Cryptogenic vs. NASH-cirrhosis: The rose exists well before its name…

‘Stat rosa pristina nomine, nomina nuda tenemus’ Introduction of “The name of the rose” by Umberto Eco Evolution of language is as old as language itself and the ever-changing terminology in the medical sciences remains a challenge for all of us except perhaps the very newest trainees who will soon find their common terms to have all too soon transitioned to anachronisms. Such language evolution is indeed relevant to the diagnosis of ‘NASH-cirrhosis’ and ‘cryptogenic cirrhosis’. The recognition that NASH cirrhosis progresses to an advanced state characterized by loss of a vital histological hallmark – steatosis and thus to loss of an even more foundational biopsy finding of ‘steatohepatitis’ was a conceptual sea-change. Early epidemiological studies indicated that this process was characteristic of the transition of NASH-cirrhosis to cryptogenic cirrhosis (Powell, Caldwell, Thulavath). Indeed, the progression of NASH is now known to be associated with loss of fat (perhaps through changes in blood flow and insulin exposure) and diminished serum aminotransferases albeit with increasing fibrosis (ref, ref). In the absence of a prior diagnosis of NASH or at least NAFLD, liver histology at this stage appears as cirrhosis of unknown cause or ‘cryptogenic cirrhosis’. Following a transition period of about 10-15 years from around 2000 to 2014, the term ‘cryptogenic’ cirrhosis has come to be essentially equated to ‘NASH-cirrhosis’. This may well be the most likely situation in the majority of cases however the authors of the present study raise a wise caution flag regarding the need to consider other possibilities.