从真武汤证看“水肝病”辨证论治

《伤寒论》第82条是太阳病发汗后导致的阳虚水泛之变证,治用真武汤。历代医家皆认为此条所述为脾肾阳虚、水湿内停之病机。然此条所述症状更多的表现为"肝风内动"的征象,导师陈明教授据此创造性地提出了"水肝病"的概念。学生通过进一步分析第82条的病机实质及真武汤组方思路,提出此条为"肝阳虚水泛证"辨证论治的假设,并进行相关论证。

Effects of acute hepatic damage on natriuresis and water excretion after acute normal saline loading in rats

AIMS To investigate the relationship between the liver function- al impairment and sodium and water retention. METHODS Acute liver damage model was established with carbon tetrachloride (CCl_4) administration to male Sprague-Daw- ley rats. Twenty-four and 48 hours later after CCl_4 administration, the excretion of acute sodium and water load was examined,and 24 hours later after normal saline administration,the excretion of acute sodium and water load was examined in control group. The concentration of plasma caffeine was analysed with high pressure liquid chromatograph (HPLC). The half life time of plasma caffein (Caft 1/2) sewed as a quantitative index of hepatic function. Plasma ALT was measured with Reitman method. The hepatic tis- sue was sectioned in the same site for water content measurement and pathological observation. The serumal and urinary sodium was measured with flame photometry. RESULTS Twenty-four hours later after CCl_4 administration, plasma alanine aminotransferase (ALT,n=6,37.5±12.6→ 189.4±34.4U,P<0.01) and water content of hepatic tissue (n =6,70.0%±1.1%→73.0%±1.0%,P<0.01) rose significantly,Caft 1/2 was prolonged significantly (94.9±18.9→ 326.4±85.8 minutes,P<0.01 ). The renal function of excretion of acute salt and water load declined obviously (n=6,Na^+: 92.4%±14.1%→50.1%±13.1%,P<0.01;H_2O:86.3%± 14.3%→42.1%±8.8%,P<0.01). Forty-eight hours later, the indexes above somewhat recovered,but were still markedly different from those of the control. Furthermore,the relationships betweenCaft 1/2 andALT (r=0.752,P<0.01),and between Caft 1/2 and excretory rate of sodium (r=-0.634,P<0.05) and water were still significant (r=-0. 612,P<0.01). CONCLUSIONS Caft 1/2 is a good index to assess the degree of hepatic damage. The hepatic dysfunction may be a factor caus- ing the renal excretory impairment to the acute sodium and water load.

Drinking water and liver cancer *

AIM To study the relationship between mutagenicity of drinking water and incidence of liver cancer in high liver cancer incidence areas in Guangxi.

Genetic and epigenetic variants influencing the development of nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease （NAFLD） is common worldwide. The importance of genetic and epigen- eric changes in etiology and pathogenesis of NAFLD has been increasingly recognized. However, the ex- act mechanism is largely unknown. A large number of single nucleotide polymorphisms （SNPs） related to NAFLD has been documented by candidate gene studies （CGSs）. Among these genes, peroxisome pro- liferatoractivated receptor-γ, adiponectin, leptin and tumor necrosis factor-α were frequently reported. Since the introduction of genome-wide association studies （GWASs）, there have been significant advances in our understanding of genomic variations of NAFLD. Patatin- like phospholipase domain containing family member A3 （PNPLA3, SNP rs738409, encoding I148M）, also termed adiponutrin, has caught most attention. The evidence that PNPLA3 is associated with increased hepatic fat levels and hepatic inflammation has been validated by a series of studies. Epigenetic modification refers to phenotypic changes caused by an adaptive mechanism unrelated to alteration of primary DNA se- quences. Epigenetic regulation mainly includes microR- NAs （miRs）, DNA methylation, histone modifications and ubiquitination, among which miRs are studied most extensively, miRs are small natural single stranded RNA molecules regulating mRNA degradation or translation inhibition, subsequently altering protein expression of target genes. The miR-122, a highly abundant miR ac- counting for nearly 70% of all miRs in the liver, is sig- nificantly under-expressed in NAFLD subjects. Inhibition of miR-122 with an antisense oligonucleotide results in decreased mRNA expression of lipogenJc genes and improvement of liver steatosis. The investigation into epigenetic involvement in NAFLD pathogenesis is just at the beginning and needs to be refined. This review summarizes the roles of genetics and epigenetics in the development of NAFLD. The progress made in this field may provide novel diagnostic biomarkers and therapeu- tic targets for NAFLD management.

