What is Fatty Liver?
“Non-alcoholic Fatty Liver Disease,” or NAFLD for short, also known as “Fatty Liver,” is a liver condition where fat cells build up in the liver without any inflammation present (a process called steatosis), and signs of inflammation occur without any significant drinking of alcohol. NAFLD can fall into two categories: Non-Alcoholic Fatty Liver (NAFL) and Non-Alcoholic Steatohepatitis (NASH).
NAFL is when there’s a build-up of fat in your liver but without any evidence of liver cell damage or inflammation. On the other hand, NASH is when there’s not only fat build-up in your liver but also inflammation and liver cell damage, which can lead to scar tissue in the liver. This process can occasionally include mixed types of inflammatory cells seen in areas near the small veins in the liver.
It’s essential to understand that NAFLD is a range of conditions, with NAFL being the less severe type and NASH and cirrhosis (severe scarring and poor function of the liver) being the more severe types. The only way to distinguish between NAFL and NASH is by examining a liver tissue sample under a microscope, usually obtained through a liver biopsy.
It’s worth noting that NAFLD is often associated with Metabolic Syndrome (a group of conditions that include high blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol levels), obesity, diabetes, and high levels of fats in the blood. Almost 80% of people with Metabolic Syndrome also have NAFLD.
What Causes Fatty Liver?
Fat can build up in the liver for several reasons. The most common of these involve either too many free fatty acids (a type of fat) arriving at the liver, the liver making too many fatty acids, the liver not breaking down these acids as it should, or an interruption in how the liver creates or releases a type of fat called very-low-density lipoprotein.
Stress from oxidation, which happens when molecules in the liver lose electrons, can activate certain cells and lead to the creation of collagen (a protein that helps in healing and provides structure to tissues) and inflammation (swelling). There are also other factors that may contribute to a fatty liver:
- Use of certain medications, like tamoxifen, amiodarone, methotrexate
- Metabolic abnormalities, such as glycogen storage disorders or homocystinuria (rare genetic disorders that affect how the body processes certain substances)
- Alcohol consumption
- Nutritional status, such as receiving nutrition directly into the bloodstream (total parenteral nutrition), severe malnutrition, overnutrition, or starvation diets
- Other health issues like Wilson’s disease (a rare inherited disease that affects copper metabolism in the body) and celiac sprue (a digestive disorder caused by an immune reaction to gluten)
Risk Factors and Frequency for Fatty Liver
Non-alcoholic fatty liver disease, or NAFLD, affects different populations at varying rates. In the United States, about 20% of people have this condition, but globally the figures range from 11.5% to 46%. Non-alcoholic steatohepatitis, or NASH, a more severe form of the disease, affects around 2% to 3% of people. The disease is more prevalent in white men than white women, but the rates are similar among Hispanic and African-American people. Most people are diagnosed around the age of 50, but it can occur at any age between 16 and 80.
- NAFLD is more common in Hispanics than in Whites, and in Whites than in Blacks.
- Obesity is a major risk factor for NAFLD.
- Among those undergoing weight loss surgery, up to 90% may have NAFLD, and some may even have cirrhosis, a serious liver disease.
- Insulin resistance, a condition where the body does not use insulin effectively, is the main predictor for NASH.
Signs and Symptoms of Fatty Liver
“Fatty liver” condition often doesn’t cause symptoms. It’s typically discovered accidentally during imaging tests done for other health issues. If symptoms do develop, they tend to be nonspecific, like general discomfort or a sense of unease in the right upper region of your abdomen. Doctors usually ask patients about their alcohol use, past medical history, family history, current and past medications, and any over-the-counter drugs or supplements they’re taking. They also inquire about your diet, physical activity, any significant weight changes (like gaining over 18 kg in 2-3 years), and check for related conditions like obesity, high cholesterol, and diabetes.
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Testing for Fatty Liver
Laboratory tests might not be able to tell the difference between Non-alcoholic Steatohepatitis (NASH) and Non-alcoholic Fatty Liver Disease (NAFLD), but they’re still important in the initial evaluation. Your doctor might order a complete liver panel, a lipid panel, and an iron test. They may also run tests to check for insulin resistance, which is when your body doesn’t respond properly to the insulin hormone. Normal results for these tests are usually under 3.99. Additional tests may also be done to rule out conditions like viral hepatitis and Hemochromatosis, a condition that leads to too much iron in the body for example.
If you have a history of high liver enzyme levels or a family history of cirrhosis, a disease that scars your liver, some specific tests might be needed. These include the antinuclear antibody test, smooth muscle antibody test, the a1-antitrypsin test, ceruloplasmin test, and the thyroid-stimulating hormone level test.
Patients with alcoholic liver disease may or may not have high levels of certain liver enzymes, called serum aminotransferase levels. The level of these liver enzymes doesn’t show the severity of the alcoholic liver disease but they can help to diagnose it. In a case of alcoholic liver damage, it’s typical for the AST liver enzyme level to be 2 to 3 times higher than the ALT liver enzyme level. People with alcoholic liver disease also tend to have high gamma-glutamyltranspeptidase levels, another kind of liver enzyme.
