Non-alcoholic fatty liver disease in children — branching viva

Station opening

Examiner: "Define paediatric fatty liver disease and outline your approach to an overweight child referred with possible fatty liver disease." [4]

Strong candidate (must-hit)

• Defines paediatric fatty liver disease, renamed metabolic dysfunction-associated steatotic liver disease, as hepatic steatosis in the presence of overweight or obesity and insulin resistance defined by one or more cardiometabolic criteria; frames the approach around confirming persistence of an abnormal alanine aminotransferase against the sex-specific thresholds, excluding mimics, staging fibrosis non-invasively, and treating with family-based lifestyle change as the cornerstone; states that no drug is approved specifically for paediatric MASLD and that cardiovascular disease is the leading long-term risk. [4]

Weak candidate

• "Fatty liver disease is fat in the liver of a fat child; I would send some bloods and tell them to lose weight." [1]

Branch A — The overweight child found on screening

Examiner: "An eleven-year-old boy with a body mass index on the ninety-second percentile has an alanine aminotransferase of 34 units per litre, reported as in-range by the laboratory up to 55. How do you interpret this, and what are the NASPGHAN thresholds?" [1]

Strong

• States that the laboratory range is misleadingly high and that 34 units per litre is abnormal by the NASPGHAN thresholds of 22 units per litre for girls and 26 for boys; confirms persistence by repeating the alanine aminotransferase; recognises that this overweight boy with a sugary, sedentary lifestyle and a father with type 2 diabetes has a high probability of fatty liver disease; explains that screening begins between ages nine and eleven for obesity or overweight with a risk factor; and initiates family-based lifestyle therapy while arranging non-invasive confirmation and comorbidity assessment. [1]

Weak

• "The lab says it is normal, so I would just check it again in a year or two." [1]

Branch B — The obese adolescent with persistent enzyme elevation

Examiner: "A fourteen-year-old girl with severe obesity and prediabetes has an alanine aminotransferase between 95 and 110 units per litre for four months, a bright liver on ultrasound, a normal exclusion panel, and a father with cirrhosis. What is your diagnosis, and what is the role of vitamin E?" [3]

Strong

• Makes the diagnosis of metabolic dysfunction-associated steatotic liver disease with a high likelihood of significant disease given the enzyme level above 80 units per litre and the family history; confirms that the exclusion of autoimmune, viral, Wilson and alpha-1-antitrypsin disease is complete; stages fibrosis non-invasively and considers liver biopsy; explains that the TONIC trial showed vitamin E at 800 IU per day for 96 weeks improved steatohepatitis histology but not fibrosis, while metformin showed no benefit, so vitamin E may be considered in selected biopsy-proven cases but no drug is approved for paediatric MASLD; and builds the plan around family-based lifestyle therapy, comorbidity control, and consideration of adolescent bariatric surgery. [3] [8]

Weak

• "I would start metformin to treat the fatty liver and recheck in six months." [3]

Branch C — The child with type 1 diabetes and an incidental steatotic liver

Examiner: "A ten-year-old with type 1 diabetes and a body mass index on the ninetieth percentile has a steatotic liver on ultrasound performed for abdominal pain, and a mildly raised alanine aminotransferase. Is this metabolic dysfunction-associated steatotic liver disease, and how do you manage it?" [4]

Strong

• Explains that steatosis can occur in type 1 diabetes through insulin resistance in the setting of overweight, but that the metabolic-criteria definition must be applied carefully against the cardiometabolic factors actually present and other causes of elevated liver enzymes excluded; manages the child jointly with the diabetes team with attention to glycaemic control and weight, rather than automatically labelling the condition; and screens for and manages the cardiometabolic comorbidities on their own merits. [4]

Weak

• "All diabetics get fatty liver, so this is MASLD and she needs vitamin E." [4]

Branch D — The teenager who presents with jaundice and ascites

Examiner: "A sixteen-year-old with longstanding obesity presents with jaundice, easy bruising, and abdominal distension, and has a low platelet count and prolonged coagulation. How do you respond, and what does this imply about the disease course?" [6]

Strong

• Recognises decompensated cirrhosis with portal hypertension and initiates the immediate airway, breathing, circulation response with paediatric hepatology and intensive care involvement; considers spontaneous bacterial peritonitis and variceal bleeding and manages them with antibiotics, albumin, octreotide and endoscopic therapy as indicated; and explains that this rare presentation signals a disease that has been silent for years and now needs tertiary hepatology, cirrhosis surveillance, and transplant assessment, while beginning the metabolic and lifestyle conversation that will underpin any long-term plan. [6]

Weak

• "I would refer her to the obesity clinic for lifestyle advice." [6]

Close

Examiner: "Summarise your approach to the child with suspected fatty liver disease in one sentence." [4]

Strong

• "Paediatric fatty liver disease, now called metabolic dysfunction-associated steatotic liver disease, is steatosis with one or more cardiometabolic criteria: I suspect it in any overweight or obese child and screen with the sex-specific alanine aminotransferase thresholds of 22 units per litre for girls and 26 for boys from age nine to eleven, confirm persistence above twice the upper limit of normal, exclude the mimics, stage fibrosis non-invasively, and treat with family-based lifestyle change targeting a 7 to 10 per cent weight reduction, reserving vitamin E for selected biopsy-proven cases and managing the cardiovascular and metabolic comorbidities that dominate long-term outcome." [1] [8]