A 51-year-old woman with a history of diabetes mellitus type 2 presents for her annual physical examination. The patient denies alcohol or drug use. Physical examination reveals an obese woman with hepatomegaly. Laboratory studies reveal the following:
A liver biopsy is performed and demonstrates macrovesicular steatosis and necrotic hepatocytes, in addition to centrilobular zone fatty accumulation.
Which of the following is the most likely diagnosis in this patient?
A. Nonalcoholic steatohepatitisNonalcoholic steatohepatitis. The patient in this question is presenting in an asymptomatic state, but has elevated AST, ALT, and alkaline phosphatase levels on laboratory testing. Given her history of hyperlipidemia, diabetes, and obesity, she likely has hepatomegaly and transaminitis secondary to underlying nonalcoholic steatohepatitis (NASH). The histology is further confirmation of this diagnosis given the macrovesicular steatosis and centrilobular zone fatty accumulation findings. (C) Of note, alcoholic hepatitis can present with similar histologic findings, so it cannot be distinguished from NASH solely on pathology. However, this patient denies alcohol use. (B) This patient has a negative smooth muscle antibody, making autoimmune hepatitis unlikely to be the diagnosis. (D) This patient is asymptomatic and does not report any symptoms consistent with cholelithiasis. Even though cholelithiasis can be asymptomatic, the history and pathologic findings in this patient support a diagnosis of NASH.