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This patient had marked steatosis, and demonstrates that obesity is not a prerequisite. More substantial support for the role of insulin resistance onwisconsin in the pathogenesis of fatty liver comes from two previous studies that demonstrate a clear association between fatty liver and insulin levels in both adults32 and children33 with fatty liver. ALT onwisconsin levels correlated significantly with fasting insulin levels, suggesting that hyperinsulinaemia is an important contributor to the development of fatty liver, more crucial to the pathogenesis than anthropomorphic data, blood glucose or serum lipids.33 Recently, a `two-hit' hypothesis for the development of steatohepatitis onwisconsin has been proposed. The first hit produces steatosis, the second, any source of oxidative stress that increases lipid peroxidation and subsequently leads to increased liver damage.34 Factors which can produce a `second hit' such as iron overload, alcohol, and drugs were conspicuously absent in our study group.
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