Fatty liver is nothing but deposition of excess fat in the liver cells. This deposition can be because of
- High carbohydrate diet
- Sedentary lifestyle
- Consumption of excess alcohol
- Drugs like steroids, hormonal contraceptives, chemotherapy and so on.
- Rare genetic causes
Fatty liver is the liver manifestation of metabolic syndrome. It is a pre-diabetes state. There is enough data suggesting early identification and if necessary, treatment of ongoing liver damage due to fatty liver, reduces insulin resistance which precipitates the onset of diabetes.
Since India is diabetic capital of the world, fatty liver is found in up to 40% of general population. It is a growing health hazard.
Simple deposition of fat in liver – steatosis – in 70-80% patients
Fat with inflammation in liver – steatohepatitis – in 20-30% patients
Ongoing damage in liver leading to cirrhosis – 5 – 10% patients
NAFLD risk is increased in:
- Persons with diabetes
- Family history of diabetes / hypertension / cardiac problems
- Obese persons associated with increased abdominal fat, poor ability to use insulin, high blood pressure and high blood levels of triglycerides
- Cancer patients undergoing chemotherapy
- Persons on long term steroid treatment
- Exposure to toxins
- Underactive thyroid gland (hypothyroidism)
- Underactive pituitary gland (hypopituitarism)
- Simple Steatosis
- No specific symptoms
- Usually detected on general check-up
Steato – Hepatitis
- Loss of appetite
- Pain in the upper right abdomen due to enlargement of the liver
- Increased acidity and abdominal bloating
- Compensated state (well preserved liver functions but structurally damaged)
- Dark pigmentation of skin
- Decompensated state (poor functions of the liver)
- Yellowing of the skin with increased itchiness and yellow tinge to the eyes (jaundice)
- Abdominal swelling (ascites) along with leg swelling
- Enlarged blood vessels just beneath the skin’s surface (spider naevi)
- Reddish palms
- Routine complete blood count (CBC)
- Prothrombin time (PT) and international normalized ratio or INR
- PT and INR are a measure of the function of certain proteins called clotting factors that normally are produced in the liver
- A high prothrombin time can be a sign of liver damage.
- Liver function test or liver panel:
- Increased liver enzymes
- Aspartate aminotransferase (AST or SGOT) and alanine aminotransferase (ALT or SGPT) levels are suggestive of liver damage, and not indicative only of fatty liver disease. However, typically raised ALT and AST is found in fatty liver disease and ALT level is more specific to the liver damage than the AST level because the AST value may also be high if there is muscle damage elsewhere in the body. Monitoring levels of these enzymes is essential to assess the level of liver damage
- Alkaline phosphatase (ALP) and y-Glutamyltransferase (GGT) levels are increased in fatty liver disease due to bile duct damage. Increase in GGT levels are also increased in ALD rather than in NAFLD
- Liver protein tests
- Albumin levels may decrease if the liver is damaged
- Low globulin levels can be a sign of liver damage
- Test for bilirubinlevel – An increase in bilirubin level manifests as jaundice, characterised by a yellowing of the eyes and skin in liver disease
- Liver protein tests
- Tests to rule out chronic viral hepatitis (hepatitis B, hepatitis C)
- Fasting blood sugar and hemoglobin A1C to test blood sugar levels
- Lipid profile, a measure of blood fats, cholesterols and triglycerides
- Thyroid function test
- 2D Echo
- If required, TMT
- Ultrasound abdomen can detect and grade the fatty liver. It is also useful to detect gallstones as it is a common association with fatty liver.
- Transient elastography (Fibroscan) is a test that measures the fat content along with any ongoing damage in the liver non-invasively. It is an excellent modality to quantify the damage at baseline and then assess periodically for improvement on treatment during follow-up.
- The basic foundation of treatment and prevention of fatty liver and its complications is diet and lifestyle modification. Due to westernization of our food habits with more carbohydrates and junk food, we are prone for fatty liver
- A strict low carbohydrate diet should be followed with regular physical activity. Small frequent meals is better than binge eating after long periods of fasting.
- Ideally, a loss of 10% body weight is desirable
- Avoiding alcohol intake or drinking alcohol in moderation
- Vaccinating against hepatitis A and hepatitis B protects against the viruses that may cause liver damage
- Checking random blood sugar levels regularly (after 40 years of age and earlier in those with a family history of diabetes)
- Taking medicines only prescribed by a doctor and following dosing recommendations
Tests are done to rule out other etiologies which can present as fatty liver or other causes which can also cause liver damage. Liver biopsy is the gold standard test to diagnose fatty liver damage but rarely required due to presence of gamut of non-invasive tests.
As discussed previously, patients with fatty liver are prone for cardiovascular disease in form of thickening and clotting of coronary blood vessels which can predispose to cardiac events. Hence it is of extreme importance to assess cardiovascular status as part of evaluation of fatty liver.
Late consequences of end stage liver cirrhosis presenting with complications such as deepening jaundice, abdominal swelling, bleeding, altered behavior with confusion and increased daytime sleepiness, liver cancer until a particular stage will be an indication for liver transplant as a long term definitive option.
Specialist management by a liver specialist should be undertaken whenever there is a suspicion of liver damage at initial assessment or at any time during monitoring. Severe fibrosis or cirrhosis may require health services that have the provision to provide a liver transplant.