Burden of Fatty Liver Disease
Fatty liver disease is a “hot” topic because it is common and carries the potential to cause serious liver disease. It has received much attention in recent years from liver disease specialists, diabetes and heart specialists because it is the most common liver disorder worldwide affecting 10 to 20 percent of the general population and is the most common cause of liver test abnormalities.
What is fatty liver?
Fatty liver is a result of excessive accumulation of fat causing enlargement of the liver. It can be caused by drinking too much alcoholic beverages or by certain medications. In the absence of significant alcohol consumption, it is commonly associated with the “metabolic syndrome” and is called Nonalcoholic Fatty Liver Disease or NAFLD.
Am I at risk to develop fatty liver?
The typical patient with fatty liver is most likely Caucasian, overweight if not obese. However, we are increasingly seeing patients outside of this typical profile. Not only is fatty liver seen in the Western world, more and more Asians are now having fatty liver disease. In fact, the epidemic of fatty liver has now arrived in Asia particularly because we are increasingly adopting the Western way of life and the Western way of eating and drinking alcohol. NAFLD is so common that we see it equally in males and females, not only in adults but also among children, in obese Westerners and lean Asians.
Why is fatty liver common in diabetics?
All diabetics need to know about NAFLD because of its significant association with the “metabolic syndrome”. Diabetes, high blood pressure, high cholesterol and being overweight make up this syndrome. It is believed that NAFLD is the expression of the metabolic syndrome in the liver. Ninety percent of those who have NAFLD also have components of the metabolic syndrome while 85 percent of those with the metabolic syndrome have NAFLD.
As physicians, we now realize how likely we are to see a patient with fatty liver in our everyday clinical practice. The next question is – do we really need to worry about fatty liver? Fortunately for us, serious liver disease only happens in approximately 10 to 20 percent of individuals who eventually develop NASH which is fatty liver with inflammation or steatohepatitis. This condition can progress to liver fibrosis or scarring, ending up in liver cirrhosis with all its adverse consequences of liver failure.
How do we diagnose fatty liver?
The distinction between fatty liver associated with alcohol intake and fatty liver which is truly nonalcoholic in nature is important. It is not uncommon for people to deny significant alcohol drinking when being asked by their physicians. The distinction lies in the AST (alanine aminotransferase) and ALT (aspartate aminotransferase) ratio. In alcohol related fatty liver, there is a greater elevation of the AST relative to the ALT, whereas in NAFLD the opposite is true.
The diagnosis of nonalcoholic fatty liver disease (NAFLD) is made by exclusion of significant alcohol intake, viral hepatitis and drug-induced liver injury as the cause of liver disease and findings of fatty liver on ultrasound. Common findings on laboratory examination are a two to four-fold elevation of the ALT and AST, elevated glucose, lipids and serum ferritin. However, these are nonspecific and rarely diagnostic. A liver biopsy confirms the diagnosis but is not required in all those suspected to have NAFLD because there are non-invasive methods used to support the diagnosis. As an initial step, we should be aware of the many other conditions giving rise to fatty liver. Table 1 lists the most common conditions and commonly prescribed medications causing fatty liver.
Can a liver ultrasound reliably predict the presence of fatty liver?
Fatty liver appears “bright” on ultrasound with a diffuse increase in echogenicity (ultrasound signal) relative to the kidney. However, the absence of these findings does not reliably confirm the absence of fatty liver because a liver ultrasound can only detect fat when >30 percent of liver cells are involved. A CT scan and an MRI is more accurate compared to an ultrasound, however with better detection comes increasing costs.
How do patients with fatty liver feel?
Most people with fatty liver are overweight and report no symptoms. Some will report symptoms which are largely non-specific ranging from fatigue, body malaise and vague abdominal discomfort. An enlarged liver is found in only 50 percent of individuals and stigmata of chronic liver disease are rare. Fatty liver is often discovered incidentally during a liver ultrasound or by the detection of an elevated ALT or AST on routine blood tests.
How will i know if i will develop complications to my liver?
Unfortunately, we cannot rely on the history, physical examination, laboratory tests and radiologic imaging to stage disease severity, evaluate prognosis and predict the presence of fibrosis or scarring. The finding of fatty liver on imaging for example does not give any information on how severely affected your liver is. Only a liver biopsy can tell you whether you have simple fat accumulation or steatosis alone, if you have fatty liver with inflammation or “steatohepatitis” (NASH) or whether your liver is developing fibrosis.
At the moment, only a liver biopsy can give you the information to stage liver disease in NAFLD in a reliable and accurate manner. Newer methods to detect the presence of fibrosis without a liver biopsy are currently available in Europe. However, their utility in clinical practice is still being investigated. Making the distinction between simple fat deposition and fat with inflammation and fibrosis is crucial in determining outcomes. Simple steatosis are benign lesions whereas steatohepatitis necessitate more aggressive intervention.
A reasonable goal is to identify patients who will benefit most from a liver biopsy. Individuals with fatty liver and the “metabolic syndrome” are at highest risk to develop complications particularly those above 50 years of age, with insulin resistance, persistently elevated ALT levels and an AST/ALT ratio greater than 1.
Can fatty liver be treated?
In the year 2007, only lifestyle modification, avoidance of excessive alcohol, good control of diabetes and hypertension have been proven to positively influence outcomes in fatty liver disease. Other than these, no single therapy has consistently been successful in reversing nonalcoholic fatty liver. Several medications have been tried such as metformin, vitamin E, thiazolidinediones and ursodeoxycholic acid with limited success and inconsistent results. Hepatic protectors such as silymarin and phospholipids have not yet been proven by well-designed studies to be of benefit in the treatment of fatty liver disease.
How can I prevent fatty liver?
Fatty liver can be prevented by avoiding excessive alcohol drinking, identification and adequate control of the metabolic factors associated with it. Good sugar, cholesterol and blood pressure control coupled with lifestyle change forms the cornerstone of prevention and treatment.
Lifestyle measures include a weight loss and exercise program. Rapid weight loss achieved through “crash” dieting or “fad” diets can actually worsen fat deposition in the liver. A reasonable goal would be to lose 10 percent of baseline weight within six months or a weight loss of 0.5-1 kg per week. Visceral fat or what we call “fat in our belly” needs to be burned and lost as this is significantly associated with worse outcomes. Increasing physical activity through aerobic exercise of at least 30 minutes three times per week and a low cholesterol diet is recommended. Use of statins for lipid control in patients with NAFLD is safe and frequent monitoring of liver tests are not routinely required.
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