Eosinophilic gastroenteritis with ascites and hepatic dysfunction

Eosinophilic gastroenteritis is a rare gastrointestinal disorder with eosinophilic infiltration of the gastrointestinal wall and various gastrointestinal dysfunctions. Diagnosis requires a high index of suspicion and exclusion of various disorders that are associated with peripheral eosinophilia. We report a case of eosinophilic gastroenteritis, which had features of the predominant subserosal type presenting with ascites and hepatic dysfunction, and which responded to a course of low-dose steroid.

Identification of differentially expressed genes in mouse hepatocarcinoma ascites cell line with low potential of lymphogenous metastasis

AIM: To identify genes differentially expressed in mouse hepatocarcinoma ascites cell line with low potential of lymphogenous metastasis. METHODS: A subtracted cDNA library of mouse hepatocarcinoma cell line with low potential of lympho- genous metastasis Hca-P and its synogenetic cell line Hca-F with high metastatic potential was constructed by suppression subtracted hybridization (SSH) method. The screened clones of the subtracted library were sequenced and GenBank homology search was performed. RESULTS: Fifteen differentially expressed cDNA fragments of Hca-P were obtained which revealed 8 known genes, 4 expressed sequence tags (ESTs) and 3 cDNAs showed no homology. CONCLUSION: Tumor metastasis is an incident involving multiple genes. SSH is a useful technique to detect differentially expressed genes and an effective method to clone novel genes.

Brain edema and intracranial hypertension in fulminant hepatic failure:Pathophysiology and management

Intracranial hypertension is a major cause of morbidity and mortality of patients suffering from fulminant hepatic failure. The etiology of this intracranial hypertension is not fully determined, and is probably multifactorial, combining a cytotoxic brain edema due to the astrocytic accumulation of glutamine, and an increase in cerebral blood volume and cerebral blood flow, in part due to inflammation, to glutamine and to toxic products of the diseased liver. Validated methods to control intracranial hypertension in fulminant hepatic failure patients mainly include mannitol, hypertonic saline, indomethacin, thiopental, and hyperventilation. However all these measures are often not sufficient in absence of liver transplantation, the only curative treatment of intracranial hypertension in fulminant hepatic failure to date. Induced moderate hypothermia seems very promising in this setting, but has to be validated by a controlled, randomized study. Artificial liver support systems have been under investigation for many decades. The bioartiflcial liver, based on both detoxification and swine liver cells, has shown some efficacy on reduction of intracranial pressure but did not show survival benefit in a controlled, randomized study. The Molecular Adsorbents Recirculating System has shown some efficacy in decreasing intracranial pressure in an animal model of liver failure, but has still to be evaluated in a phase Ⅲ trial.

Hepatorenal syndrome

Hepatorenal syndrome(HRS) is defined as a functional renal failure in patients with liver disease with portal hypertension and it constitutes the climax of systemic circulatory changes associated with portal hypertension.This term refers to a precisely specified syndrome featuring in particular morphologically intact kidneys,where regulatory mechanisms have minimised glomerular filtration and maximised tubular resorption and urine concentration,which ultimately results in uraemia.The syndrome occurs almost exclusively in patients with ascites.Type 1 HRS develops as a consequence of a severe reduction of effective circulating volume due to both an extreme splanchnic arterial vasodilatation and a reduction of cardiac output.Type 2 HRS is characterised by a stable or slowly progressive renal failure so that its main clinical consequence is not acute renal failure,but refractory ascites,and its impact on prognosis is less negative.Liver transplantation is the most appropriate therapeutic method,nevertheless,only a few patients can receive it.The most suitable "bridge treatments" or treatment for patients ineligible for a liver transplant include terlipressin plus albumin.Terlipressin is at an initial dose of 0.5-1 mg every 4 h by intravenous bolus to 3 mg every 4 h in cases when there is no response.Renal function recovery can be achieved in less than 50% of patients and a considerable decrease in renal function may reoccur even in patients who have been responding to therapy over the short term.Transjugular intrahepatic portosystemic shunt plays only a marginal role in the treatment of HRS.

