25 It has been recognized for many years that a fatty liver is sometimes found in patients who do not drink alcohol. The term 'non-alcoholic steatohepatitis' (NASH) was introduced in the 1990s. Subsequently, it has been recognized that some patients have a fatty liver on biopsy with no accompanying inflammation; this group is called non-alcoholic fatty liver disease (NAFLD). It seems that only patients with evidence of NASH on biopsy progress to chronic liver disease with fibrosis and cirrhosis. Some of these patients do have high lipid levels (both cholesterol and triglycerides) but this is by no means invariable

26 NASH, non-alcoholic steatohepatitis, was introduced a few years ago for patients with fatty liver not due to alcohol. The meaning has now been changed slightly in that the term 'NASH' is used only for a small group of patients with non-alcoholic fatty liver disease (NAFLD) who have inflammation as well as fat on liver histology. Further reading Malnick SD et al (2003) Nonalcoholic fatty liver disease. Quarterly Journal of Medicine 96: 699-709.

27 Terlipressin has been shown to reduce mortality but has more side-effects than somatostatin.

28 The hyperdynamic circulation that occurs is partly due to the opening of portosystemic collaterals. In addition, there are increased levels of circulatory vasodilators, e.g. glucagon and vasoactive intestinal polypeptide (VIP). There is also an increased production of nitric oxide, which is a potent vasodilator.

29 Antigen absorbed from the gut bypasses the liver in cirrhosis and also there is decreased function of the Kupffer cells in cirrhosis. Both of these allow antigen to stimulate the reticuloendothelial system in the spleen and lymph nodes to produce immunoglobulins.

30 There is some evidence that fibrosis following liver damage is reversible. There are no drugs currently available to act on TIMPS