The Big (& Small) Picture of NASH Building Your Understanding to Combat a Growing Problem

Arun J. Sanyal, MBBS, MD, FAASLD

Jointly provided by Postgraduate Institute for Medicine and Integritas Communications.


This activity has been supported by independent educational grants from Gilead Sciences, Inc.


Arun J. Sanyal, MBBS, MD, FAASLD
Professor of Medicine, Physiology and Molecular Pathology
Virginia Commonwealth University (VCU)
Richmond, Virginia

Course Description

Nonalcoholic steatohepatitis (NASH), part of the nonalcoholic fatty liver disease (NAFLD) spectrum, is characterized by steatosis, lobular inflammation, hepatocyte ballooning, and varying degrees of fibrosis.Both obesity and diabetes play large roles in development and progression of NAFLD and NASH, and the growing prevalence of NAFLD and NASH parallel the rise in obesity and diabetes.In addition to obesity and diabetes, multiple comorbidities occur with NASH; the 2 comorbidities that are strongly tied to mortality are cardiovascular disease and malignancy.3,4 Liver biopsy, often impractical or unfeasible, is the gold standard for diagnosis.Recently, noninvasive modalities, particularly imaging, have been used as substitutes to identify patients at risk for disease progression; there are, however, deficits in knowledge and access to some noninvasive modalities. Though there is no US Food and Drug Administration (FDA)-approved treatment for NASH, fibrosis, along with other histopathologic markers of NASH, can be improved through lifestyle modification or off-label use of therapies.Recent clinical trial data have been encouraging, but management of patients with NASH still proves difficult, necessitating education about diagnosis and management.  


  1. Buzzetti E, Pinzani M, Tsochatzis EA. The multiple-hit pathogenesis of non-alcoholic fatty liver disease (NAFLD). Metabolism. 2016;65(8):1038-1048.
  2. Lonardo A, Bellentani S, Argo CK, et al. Epidemiological modifiers of non-alcoholic fatty liver disease: focus on high-risk groups. Dig Liver Dis. 2015;47(12):997-1006.
  3. Calzadilla Bertot L, Adams LA. The natural course of non-alcoholic fatty liver disease. Int J Mol Sci. 2016;17(5):E774.
  4. Stepanova M, Rafiq N, Makhlouf H, et al. Predictors of all-cause mortality and liver-related mortality in patients with non-alcoholic fatty liver disease (NAFLD). Dig Dis Sci. 2013;58(10):3017-3023.
  5. Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of nonalcoholic fatty liver disease: practice guidance from the American Association for the Study of Liver Diseases. Hepatology. 2018;67(1):328-357.

Target Audience

This activity presents a review of the pathophysiology of NASH, noninvasive and invasive diagnostic methods, existing management options, and investigational targeted therapies through innovative infographic panels, which allow the learner to, at his or her pace, delve into each concept presented in the multiple layers of the panel.  

Educational Objectives

Upon completion of this activity, participants will be better able to do the following:

  • Identify patients with or at risk for the development of nonalcoholic steatohepatitis (NASH) using current epidemiologic and demographic data
  • Select appropriate invasive biopsy and/or noninvasive assessment modalities for diagnosing, staging, and monitoring NASH
  • Describe late-stage emerging NASH therapies in terms of mechanisms of action, relationships with disease pathophysiology and fibrosis progression, and the most recent efficacy and safety clinical data

Conflict of Interest Policy/ Disclosure Statement

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers, and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality activities and related materials that promote improvements or quality in health care and not a specific proprietary business interest of a commercial interest.

Arun J. Sanyal, MBBS, MD, FAASLD: Consulting Fees: Ardelyx, Inc., Eli Lilly and Company, Gilead Sciences, Inc., HemoShear Therapeutics, LLC, Mallinckrodt Pharmaceuticals, Nimbus Therapeutics, LLC, Nitto Denko Technical Corporation, Pfizer Inc., Salix Pharmaceuticals, Sanyal Biotechnology; Contracted Research: Bristol-Myers Squibb, Conatus Pharmaceuticals Inc., Galectin Therapeutics, Inc., Gilead Sciences, Inc., Mallinckrodt Pharmaceuticals, Merck & Co., Inc., Novartis Pharmaceuticals Corporation, Salix Pharmaceuticals, Sequana Medical AG; Salary: Sanyal Biotechnology; Ownership Interest: Akarna Therapeutics Ltd., GENFIT SA, Natural Shield, NewCo LLC, Tiziana Life Sciences plc


The PIM planners and managers have nothing to disclose. The Integritas Communications planners and managers have nothing to disclose.

Financial Support

This activity has been supported by independent educational grants from Gilead Sciences, Inc., Merck & Co., Inc., and AbbVie Inc.

Provider Information

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and Integritas Communications. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the health care team.

The Postgraduate Institute for Medicine designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Inquiries/Special Needs

For information about the accreditation of this program, please contact PIM via email at

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.


Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient's conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer's product information, and comparison with recommendations of other authorities.

Method of Participation and Request for Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

Follow these steps to earn CME/CE credit:

  1. Read the educational objectives, accreditation information, and faculty disclosures at the beginning of this activity.
  2. Complete the Preactivity Questions.
  3. Read or review the activity content.
  4. Complete the Postactivity Test Questions and Evaluation.
  5. Physicians must achieve a grade of 100% on the Postactivity Test Questions and complete the Evaluation to receive a CME Certificate.
  6. All other participants who achieve a grade of 100% on the Postactivity Test Questions and who complete the Evaluation will receive a Certificate of Participation.

Click "Begin Activity" to acknowledge that you have reviewed the preamble information for this activity.

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expiration 01/31/2020

type Interactive Activity