Successful percutaneous drainage of a giant hydatid cyst in the liver

A 35-year-old female was hospitalized for abdominal pain, bloating, and vomiting. Plain X-ray pictures exhibited bowel obstruction for which she underwent emergency surgery. On the second postoperative day, she started to complain about dull right upper quadrant abdominal pain and bloating. Abdominal CT scans revealed very large cystic lesion with an inhomogeneous fluid content. The cyst occupied the whole right lobe of the liver compressing the surrounding organs and dislocating the left lobe of the liver towards the left hypochondrium （Figure 1）. Additionally, several more cysts of various sizes were seen in the whole abdomen. This radio-morphology raised the possibility of a hydatid disease （caused by ruptured hydatid cyst） confirmed through positive echinococcus IgG serology （ELISA）. Interestingly, no hypereosinophilia could be detected through repeated blood tests.

Quantitation of HBsAg predicts response to entecavir therapy in HBV genotype C patients

AIM： To analysis the factors that predict the response to entecavir therapy in chronic hepatitis patients with hepatitis B virus （HBV） genotype C. METHODS： Fifty patients [hepatitis B e antigen （HBeAg）- negative：HBeAg-positive = 26：24] with HBV genotype C, who received nalve entecavir therapy for 〉 2 years, were analyzed. Patients who showed HBV DNA levels ≥ 3.0 log viral copies/mL after 2 years of entecavir ther- apy were designated as slow-responders, while those that showed 〈 3.0 log copies/mL were termed rapid- responders. Quantitative hepatitis B surface antigen （HBsAg） levels （qHBsAg） were determined by the Archi- tect HBsAg QT immunoassay. Hepatitis B core-related antigen was detected by enzyme immunoassay. Pre-C and Core promoter mutations were determined using by polymerase chain reaction （PCR）. Drug-resistance muta- tions were detected by the PCR-Invader method. RESULTS： At year 2, HBV DNA levels in all patients in the HBeAg-negative group were 〈 3.0 log copies/mL. In contrast, in the HBeAg-positive group, 41.7% were slow-responders, while 58.3% were rapid-responders. No entecavir-resistant mutants were detected in the slow-responders. When the pretreatment factors were compared between the slow- and rapid-responders; the median qHBsAg in the slow-responders was 4.57 log IU/mL, compared with 3.63 log IU/mL in the rapid- responders （P 〈 0.01）. When the pretreatment factors predictive of HBV DNA-negative status at year 2 in all 50 patients were analyzed, HBeAg-negative status, low HBV DNA levels, and low qHBsAg levels were signifi- cant （P 〈 0.01）. Multivariate analysis revealed that the low qHBsAg level was the most significant predictive factor （P = 0.03）. CONCLUSION： Quantitation of HBsAg could be a use- ful indicator to predict response to entecavir therapy.

Expression characteristics and diagnostic value of annexin A2 in hepatocellular carcinoma

AIM： TO investigate the characteristics and diagnostic value of annexin A2 （ANXA2） expression in cancerous tissues and sera of patients with hepatitis B virus （HBV）-related hepatocellular carcinoma （HCC）. METHODS： Levels of liver ANXA2 gene transcription or protein expression were analyzed in HCC-, their self- controlled precancerous-, and distant cancerous- tissues from 30 HCC. Serum levels of ANXA2 expression in 115 patients with HCC, 25 with metastatic liver can cer, 35 with chronic hepatitis, 28 with acute hepatitis, 38 with cirrhosis, and 30 healthy controls were deter- mined. Clinicopathological characteristics of circulating ANXA2 expression were analyzed, and its diagnostic efficiency and clinical values in HCC were evaluated. RESULTS： ANXA2 expression was localized in both cell membrane and cytoplasm in HCC tissue, mainly in the cytoplasm of matched adjacent cancerous tissue, and there was almost no positive staining in matched distant cancerous tissue. Abnormal expression of liver ANXA2 was present in HCC tissues compared with self-con- trolled adjacent- and distant-cancerous tissues at pro- tein or mRNA level. Circulating ANXA2 in HCC patients was significantly higher than that of other liver diseases （P 〈 0.01） except metastatic liver cancer. If the diag- nostic cutoff value of ANXA2 level was more than 18 ng/ mL, the incidence of serum ANXA2 was 86.96% in the HCC group, 80% in the metastatic liver cancer group, 31.58% in the liver cirrhosis group, none in the chronic hepatitis or acute hepatitis or normal control group, respectively. Serum ANXA2 expression in HCC patients was correlated with HBV infection （27.38 ± 5.67 ng/mL vs 18.58 ± 7.83 ng/mL, P 〈 0.01）, extrahepatic metas- tasis （26.11±5.43 ng/mL ys 22.79 ± 5.64 ng/mL, P 〈 0.01）, and portal vein thrombus （26.03 ± 5.99 ng/mL vs 23.06 ± 5.03 ng/mL, P 〈 0.01）, and was significantly higher （P 〈 0.01） in the moderately- （26.19±5.34 ng/ mL） or the poorly- differentiated group （27.05 ± 5.13 ng/mL） than in the well differentiated group （20.43 ± 4.97 ng/mL）, and in the tumor node metastasis stages Ⅲ-Ⅳ（P 〈 0.01） than in stages Ⅰ-Ⅱ. ANXA2 was not correlated with patient sex, age, size or α-fetoprotein （AFP） level. Area under the receiver operating charac- teristic curve for the whole range of sensitivities and specificities was 0.796 for ANXA2 and 0.782 for AFP. Combining detection of serum ANXA2 and AFP substan- tially improved the diagnostic efficiency （96.52%） and the neclative predictive value （＇96.61%） for HCC.of ANXA2 expression has good diagnostic potential for HCC diagnosis.

