NAFLD is often asymptomatic but may rarely cause fatigue and right upper
quadrant pain. Physical examination may reveal hepatomegaly, palmar erythema
(see Fig. 148-2 in Chapter 148), and spider nevi. If liver disease is
advanced, the features of liver failure, such as ascites, encephalopathy, and
abdominal collateral vessels, are present. Simple steatosis is benign with a
minimal risk of cirrhosis, whereas NASH is progressive and can lead to cirrhosis
(Chapter 156) and liver failure (Chapter 157). In up to 20% of patients
with NASH, liver histology will worsen and cirrhosis will develop over a 10-
to 15-year period. Severe obesity, advancing age, and diabetes are believed to
be risk factors for disease progression. Disease progression during the early
phase can be identified only with a repeat liver biopsy, but in later stages, the
signs and symptoms of portal hypertension (e.g., abdominal collateral vessels
and low platelet count) indicate the development of cirrhosis. Patients with
NASH-induced cirrhosis are at risk of developing hepatocellular carcinoma
(Chapter 202). Patients with NAFLD have several metabolic risks that predispose
them to atherosclerosis, and coronary artery disease is the single
most common cause of death in patients with NAFLD.