Paeds Vivas · gastroenterology-hepatology-and-nutrition
Non-alcoholic fatty liver disease in children — branching viva
Branching viva from the definition and new nomenclature of paediatric fatty liver disease through the overweight child found on screening, the obese adolescent with persistent enzyme elevation, the child with type 1 diabetes and steatosis, and the rare decompensated presentation, testing the sex-specific alanine aminotransferase thresholds, the exclusion of mimics, the limited role of vitamin E from the TONIC trial, and the cardiovascular-predominant prognosis.
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Target exams
RACP General PaediatricsRACP DCEMRCPCH ClinicalRCPSC Pediatrics
Prompt
You are the paediatric registrar in a general clinic. The consultant asks you to talk through four children referred with possible fatty liver disease: an overweight eleven-year-old found on screening to have a mildly raised alanine aminotransferase, an obese adolescent with persistent enzyme elevation and a father with cirrhosis, a child with type 1 diabetes and an incidental steatotic liver, and a teenager who presents with jaundice and ascites.
Station opening
Examiner: "Define paediatric fatty liver disease and outline your approach to an overweight child referred with possible fatty liver disease." [4]
Strong candidate (must-hit)
- Defines paediatric fatty liver disease, renamed metabolic dysfunction-associated steatotic liver disease, as hepatic steatosis in the presence of overweight or obesity and insulin resistance defined by one or more cardiometabolic criteria; frames the approach around confirming persistence of an abnormal alanine aminotransferase against the sex-specific thresholds, excluding mimics, staging fibrosis non-invasively, and treating with family-based lifestyle change as the cornerstone; states that no drug is approved specifically for paediatric MASLD and that cardiovascular disease is the leading long-term risk. [4]
Weak candidate
- "Fatty liver disease is fat in the liver of a fat child; I would send some bloods and tell them to lose weight." [1]
References5ShowHide
- [1]Vos MB, Abrams SH, Barlow SE, Caprio S, Daniels SR, Kohli R, et al NASPGHAN Clinical Practice Guideline for the Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease in Children: Recommendations from the Expert Committee on NAFLD (ECON) and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). J Pediatr Gastroenterol Nutr, 2017.PMID 28107283
- [3]Lavine JE, Schwimmer JB, Van Natta ML, Molleston JP, Murray KF, Rosenthal P, et al Effect of vitamin E or metformin for treatment of nonalcoholic fatty liver disease in children and adolescents: the TONIC randomized controlled trial. JAMA, 2011.PMID 21521847
- [4]Rinella ME, Lazarus JV, Ratziu V, Francque SM, Sanyal AJ, Kanwal F, et al A multisociety Delphi consensus statement on new fatty liver disease nomenclature. J Hepatol, 2023.PMID 37364790
- [6]Newsome PN, Cramb R, Davison SM, Dillon JF, Foulerton M, Godfrey EM, et al Guidelines on the management of abnormal liver blood tests. Gut, 2018.PMID 29122851
- [8]Sood V, Alam S, Nagral A, Srivastava A, Deshmukh A, Bavdekar A, et al Practice Recommendations for Metabolic Dysfunction-Associated Steatotic Liver Disease by the Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition (ISPGHAN). Indian Pediatr, 2024.PMID 39297398