Liver-targeted hydrodynamic gene therapy: Recent advances in the technique

One of the major research focuses in the field of gene therapy is the development of clinically applicable, safe, and effective gene-delivery methods. Since the first case of human gene therapy was performed in 1990, a number of gene-delivery methods have been developed, evaluated for efficacy and safety, and modified for human application. To date, viral-vectormediated deliveries have shown effective therapeutic results. However, the risk of lethal immune response and carcinogenesis have been reported, and it is still controversial to be applied as a standard therapeutic option. On the other hand, delivery methods for nonviral vector systems have been developed, extensively studied, and utilized in in vivo gene-transfer studies. Compared to viral-vector mediated gene transfer, nonviral systems have less risk of biological reactions. However, the lower gene-transfer efficiency was a critical hurdle for applying them to human gene therapy. Among a number of nonviral vector systems, our studies focus on hydrodynamic gene delivery to utilize physical force to deliver naked DNA into the cells in the living animals. This method achieves a high gene-transfer level by DNA solution injections into the tail vein of rodents, especially in the liver. With the development of genome editing methods, in vivo gene-transfer therapy using this method is currently the focus in this research field. This review explains the method principle, efficiency, safety, and procedural modifications to achieve a high level of reproducibility in large-animal models.

Colchicine sensitizes human hepatocellular carcinoma cells to damages caused by radiation

AIM： We studied the effect of colchicine combined with radiation on the survival of human hepatocellular carcinoma （HCC） HA22T/VGH cells.METHODS： Twenty-four hours after treatment with 0-8 ng/mL colchicine, HA22T/VGH cells were irradiated at various doses （0, 1, 2, 4, and 8 Gy）. Colony assay was performed to assess the surviving cell fraction. Survival curves were fitted by using a linear-quadratic model to estimate the sensitizer enhancement ratio （SER）. Flow cytometry was used for cell cycle analysis.RESULTS： Colchicine at lower concentrations （1 and 2 ng/mL） had obvious synergy with radiation to inhibit HCC cell growth, whereas higher concentrations （4 and 8 ng/mL） had only additive effect to radiation. Pretreatment with 1 and 2 ng/mL colchicine for 24-h enhanced cell killing by radiation with SERs of 1.21 and 1.53, respectively.G2/N arrest was only observed with higher colchicine doses （8 and 16 ng/mL） after 24-h treatment, this effect was neither seen with lower doses （1, 2, and 4 ng/mL）nor with any dose after only 1 h of treatment.CONCLUSION： Our results suggest that colchicine has potential as an adjunct to radiotherapy for HCC treatment.Lower doses of colchicine possess radiosensitizing effects via some mechanism other than G2/M arrest. Further study is necessary to elucidate the mechanism.

Increased serum and ascitic fluid levels of soluble tumor necrosis factor-p55 in hepatocellular carcinoma patients