Imaging tests play an essential role in diagnosing NAFLD, with the most common being an ultrasound. This test is straightforward, fairly inexpensive, and helps detect NAFLD 60% to 90% of the time with about 90% accuracy. Other options include an unenhanced abdominal Computed Tomography (CT) or magnetic resonance imaging (MRI). Although, these can be more expensive and not necessarily superior to an ultrasound.
A liver biopsy, which involves taking a small sample of liver tissue for testing, is needed to diagnose NASH. However, not all patients with NAFLD require a liver biopsy. The decision to do this more invasive and costly test depends on factors like risk level, laboratory workup results, and disease severity. According to the 2012 guidelines from the American Association for the Study of Liver Disease, a liver biopsy should only be done on patients who can benefit from the results, for patients when other diagnoses are possible and for children whose diagnosis isn’t clear or for whom medication is being considered.
Treatment Options for Fatty Liver
The main approach to treating obesity-related diseases involves lifestyle changes and losing weight. For individuals with substantial obesity, weight-loss surgery, such as a gastric bypass, may be a consideration. Evidence has shown that losing weight can help reduce fat in the liver. It’s believed that losing 3% to 5% of one’s weight can help improve liver steatosis (fat accumulation in the liver), but greater weight loss (up to 10%) is needed to improve liver inflammation.
Patients should avoid alcohol and medicines that can harm the liver. There are also medications that can help, such as Metformin, Vitamin E, fish oil, Orlistat (which helps block fat digestion), and Sibutramine. However, the evidence supporting these treatment options is not very strong, and some treatments have been found to be unsupported in the absence of diabetes in patients with nonalcoholic fatty liver disease.
For example, studies have found that Metformin, a medication for diabetes, does not significantly affect liver health, so it’s typically only suggested if there are other health reasons to use it. Vitamin E is currently only suggested for patients with non-diabetic with a specific type of fat-related liver disease (NASH) confirmed by a biopsy. Another medication, Pioglitazone, can be used to treat patients with proven steatohepatitis (a kind of fatty liver disease), but the long-term implications of this are unknown.
Some research found improvements in liver enzyme levels with the use of vitamin E and Pioglitazone for nonalcoholic steatohepatitis, but didn’t see an improvement in liver scarring (fibrosis). For patients with severe disease and cirrhosis, a liver transplant may have to be considered.
What else can Fatty Liver be?
If a person has a fatty liver, it might be caused by several different diseases or conditions. These may include:
- Viral Hepatitis
- Alcoholic hepatitis
- Alpha1 Antitrypsin Deficiency
- Primary sclerosing cholangitis
- Wilson disease
- Primary biliary cholangitis
- Cirrhosis
What to expect with Fatty Liver
Patients who have Non-alcoholic fatty liver disease (NAFL), a condition where fat builds up in the liver of individuals who drink little to no alcohol, tend to have healthcare costs that are 26% higher over a period of five years.
Possible Complications When Diagnosed with Fatty Liver
Possible complications of having a fatty liver include:
- Cirrhosis, where the liver becomes heavily scarred
- Ascites, which is abnormal fluid build-up in the abdomen
- Esophageal varices, which are enlarged veins in the esophagus
- Liver failure, where the liver stops functioning properly
- Liver cancer
- Type 2 diabetes, a chronic condition affecting the body’s ability to use sugar
Recovery from Fatty Liver
After surgery or during the period of recovery for fatty liver disease, there are some important steps that should be taken:
Patients should be tested for other conditions that can damage the liver, such as hepatitis B. If they haven’t been vaccinated against hepatitis B, they should consider doing so.
Medications that can harm the liver should be stopped. It’s important to discuss this with your doctor to ensure it’s safe to stop these medications.
The progression of the disease will be closely watched for symptoms that may indicate the liver isn’t working as well as it should. These signs may include fluid build-up in the abdomen (ascites), redness of the palms (palmar erythema), lower than normal levels of a protein called albumin, and higher than normal levels of a test called INR which measures how fast your blood clots.
Regular blood tests may be done to check the level of alcohol in the blood. This helps to confirm that the patient is abstaining from alcohol, as alcohol can worsen liver disease.
Patients with very severe liver disease should be checked for liver cancer and gastroesophageal varices. Varices are enlarged veins in the esophagus (the tube that connects the mouth and stomach) that can lead to bleeding.
Preventing Fatty Liver
When it comes to fatty liver, there are certain things that patients should keep in mind and actions they can take to manage the condition:
* It’s recommended that patients avoid alcohol. Since alcohol can contribute to liver damage, refraining from it can help protect the liver.
* Maintaining a balanced diet is crucial, as malnutrition is commonly observed in patients with fatty liver. Consulting a dietitian could provide beneficial dietary advice. A diet low in fats, combined with weight loss, is typically suggested.
* Regular physical exercise can be very beneficial. It’s highly suggested that patients participate in an ongoing exercise program, as this can help reduce the fat in the liver and improve overall health.