I read with interest the excellent review of NASH by Sheth and colleagues [1]. The recommendation that liver biopsy be done in all patients with abnormal liver test results and negative results on a noninvasive evaluation deserves comment. Although the ability to diagnose fatty liver without a biopsy specimen was poor, the positive predictive value of a prebiopsy diagnosis of chronic necroinflammatory disease, such as NASH, was 81% [2]. Serum aminotransferase values exceeding three times the upper limit of normal also increased the accuracy of the prebiopsy diagnosis [2]. Furthermore, there is no proven treatment for NASH, despite the recent report of significant improvement in serum levels of alkaline phosphatase, alanine aminotransferase, and -glutamyltranspeptidase and of hepatic steatosis after 12 months of ursodeoxycholic acid treatment [3]. The decision to do liver biopsy must be placed in the context of the manner in which the diagnosis will alter patient management.

Others have suggested that liver biopsy is not warranted in this disorder [4]. The risk for major complications, including death, after liver biopsy is small but not insignificant [4] and should be factored into the decision-making process. It would be prudent to recommend, instead, an individualized approach to the patient suspected of having NASH that includes (after a thorough noninvasive evaluation) a trial of gradual weight reduction in obese patients and consideration of ursodeoxycholic therapy in nonobese patients, with liver biopsy reserved for patients who do not respond to these conservative measures or present a diagnostic dilemma. The debate over the role of liver biopsy in the approach to the patient suspected of having NASH, which resembles a similar controversy involving the role of liver biopsy in patients receiving long-term methotrexate therapy [5], will probably continue, however, until the pathogenesis and treatment of this common disorder are better understood.