Metabolic dysfunction-associated steatohepatitis (MASH), historically known as Non-Alcoholic Steatohepatitis (NASH), is a severe form of steatotic liver disease. It is characterized by fat accumulation in the liver, inflammation, and progressive damage. Unmanaged, this damage can lead to advanced scarring (fibrosis), which may progress to cirrhosis and liver failure. The metabolic nature of MASH means that treatment is complex and requires a highly coordinated effort involving multiple medical specialists.
Primary Care Screening and Initial Management
Care for steatohepatitis often begins with the Primary Care Physician (PCP) or an Internal Medicine specialist. These practitioners are the first to identify patients at high risk due to common associated conditions. Individuals with Type 2 diabetes, obesity, hypertension, or high cholesterol are candidates for screening, reflecting the disease’s connection to metabolic syndrome.
Initial screening involves routine blood tests measuring liver enzymes, such as Alanine Aminotransferase (ALT) and Aspartate Aminotransferase (AST). While elevated enzymes suggest inflammation, they can be normal even if liver disease is present. PCPs also utilize non-invasive scoring tools, such as the Fibrosis-4 (FIB-4) index, which estimates the likelihood of advanced liver scarring using simple laboratory values.
Risk stratification is crucial for determining the next steps in care. For those with a low-risk score, the PCP initiates intensive lifestyle counseling. This advice focuses on achievable weight loss, often targeting a 7% to 10% reduction in total body weight, which can significantly improve liver inflammation and fibrosis. If the non-invasive score indicates a higher risk of advanced fibrosis, or if lifestyle changes fail to improve their condition, the PCP makes a prompt referral to a liver specialist.
The Central Role of Liver Specialists
The management of MASH is primarily overseen by a liver specialist, who is either a Hepatologist or a Gastroenterologist with advanced training in liver diseases. This specialist’s role is to confirm the diagnosis and accurately stage the extent of liver damage. This staging process is critical because the presence and severity of fibrosis dictate the urgency and type of treatment required.
To stage the disease, the specialist orders advanced, non-invasive imaging techniques. Magnetic Resonance Elastography (MRE) or Vibration-Controlled Transient Elastography (VCTE), known as FibroScan, are used to measure liver tissue stiffness, a reliable proxy for fibrosis severity. A liver biopsy remains the gold standard, providing the most detailed information by allowing a pathologist to visualize inflammation, fat accumulation, and scar tissue.
Once staged, the specialist determines the appropriate course of liver-specific pharmacotherapy. For patients with confirmed MASH and moderate to advanced fibrosis, certain medications are prescribed to target the underlying liver injury. These include older agents like high-dose Vitamin E or pioglitazone, or newer therapies like resmetirom, which was recently approved for this indication. The hepatologist manages these drug treatments, carefully monitoring for side effects and assessing their efficacy in slowing or reversing damage progression.
Multidisciplinary Care for Associated Conditions
Because MASH progression is driven by metabolic dysfunction, a team approach involving other specialists is necessary to manage the root causes of the disease. The Endocrinologist manages insulin resistance and Type 2 diabetes, which are strongly linked to liver inflammation. They ensure optimal glucose control, often utilizing newer drug classes like GLP-1 receptor agonists, which benefit both liver health and weight loss.
Cardiologists are also integrated into the care team, as patients with MASH face a higher risk of cardiovascular events than liver-related mortality. Their focus is on aggressively managing associated conditions like hypertension and high lipid levels, often prescribing medications such as statins to reduce heart disease risk. This co-management ensures that both the liver and the cardiovascular system are addressed simultaneously.
A Registered Dietitian or Nutritionist is an indispensable member of the multidisciplinary team. While the PCP initiates general lifestyle advice, the dietitian provides personalized, structured nutrition counseling. They help patients implement a sustainable diet plan, such as the Mediterranean diet, and create the caloric deficit necessary to achieve weight loss goals that can halt disease progression.
Advanced Interventions and Liver Transplant
For the subset of patients whose MASH progresses to advanced cirrhosis, a specialized surgical and medical team becomes involved. The Transplant Surgeon and the comprehensive Transplant Team evaluate patients who develop end-stage liver failure. This team assesses the patient’s overall health and the severity of their liver disease to determine if they meet the strict criteria for placement on the liver transplant waiting list.
The Transplant Team, which includes transplant hepatologists, surgeons, and social workers, manages the complex process of pre-transplant evaluation, the surgery itself, and lifelong post-transplant care. The goal is to replace the failing liver with a healthy organ, offering a life-saving intervention for those with irreversible damage.
Bariatric Surgeons may also be consulted for patients with severe obesity who have not progressed to end-stage disease. Weight-loss surgery, such as gastric bypass, can result in significant and sustained weight loss. This intervention can dramatically improve or even resolve MASH in carefully selected patients.