Objective: To explore the levels of serum and ascitic fluid soluble tumor necrosis factor receptor-p55 (sTNFR-p55) and understand their clinical implication in primary hepatocellular carcinoma (HCC) patients. Methods: Enzyme-linked immunosorbent assay (ELISA) was used to examine the levels of sTNFR-p55 in the serum and ascitic fluid in 25 HCC patients and 25 patients with liver cirrhosis (LC). The test was also performed on the serum of 30 healthy subjects who served as control group. To assess the clinical effects of increased serum concentrations of sTNFR-p55, four parameters were analyzed by logistic regression. Results: Serum and ascitic fluid levels of sTNFR-p55 in HCC patients were significantly higher than those in LC patients and controls (P=0. 001). No significant difference was found between serum sTNFR-p55 levels in the latter 2 groups (P = 0. 19), and positive correlation between serum levels of sTNFR-p55 and that in ascitic fluid was noted in the 2 patient groups (r=1. 000, P<0. 001). Levels of the sTNFR-p55 positively correlated with TBIL and AFP in the peripheral blood of HCC patients (r=0. 524, P = 0. 01 and r=0. 234, P = 0. 03, respectively). Conclusion: Increased levels of sTNFRs-p55 in the serum and ascitic fluid could reflect the abnormal immune status of the HCC patients and may help predict the development of the tumor.

DNA-guided hepatitis B treatment:Viral load is insufficient with few exceptions

In DNA-guided hepatitis B treatment, viral load is insufficient, and requires other viral markers for treatment of hepatitis B patients as in patients with acute exacerbation of chronic hepatitis B, end-stage renal disease on dialysis, human immunodeficiency virus co-infected patients. There are exceptions to this rule： a residual level hepatitis B virus （HBV） DNA at 24 wk predicts beneficial outcome and reduced resistance at i year. The genotypic viral resistance to antiviral agents and occult HBV infection can be determined by HBV-DNA levels.

Elevated serum alpha fetoprotein levels promote pathological progression of hepatocellular carcinoma

AIM:To investigate the biological role of alpha fetoprotein (AFP) and its clinical signif icance in carcinogenesis of hepatocellular carcinoma (HCC).METHODS:Clinical analysis of HCC patients and im-munohistochemical examination were conducted to evaluate the relationship between serum AFP level and patient mortality. Confocal microscopy,Western blotting, dimethylthiahzolyl-2,5-diphenyl-tetrazolium bromide,Cell Counting Kit-8 assays and flow cytometry were performed to explore the possible mechanism.RESULTS: Among the 160 HCC patients enrolled in this study,130 patients survived 2 years (81.25%),with a survival rate of 86.8% in AFP < 2 0 μg/L group,88.9% in AFP 20-250 μg/L group,and 69.6% in AFP > 250 μg/L group, demonstrating a higher mortality rate in HCC patients with higher AFP levels. Surgical treatment was benef icial only in patients with low AFP levels.The mortality rate of HCC patients with high AFP levels who were treated surgically was apparently higher than those treated with conservative management.The results of immunohistochemistry showed that AFP and AFP receptor were merely expressed in tissues of HCC patients with positive serum AFP.Consistently,in vitro analysis showed that AFP and AFPS were expressed in HepG2 but not in HLE cells. AFP showed a capability to promote cell growth,and this was more apparent in HepG2 cells,in which the proliferation was increased by 3.5 folds. Cell cycle analysis showed that the percent-age of HepG2 cells in S phase after exposure to AFP was modestly increased.CONCLUSION:HCC patients with higher AFP levels show a higher mortality rate,which appears to be attributable to the growth promoting properties of AFP.

Tenofovir rescue therapy for chronic hepatitis B patients after multiple treatment failures

AIM:To evaluate the efficacy and safety of tenofovir disoproxil fumarate(TDF) for chronic hepatitis B(CHB) patients after multiple failures.METHODS:A total of 29 CHB patients who had a suboptimal response or developed resistance to two or more previous nucleoside/nucleotide analogue(NA) treatments were included.Study subjects were treated with TDF alone(n = 13) or in combination with lamivudine(LAM,n = 12) or entecavir(ETV,n = 4) for ≥ 6 mo.Complete virologic response(CVR) was defined as an achievement of serum hepatitis B virus(HBV) DNA level ≤ 60 IU/mL by real-time polymerase chain reaction method during treatment.Safety assessment was based on serum creatinine and phosphorus level.Eleven patients had histories of LAM and adefovir dipivoxil(ADV) treatment and 18 patients were exposed to LAM,ADV,and ETV.Twenty-seven patients(93.1%) were hepatitis B e antigen(HBeAg) positive and the mean value of the baseline serum HBV DNA level was 5.5 log IU/mL ± 1.7 log IU/mL.The median treatment duration was 16 mo(range 7 to 29 mo).RESULTS:All the patients had been treated with LAM and developed genotypic and phenotypic resistance to it.Resistance to ADV was present in 7 patients and 10 subjects had a resistance to ETV.One patient had a resistance to both ADV and ETV.The cumulative probabilities of CVR at 12 and 24 mo of TDF containing treatment regimen calculated by the Kaplan Meier method were 86.2% and 96.6%,respectively.Although one patient failed to achieve CVR,serum HBV DNA level decreased by 3.9 log IU/mL from the baseline and the last serum HBV DNA level during treatment was 85 IU/mL,achieving near CVR.No patients in this study showed viral breakthrough or primary non-response during the follow-up period.The cumulative probability of HBeAg clearance in the 27 HBeAg positive patients was 7.4%,12%,and 27% at 6,12,and 18 mo of treatment,respectively.Treatment efficacy of TDF containing regimen was not statistically different according to the presence of specific HBV mutations.History of prior exposure to specific antiviral agents did not make a difference to treatment outcome.Treatment efficacy of TDF was not affected by combination therapy with LAM or ETV.No patient developed renal toxicity and no cases of hypophosphatemia associated with TDF therapy were observed.There were no other adverse events related to TDF therapy observed in the study subjects.CONCLUSION:TDF can be an effective and safe rescue therapy in CHB patients after multiple NA therapy failures.

