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gi.masld.core.v1

MASLD / MASH (formerly NAFLD/NASH)

gastroenterologychronicadultoutpatient
Start encounter →Print handoutPRODUCTION

Comprehensive MASLD dossier (2023 Rinella nomenclature). STEP 3 deepened (2026-05-16): design brief + research bundle authored (§5.5 items 1-2); §5.5.2 FIB-4→VCTE sequential Bayesian chain wired with operating characteristics (FIB-4 <1.3 NPV ~90%/sens ~74%; >2.67 spec ~80%/PPV ~80%; VCTE LSM 8/12-15 kPa conditional thresholds) + treat/test thresholds + gi.cirrhosis F4 routing; §5.5.1 effect sizes retained/expanded (PIVENS vit E 43% vs 19%, pioglitazone NAS 34% vs 19%; Newsome semaglutide 59% vs 17%; LEAN liraglutide 39% vs 9%; MAESTRO-NASH resmetirom 25.9-29.9% vs 9.7%, fibrosis ↓≥1 stage 24.2-25.9% vs 14.2%); evidence.pmids 6→8 (+Cusi 27322798, +LEAN 26608256); last_reconciled 2026-05-16. Re-promoted SCAFFOLDED→PRODUCTION (design_brief present; all completeness tiers satisfied; verified via dossier:audit). RxCUIs pending research:rxnav drug-data commit.

Entry points (5)

  • lab_abnormality
    Incidentally elevated ALT or hepatic steatosis on imaging
    elevated_alt
  • imaging
    Hepatic steatosis on US/CT/MRI
    hepatic_steatosis
  • lab_abnormality
    Elevated FIB-4 score (≥1.3) on routine screening in at-risk population
    elevated_fib4
  • problem_list
    Known MASLD/NAFLD on problem list — follow-up or progression concern
    masld_nafld
  • history
    T2DM, obesity, metabolic syndrome — screening for MASLD
    metabolic_risk_factors

Required inputs (18)

  • agerequired
    demographic • used at CONTEXT
    FIB-4 calculation; risk stratification; guides non-invasive testing interpretation (AASLD 2023)
  • sexrequired
    demographic • used at CONTEXT
    MASLD prevalence differs; ALT thresholds differ by sex (AASLD 2023)
  • bmirequired
    demographic • used at CONTEXT
    Obesity is cardinal metabolic risk factor; guides lifestyle intervention intensity; lean MASLD (BMI <25) is distinct phenotype (AASLD 2023)
  • bprequired
    vital • used at CONTEXT
    Hypertension as metabolic syndrome component; cardiovascular risk (AASLD 2023)
  • altrequired
    lab • used at INITIAL_WORKUP
    Primary liver injury marker; persistently elevated ALT triggers advanced workup (AASLD 2023)
  • astrequired
    lab • used at INITIAL_WORKUP
    AST:ALT ratio; FIB-4 calculation (AASLD 2023)
  • plateletsrequired
    lab • used at INITIAL_WORKUP
    FIB-4 denominator; thrombocytopenia suggests advanced fibrosis/cirrhosis (AASLD 2023)
  • hba1crequired
    lab • used at INITIAL_WORKUP
    T2DM screening/monitoring — strongest metabolic risk factor for MASH progression (AASLD 2023)
  • fasting_glucoserequired
    lab • used at INITIAL_WORKUP
    Metabolic syndrome criterion; insulin resistance assessment (AASLD 2023)
  • lipid_panelrequired
    lab • used at INITIAL_WORKUP
    Dyslipidemia as metabolic syndrome component; cardiovascular risk (AASLD 2023)
  • total_bilirubinrequired
    lab • used at INITIAL_WORKUP
    Liver synthetic function; exclude other liver diseases (AASLD 2023)
  • albuminrequired
    lab • used at INITIAL_WORKUP
    Liver synthetic function; advanced fibrosis marker (AASLD 2023)
  • inr
    lab • used at INITIAL_WORKUP
    Liver synthetic function assessment (AASLD 2023)
  • fib4_scorerequired
    lab • used at RISK_STRATIFICATION
    FIB-4 is recommended first-line non-invasive test for fibrosis risk stratification (AASLD 2023): <1.3 low risk, 1.3-2.67 indeterminate, >2.67 high risk
  • vcte_fibroscan
    imaging • used at BRANCHING_WORKUP
    Vibration-controlled transient elastography (VCTE/FibroScan) — second-line for indeterminate FIB-4 (1.3-2.67) or high FIB-4 confirmation; LSM <8 kPa excludes advanced fibrosis, ≥8 kPa suggests significant fibrosis (AASLD 2023; EASL 2024)
  • alcohol_intakerequired
    history • used at CONTEXT
    Must quantify alcohol — MASLD requires <20g/day women, <30g/day men; excess alcohol = MetALD or ALD (Rinella Hepatology 2023)
  • metabolic_comorbiditiesrequired
    history • used at CONTEXT
    At least one cardiometabolic criterion required for MASLD diagnosis: BMI ≥25, T2DM, HTN, dyslipidemia, waist circumference (Rinella Hepatology 2023)
  • current_medsrequired
    medication • used at CONTEXT
    Steatogenic drugs (tamoxifen, amiodarone, methotrexate, corticosteroids); current diabetes/lipid/HTN meds for metabolic management (AASLD 2023)

12-phase flow (12)

