Fatty Liver Disease
Presented by Meditalk — your health our priority
Definition:
Fatty liver disease (FLD), also known as hepatic steatosis, is a condition where excess fat builds up in the liver. It is commonly categorized into two types: Non-Alcoholic Fatty Liver Disease (NAFLD) and Alcoholic Fatty Liver Disease (AFLD).
Classification:
- Non-Alcoholic Fatty Liver Disease (NAFLD): Fat accumulation without significant alcohol use.
- Non-Alcoholic Steatohepatitis (NASH): A severe form of NAFLD with inflammation and liver cell damage.
- Alcoholic Fatty Liver Disease (AFLD): Caused by chronic alcohol intake.
Etiology (Causes):
- Obesity
- Type 2 Diabetes Mellitus
- Dyslipidemia (high triglycerides and LDL)
- Metabolic Syndrome
- Chronic alcohol consumption
- Medications (e.g., corticosteroids, methotrexate)
- Genetic predisposition
Pathophysiology:
Fat accumulation in hepatocytes results from an imbalance between lipid acquisition and removal. In NAFLD, insulin resistance promotes free fatty acid influx to the liver, leading to steatosis, oxidative stress, and inflammation (as in NASH), which can progress to fibrosis, cirrhosis, and hepatocellular carcinoma.
Clinical Features:
- Most patients are asymptomatic
- Fatigue
- Mild right upper quadrant discomfort
- Hepatomegaly (on examination)
- In advanced disease: signs of liver dysfunction or cirrhosis
Investigations:
- Liver Function Tests (LFTs): Mild elevation in ALT > AST in NAFLD; reversed in AFLD
- Ultrasound: Bright liver, increased echogenicity
- Fibroscan: Non-invasive assessment of liver fibrosis
- MRI or CT: Quantify fat content
- Liver biopsy: Gold standard to differentiate NAFLD from NASH and assess fibrosis
Management:
Non-Pharmacologic:
- Weight loss (target 7–10% loss of body weight)
- Regular exercise (aerobic + resistance training)
- Diet: low-carb, Mediterranean-style, reduced saturated fat
- Avoid alcohol and hepatotoxic drugs
Pharmacologic: (only in select cases)
- Vitamin E (800 IU/day) in non-diabetic NASH
- Pioglitazone in biopsy-proven NASH with diabetes
- GLP-1 agonists (e.g., liraglutide) for obese diabetics
- Statins (for dyslipidemia; safe in NAFLD)
Complications:
- Progression to cirrhosis
- Hepatocellular carcinoma
- Portal hypertension
- Liver failure
- Cardiovascular disease (leading cause of death in NAFLD)
Follow-Up and Monitoring:
- Regular LFTs and imaging
- Assess metabolic risk factors (HbA1c, lipid profile, BMI)
- Screen for cirrhosis complications in advanced cases
Prognosis:
NAFLD is reversible with lifestyle changes. NASH may progress to cirrhosis and cancer if untreated. Early identification and intervention are key.
Clinical Pearls:
- ALT is typically greater than AST in NAFLD (opposite in AFLD)
- Consider liver biopsy when diagnosis is uncertain or when fibrosis assessment is essential
- All patients with NAFLD should be screened for cardiovascular risk factors
Key References:
- Harrison's Principles of Internal Medicine
- Davidson's Principles and Practice of Medicine
- AASLD Guidelines 2023 for NAFLD/NASH
- Recent studies: NEJM, Hepatology Journal
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