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Recently, a `two-hit' hypothesis plump mom for the development of steatohepatitis has been proposed. The first hit produces steatosis, the second, any source of oxidative stress that plump mom 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. For example, only two of our patients had (minimally) elevated iron levels, in contrast to 58% in Bacon et al..9 It was easier to exclude the effects of alcohol plump mom in our patients, since the prevalence of alcoholism and even social drinking in Israel remains very low. The careful exclusion of these factors may explain the remarkably benign clinical course. None of the 48 patients developed signs suggestive of advanced liver disease, and in all but two patients, liver enzyme levels were significantly reduced during follow-up, becoming normal in half of the patients.
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