12 months.
Question 3: Advanced NASH with HCC
Assessment: Confirm HCC with contrast MRI; stage with Child-Pugh and MELD.
Management: Initiate 3-monthly surveillance; discuss locoregional therapies (TACE); refer for transplant evaluation.
Assessment: Evaluate surgical risk, cardiopulmonary status; confirm Milan criteria eligibility.
Management: Coordinate transplant listing; optimize nutrition; plan bridging therapy as needed.
Assessment: Assess feasibility of sleeve gastrectomy pre-transplant.
Management: If chosen, perform in staged fashion; monitor post-operative improvement in portal hypertension.
Assessment: Tighten glycemic control; screen cardiovascular risk.
Management: Manage steroid-induced hyperglycemia post-transplant; adjust insulin dosing.
Assessment: Perform triphasic CT/MRI for HCC monitoring.
Management: Guide interventional radiology (RFA/TACE); post-transplant imaging quarterly.
Question 4: Bariatric Surgery in NASH
Assessment: Verify BMI ≥35 with T2DM; evaluate liver stiffness and absence of varices.
Management: Perform sleeve gastrectomy; provide enhanced recovery program; monitor liver function and weight trajectory.
Assessment: Rule out portal hypertension (endoscopy), synthetic function.
Management: Clear for surgery; schedule elastography at 6 and 12 months post-op.
Assessment: Optimize pre-op glycemic control (HbA1c <7%).
Management: Anticipate diabetes remission; adjust medications to avoid hypoglycemia.
Assessment: Baseline MRI-PDFF and elastography.
Management: Quantify fat reduction and fibrosis regression at 6 and 12 months.
Question 5: Resmetirom Introduction
Assessment: Confirm F2–F3 by elastography/biopsy; check thyroid baseline.
Management: Prescribe resmetirom 80 mg (<100 kg) or 100 mg (≥100 kg) daily; schedule liver function and lipid panel at 3 and 6 months.
Assessment: Evaluate thyroid function periodically; monitor HbA1c.
Management: Coordinate lipid-lowering therapy; adjust antidiabetic agents if weight loss occurs.
Assessment: Baseline elastography and MRI-PDFF.
Management: Repeat noninvasive imaging at 6 and 12 months to assess fat and stiffness changes.
Assessment: Reevaluate surgical candidacy post-resmetirom if persistent obesity.
Management: Coordinate combined therapeutic strategy if both modalities pursued.
Question 6: Elastography Modality Selection
Assessment: Choose FibroScan first-line; use XL probe for BMI>30; if failure or ascites, proceed to MRE; if anatomical correlation needed, use 2D-SWE.
Management: Provide clear scheduling; minimize patient time; ensure quality metrics (IQR/median ≤30%).
Assessment: Define indication (screening vs staging vs therapy monitoring).
Management: Request repeat using same modality; interpret results in conjunction with FIB-4 and clinical context.
Assessment: Optimize glycemic status before imaging; consider post-prandial state.
Management: Interpret stiffness changes in light of metabolic control; avoid false positives from inflammation.
Elastography Reference Metrics
- FibroScan (VCTE): AUROC 0.83–0.89 for ≥F2; failure 5–20% (BMI dependent).
- 2D-SWE: AUROC 0.80–0.89; real-time mapping; better in obesity.
- MRE: AUROC 0.90–0.95; failure ~3.5% at 1.5T; whole-liver assessment.
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