NAFLD

Question 1

raised ALT - differentials

Answer 1

NAFLD
NASH
Alcoholic hepatitis (although AST > ALT)
Medication (paracetamol, sulphasalazine, amiodarone, flucloxacillin)
Autoimmune hepatitis
Viral hepatitis
Cirrhosis
Primary biliary cirrhosis
Haemochromatosis
Wilson’s disease
Alpha-1 antitrypsin deficiency

Question 2

NAFLD - definition

Answer 2

• spectrum of conditions characterised histologically by macrovesicular hepatic steatosis in those who do not consume alcohol in amounts generally considered harmful to the liver

Question 3

What is the spectrum of diseases in NAFLD?

Answer 3

spectrum of liver disease from benign NAFLD (reversible) to the more aggressive non-alcoholic steatohepatitis (NASH)

NAFLD - characterised by excess fatty infiltration of the hepatocytes

NASH – necro-inflammation with fibrosis, and has the potential to develop to cirrhosis or HCC

Question 4

NAFLD - pathophys

Answer 4

• strongly a/w insulin resistance
  1. ↑ intracellular fat storage + ↓ fatty acid oxidation
  2. low secretion of lipids to the blood and ↑ uptake by liver cells
  3. steatosis = fat droplets in hepatocytes push nuclei to the edge of the cells
  4. fatty acids + ROS damage hepatocytes
  5. inflammation = steatohepatitis (NASH) - presence of mallory denk bodies and neutrophils
  6. Chronic SH –> fibrosis

Question 5

NAFLD vs ALD

Answer 5

• For a diagnosis of NAFLD to be reached, max alcohol intake should be 14 units/week
• Predictors of ALD are
  1. macrocytosis
  2. a normal or reduced BMI
  3. AST:ALT ratio of greater than 2 (AST>ALT)

Question 6

NAFLD - risk factors

Answer 6

• age > 45 years
• metabolic syndrome (3 out of 5 of:)
  1. HTN
  2. hyperlipidaemia/ low serum HDL
  3. hypertriglyceridaemia
  4. DM (esp T2)
  5. abdominal obesity/ high BMI
• other: history of rapid weight loss, medications, and total parenteral nutrition

Question 7

NAFLD - clinical features

Answer 7

Often asymptomatic, incidental finding on LFTs.
Symptoms are vague:
- fatigue
- chronic malaise
- disturbed sleep
- abdominal pain (RUQ)
Signs:
- hepatosplenomegaly
- trunchal obesity
(other signs of chronic liver disease are less common but possible)

Question 8

NAFLD - investigations

Answer 8

• LFTs (↑↑ ALT, ↑AST, mildly elevated bili/GGT/ALP)
• FBC (might have anaemia due to hyposplenism)
• U+E (renal function might deteriorate)
• lipid profile (elevated total cholesterol, LDL, triglyceride, and low HDL)
• PT and INR
• serum albumin (might be low)
• Liver USS (abnormal echotexture- bright liver)
• Liver biopsy

Question 9

Which 3 things are important to monitor in NAFLD patients?

Answer 9

• BP
• glucose
• lipids/BMI

Question 10

NAFLD - management

Answer 10

• Weight loss > 5% of body mass by diet and increased physical activity can normalise liver biochemistry
• Control HTN, DM and lipids (consider statin)
• if morbidly obese, consider a gastric bypass