About This Page
This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
Key points
- MASLD is hepatic steatosis associated with metabolic risk
- Most patients are asymptomatic with mild ALT/AST elevation or incidental steatosis
- Risk is determined by fibrosis stage, not steatosis alone
- Initial fibrosis risk stratification often uses FIB-4
- Treatment is weight loss, exercise, cardiometabolic risk control, and selected pharmacotherapy
Overview
NAFLD/MASLD is a spectrum from steatosis to MASH, fibrosis, cirrhosis, and HCC. It is a hepatic manifestation of insulin resistance and cardiometabolic disease; Step 2 CK may use NAFLD/NASH terminology.
Epidemiology
It is the most common chronic liver disease in the United States. Risk factors include obesity, type 2 diabetes, metabolic syndrome, PCOS, OSA, dyslipidemia, and sedentary lifestyle. Cardiovascular disease is the leading cause of death.
Clinical Features
Symptoms
Usually asymptomatic
Fatigue or vague RUQ discomfort
Metabolic syndrome features
Decompensated cirrhosis symptoms if advanced
Signs
Central adiposity
Hepatomegaly may be present
Acanthosis nigricans
Stigmata of cirrhosis if advanced
Investigations
First-line
Liver enzymesMild ALT/AST elevation; ALT often >AST until cirrhosis
Ultrasound or imagingHepatic steatosis often incidentally found
Exclude other causesAlcohol history, viral hepatitis, medications, autoimmune/metabolic causes
Second-line
FIB-4Low values rule out advanced fibrosis in primary care
Transient elastographyAssesses liver stiffness and steatosis
HbA1c/lipidsCardiometabolic risk assessment
Specialist
HCC surveillanceUltrasound with or without AFP every 6 months when indicated
Transplant/hepatology evaluationAdvanced fibrosis, decompensation, or early HCC
1
Lifestyle
- Weight loss: >=5% improves steatosis; 7-10% improves steatohepatitis/fibrosis more
- Mediterranean-style diet/calorie deficit
- Exercise independent of weight loss
2
Medications
- GLP-1 receptor agonists for obesity/diabetes can help weight and MASH activity
- Pioglitazone or vitamin E in selected biopsy-proven NASH patients
- Statins are safe and indicated for dyslipidemia/CV risk
3
Advanced fibrosis/cirrhosis
- Hepatology referral
- HCC surveillance and variceal screening if cirrhosis
- Transplant referral if decompensated
Complications
- Cirrhosis/portal hypertension: Ascites, varices, encephalopathy.
- HCC: Risk rises with cirrhosis and chronic HBV.
- Acute liver failure: Severe hepatitis can cause coagulopathy and encephalopathy.
- Extrahepatic disease: Vasculitis, renal disease, metabolic complications depending on etiology.
USMLE Step 2 CK Exam Tips
- 1ALT can be normal in advanced NAFLD/MASLD
- 2Fibrosis stage predicts prognosis better than steatosis
- 3FIB-4 is a common first risk tool
- 4Weight loss benefit is dose-dependent
- 5Statins are safe in NAFLD
- 6AST>ALT may appear once cirrhosis develops
- 7Exclude alcohol, viral hepatitis, and medications
Put your reading into practice
Topic-specific question practice is not linked for this article yet.
Choose USMLE Step 2 CK questions from the existing bank. General exam practice covers your selected topics; it is not filtered to this article. Your usual question-bank access applies.
Choose USMLE Step 2 CK practiceAfter your session, return to this section to revisit the reading and choose your next review.
Verified Sources & References
related resources
Save your place and choose what comes next
Gastroenterology & Hepatology · Article 17 of 25