The central role of toll-like receptor 4 (TLR4) activation in nonalcoholic steatohepatitis (NASH) has been well-recognized, specifically its role in the activation of innate immune responses, hepatocyte apoptosis, and fibrosis. TLR4 could be activated by various signals; in the context of NASH dysregulation of gut microbial homeostasis, gut leakiness and consequent increase in bacteria-derived lipopolysaccharide (LPS) seem to play a major role. Activation of TLR4 involves adapter proteins including MyD88-adaptor-like and TRIF-related adaptor molecule (TRAM) recruiting Myd88 and TRIF, respectively, and ultimately leading to the activation of nuclear factor kappa B and/or interferon-regulatory factor 3 (IRF3).