Evaluation and management of patients with refractory ascites

Some patients with ascites due to liver cirrhosis become no longer responsive to diuretics. Once other causes of ascites such as portal vein thrombosis, malignancy or infection and non-compliance with medications and low sodium diet have been excluded, the diagnosis of refractory ascites can be made based on strict criteria. Patients with refractory ascites have very poor prognosis and therefore referral for consideration for liver transplantation should be initiated. Search for reversible components of the underlying liver pathology should be undertaken and targeted therapy, when available, should be considered. Currently, serial large volume paracentesis （LVP） and transjugular intrahepatic portasystemic stent-shunt （TIPS） are the two mainstay treatment options for refractory ascites. Other treatment options are available but not widely used either because they carry high morlJidity and mortality （most surgical options） rates, or are new interventions that have shown promise but still need further evaluation. In this comprehensive review, we describe the evaluation and management of patients with refractory ascites from the prospective of the practicing physician.

Ultrasound Elastography of Ethanol-induced Hepatic Lesions:In Vitro Study

Objective To study the value of ultrasound elastography in evaluation of ethanol-induced lesions of liver. Methods Alcohol with a dose of 2 ml was injected into a fresh porcine liver under ultrasound guidance to create stiff necrosis. Then freehand elastography of the lesion from the identical scan plane was obtained with SONOLINE Antares system using VF10-5 probe at about every 30 seconds till 6 minutes later. The original high quality radiofrequency data were acquired through an ultrasound research interface which was provided by the ultrasound system. Then, corresponding elastograms were produced offline using cross-correlation technique and compared with gross pathology findings. Results Gray-scale sonogram showed a hyperechoic area with acoustic shadow below appeared immediately after alcohol injection. The hyperechoic area tended to be diffuse and its boundary to be illegible with time. On the contrary, the ethanol-induced lesion in elastogram appeared as a low swain hard region surrounded by high strain soft hepatic tissues, with clear but irregular boundaries. Sequential elastograms with the sketched lesion boundaries showed that the lesion area increased in the first 3 minutes after ethanol injection, and then reached a plateau which corresponding to gross specimen. Conclusion Ultrasound elastography is capable of detecting and evaluating the diffusion of ethanol-induced hepatic lesion, and more sensitive and accurate than routine sonography.

Non-alcoholic steatohepatitis with normal aminotransferase values

AIM： To investigate the aspects of liver histology in patients with non-alcoholic steatohepatitis （NASH） who had normal aminotransferase levels. METHODS： Thirty-four patients diagnosed with liver steatosis by ultrasonographic examination participated in the study. We compared all non- alcoholic fatty liver disease and NASH cases, according to aminotransferase level, aspartate aminotransferase （AST）/alanine aminotransferase （ALT） ratio and presence of metabolic syndrome. RESULTS： Sixteen of 25 patients with high aminotransferase levels were diagnosed with NASH and nine with simple fatty liver according to liver histology. Among the nine patients with normal aminotransferase levels, seven had NASH and two had simple fatty liver. The patients with normal and high liver enzyme levels had almost the same prevalence of NASH and metabolic syndrome. Liver histology did not reveal any difference according to aminotransferase levels and AST/ALT ratio. CONCLUSION： Aminotransferase levels and AST/AIT ratio do not seem to be reliable predictors for NASH. Despite numerous non-invasive biomarkers, all patients with fatty liver should undergo liver biopsy.