NAFLD (see DM)

Question 1

complications of NAFLD (2)

Answer 1

cirrhosis; hepatocellular carcinoma (HCC)

Question 2

what are the 2 types of NAFLD

Answer 2

1. NAFL - excess fat, doesn’t cause inflammation of scarring
2. NASH (non-alcoholic steato-hepatitis) - lobular inflammation, scar tissue and hepatocyte ballooning

Question 3

investigations for NAFLD (4)

Answer 3

1. ALT and GTT - raised
2. AST:ALT ratio - a ration <0.8 exludes advanced fibrosis
3. US - can detect steatosis (if >33% of hepatocytes are steatotic)
4. non-invasive screening
5. ferratin - marginally raised
6. liver biopsy - gold standard for staging

Question 4

scoring systems for NALFD (2)

Answer 4

1. NAFLD fibrosis score
2. Fib-4

Question 5

what is steatosis

Answer 5

a largely harmless build-up of fat in the liver cells

Question 6

steatosis vs steatohepatitis

Answer 6

steatosis - simple fatty liver;
steatohepatitis - a state of hepatocellular inflammation and damage in response to the accumulated fat (i.e. advanced stage fatty liver)

Question 7

what test can be used to distinguish liver firbrosis levels

Answer 7

elastography - measures shear wave (pulsed US) in liver, fibrotic tissue has reduced elasticity and so gives different signals compared to non fibrotic

Question 8

what is the gold standard test for NAFLD diagnosis and staging

Answer 8

liver biopsy

Question 9

simple steatosis histology appearance (3)

Answer 9

1. macrovesicular;
2. no inflammatory infiltrate;
3. perivenular pattern

Question 10

NASH histology appearance

Answer 10

1. fatty change
2. ballooned hepatoytes
3. mallory’s hyaline (irregular, ropelike eosinophilic intracytoplasmic strings that represent aggregates of cytokeratin intermediate filaments)
4. neutrophilic infiltrate

Question 11

what histological feature is more common in NAFLD vs alcoholic liver disease

Answer 11

nuclear vacuolation

Question 12

what gene is associated with increased NAFLD risk

Answer 12

PNPLA3 - codes for an adipose triglyceride lipase

Question 13

causes of liver steatosis

Answer 13

1. hep C
2. alcohol excess
3. genetic disorders (e.g. abetolipoprotienanemia, glycogen storage disease)
4. medications (e.g. amiodarone, mtx)
5. hypothyroidism
6. other (rarer causes e.g. wilson’s disease)

Question 14

what is the main cause for NAFLD

Answer 14

metabolic associated dysfunction -> liver insulin resistance, adipose insulin resistance etc.

Question 15

what are the 4 main components to NAFLD mgx

Answer 15

1. life style modification
2. targeting components of metabolic syndrome
3. liver directed pharmacotherapy
4. managing complications of cirrhosis

Question 16

how should lifestyle be modified in NAFLD mgx (4)

Answer 16

1. calorie restricted diet, avoid fats, simple carbs and sweetened drinks
2. increase exercise
3. advise weight loss
4. coffee - decreases the risk of liver cancer

Question 17

what are the (pharmaco)therapies for the liver in NAFLD mgx (3)

Answer 17

1. bariatric surgery (unless they hv portal hypertension/cirrhosis)
2. glitazones
3. vitamin E

Question 18

how should metabolic syndrome components be trageted in NAFLD mgx (3)

Answer 18

1. DM control - metformin, pioglitazone, GLP-1 analogues
2. HTN control - ACEi/ARB should be first line as it also haa anti-fibrotic effects
3. OSHA treatment

Question 19

treatment of complicated cirrhosis in NAFLD (4)

Answer 19

1. varices surveillance
2. HCC surveillance
3. osteoporosis mgx
4. liver transplantation