The management of
nonalcoholic fatty liver has been limited by a paucity of well-conducted studies that are of sufficient duration and quality to determine the outcome, which is best defined by liver biopsy. The mainstays, diet and physical activity plus behavioral modifications, are not always successful, particularly in the very obese. Although it is intuitive to expect that
weight loss should diminish steatosis, only limited evidence exists that liver
enzymes improve with reduction in
body weight. The available pharmacologic
therapy has focused on the two limbs of the pathogenetic basis for
nonalcoholic steatohepatitis (NASH),
insulin resistance and oxidative stress, but with quite limited success. Neither behavioral, nor dietary, nor
drug therapy has been particularly effective either in
obesity or NASH. In the severely obese, the
fatty liver and its stages often have progressed to NASH or
cirrhosis even before contemplating
therapy. In the severely obese, the best therapeutic modality is
bariatric surgery, which is safe and has been successful in producing a 61%
weight loss overall. The result is improvement in
diabetes mellitus, the
metabolic syndrome, and presumably its sequelae. Early reports (and procedures) were attended with dramatic
weight loss but markedly aggravated the inflammatory
liver disease. In recent trials with more modest
weight loss and less
malnutrition,
bariatric surgery reduced the fat,
inflammation, and even the
fibrosis in well-documented NASH. These promising procedures will undoubtedly increase and constitute the major therapeutic modality for those who are severely obese.