  1. 1FRAME
    Confirm MASLD scope: hepatic steatosis + ≥1 cardiometabolic criterion + alcohol <20g/day (women) or <30g/day (men); distinguish MASLD from MetALD (moderate alcohol + metabolic) and ALD (Rinella Hepatology 2023)
    inputs: alcohol_intake, metabolic_comorbidities
    advance: MASLD diagnosis confirmed per Rinella 2023 nomenclature criteria
  2. 2ENTRY
    Incidental steatosis on imaging, elevated ALT, elevated FIB-4 in at-risk patient, or known MASLD follow-up (AASLD 2023)
    inputs: age
    advance: MASLD suspected or confirmed
  3. 3CONTEXT
    BMI, waist circumference, BP, alcohol quantification, metabolic comorbidities (T2DM, dyslipidemia, HTN, metabolic syndrome), medication review for steatogenic drugs (AASLD 2023; Rinella Hepatology 2023)
    inputs: bmi, bp, sex, alcohol_intake, metabolic_comorbidities, current_meds
    advance: metabolic profile and alcohol intake quantified
  4. 4RED_FLAGS
    Signs of advanced fibrosis/cirrhosis: thrombocytopenia, splenomegaly, ascites, spider angiomata, palmar erythema; FIB-4 >2.67 = high fibrosis probability (AASLD 2023)
    inputs: platelets, albumin
    advance: advanced fibrosis/cirrhosis signs assessed
  5. 5INITIAL_WORKUP
    ALT, AST, platelets (for FIB-4), HbA1c, fasting glucose, lipid panel, total bilirubin, albumin; exclude other causes: HBsAg, anti-HCV, iron studies, ANA, ASMA, IgG, ceruloplasmin, A1AT (AASLD 2023)
    inputs: alt, ast, platelets, hba1c, fasting_glucose, lipid_panel, total_bilirubin, albumin
    actions: panel.lft, panel.glucose_a1c, calc.meld3
    advance: baseline labs + FIB-4 calculated + other liver diseases excluded
  6. 6BRANCHING_WORKUP
    Sequential Bayesian fibrosis testing — FIB-4 first (rule-out NPV ~90%, sensitivity ~74% for advanced fibrosis at <1.3; rule-in specificity ~80% / PPV ~80% at >2.67): <1.3 → low risk, reassess 2-3 y (T_test crossed); >2.67 → hepatology directly (T_treat crossed); 1.3-2.67 (defer zone) → conditional second test VCTE/FibroScan — LSM <8 kPa rules out advanced fibrosis, 8-12 kPa indeterminate (escalate to ELF or MRE), ≥12-15 kPa → advanced fibrosis likely (hepatology). FIB-4 information value is conditional on pre-test metabolic-risk population (not portable without that context) — AASLD 2023; EASL 2024; Sterling Hepatology 2006 (FIB-4 derivation)
    inputs: fib4_score, vcte_fibroscan
    actions: workup.abnormal_lft, workup.lymphadenopathy_biopsy
    advance: fibrosis risk stratum assigned (low / indeterminate / high)
  7. 7DIFFERENTIAL
    MASLD vs MetALD (alcohol 20-50g/day women, 30-60g/day men + metabolic) vs ALD (excess alcohol) vs drug-induced steatosis (amiodarone, tamoxifen, MTX, steroids) vs other chronic liver disease; MASH vs simple steatosis (requires biopsy or biomarker) (Rinella Hepatology 2023; AASLD 2023)
    advance: MASLD confirmed; MASH vs simple steatosis assessed
  8. 8RISK_STRATIFICATION
    FIB-4 → VCTE sequential pathway for fibrosis staging (NFS alternative); cardiovascular risk dominates prognosis — CV disease is the #1 cause of death in non-cirrhotic MASLD (statin SAFE in MASLD + compensated cirrhosis, do NOT withhold for steatosis/mild ALT); T2DM control (HbA1c); BMI/metabolic-syndrome severity. Treat-vs-test thresholds: F2-F3 fibrosis = resmetirom-eligible (treat); F4 → route gi.cirrhosis.core.v1 (AASLD 2023; EASL 2024)
    inputs: fib4_score
    actions: calc.meld3, calc.meld_na
    advance: fibrosis stage + CV risk + metabolic burden documented
  9. 9TREATMENT
    Lifestyle (weight loss ≥5% for steatosis, ≥7-10% for MASH/fibrosis); pioglitazone for MASH in T2DM or non-T2DM (PIVENS Sanyal NEJM 2010); vitamin E 800 IU/day for non-diabetic non-cirrhotic MASH (PIVENS); GLP-1RA semaglutide (Newsome Lancet Gastro 2021); resmetirom 80-100 mg daily — first FDA-approved drug for MASH with F2-F3 fibrosis (MAESTRO-NASH Harrison NEJM 2024); manage CV risk factors aggressively (AASLD 2023; EASL 2024)
    inputs: bmi, hba1c, fib4_score
    advance: lifestyle + pharmacotherapy plan initiated
  10. 10DISPOSITION
    Primary care manages low-risk MASLD (FIB-4 <1.3); hepatology referral for indeterminate/high FIB-4 (≥1.3 with elevated VCTE) or confirmed advanced fibrosis/cirrhosis; endocrinology co-management for T2DM (AASLD 2023)
    inputs: fib4_score
    advance: care team and referrals assigned
  11. 11MONITORING
    FIB-4 reassessment q1-2 years for low-risk; VCTE q1-2 years for indeterminate/high risk; ALT q6-12mo; HbA1c q3-6mo if T2DM; lipids annually; HCC surveillance (US + AFP q6mo) if cirrhosis (AASLD 2023; EASL 2024)
    inputs: alt, fib4_score, hba1c
    actions: calc.meld3
    advance: monitoring cadence set
  12. 12FOLLOWUP
    Lifestyle reinforcement; weight loss maintenance; medication adherence; cardiovascular risk reduction (leading cause of death in MASLD); HCC surveillance if cirrhotic; consideration of bariatric surgery if BMI ≥35 with MASH (AASLD 2023)
    advance: follow-up scheduled