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Nonalcoholic Steatohepatitis
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
TO THE EDITOR:
In Sheth and colleagues' review of NASH [1], the authors advocate extensive evaluation of patients with unexplained elevations in liver enzyme levels. After a history and, presumably, a physical examination, specific recommendations include viral hepatitis serologic testing; iron studies; measurement of ceruloplasmin levels, α-antitrypsin levels and phenotype, and anti-mitochondrial and antinuclear antibodies; liver ultrasonography; and Doppler assessment of hepatoportal vasculature. The authors advise that “if none of the above tests are definitive, then a liver biopsy is recommended to confirm or rule out NASH … .”
I believe that their diagnostic approach is excessive. Do the authors suggest that all elderly patients with elevated liver enzyme levels be screened for Wilson disease? Should men with elevated aminotransferase levels but without cholestasis have antimitochondrial antibody titers checked routinely? In addition, imaging studies of the liver are rarely useful in patients with a hepatocellular injury pattern. Finally, why consider liver biopsy, given its risks, to diagnose NASH when the authors later point out that “no proven therapy for NASH exists”?
Physicians treating patients with abnormal liver blood test results should individualize the evaluation. Moreover, tests should be recommended when the results would have meaningful management implications for patients. As in all clinical decision making, we should avoid using diagnostic “grapeshot” and pursue what we need to know rather than what we want to know.
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
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