non alcoholic fatty liver disease

Question 1

what is the progression to non alcoholic fatty liver disease?

Answer 1

Insulin resistance is thought to contribute to the accumulation of excessive triglyceride in the liver and subsequent development of hepatic steatosis

Steatosis is thought to induce oxidative stress and mitochondrial dysfunction within the liver leading to a chronic hepatic inflammatory state and the development of NASH- nonalcoholic steatohepatitis

Liver healing in response to chronic inflammation results in liver fibrosis

The final stage of fibrosis is cirrhosis which is characterised by distorted hepatic architecture and regenerative nodules

Question 2

what are non metabolic risk factors for non alcoholic fatty liver disease?

Answer 2

Obstructive sleep apnoea

Endocrine disorders: polycystic ovary syndrome, hypothyroidism

Family history

Ethnicity: higher risk in Hispanic and Asian people, lower risk in black people

Nutritional: TPN, rapid weight loss, jejunoileal bypass surgery

Drugs: NSAIDs, amiodarone, corticosteroids, diltiazem, methotrexate, tamoxifen

Other liver conditions: hepatitis C, Wilson’s disease

Question 3

what are the complications of NAFLD?

Answer 3

Ascites: 60% of cirrhotic patients will develop ascites within 10 years
Variceal haemorrhage: 30% mortality rate
Hepatocellular carcinoma
Hepatic encephalopathy: 35-45% of cirrhotic patients
Hepatorenal syndrome
Hepatopulmonary syndrome
Death

Question 4

what is included in a non invasive liver screen (which is used when someone has abnormal LFTs without a clear cause)?

Answer 4

• Hepatitis B and C serology
• Autoantibodies (autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis)
• Immunoglobulins (autoimmune hepatitis and primary biliary cirrhosis)
• Caeruloplasmin (Wilsons disease)
• Alpha 1 Anti-trypsin levels (alpha 1 anti-trypsin deficiency)

Ferritin and Transferrin Saturation (hereditary haemochromatosis)

Question 5

which blood test is used specifically for non alcoholic fatty liver disease?

Answer 5

Enhanced Liver Fibrosis (ELF) blood test. This is the first line recommended investigation for assessing fibrosis but it is not currently available in many areas.

< 7.7 indicates none to mild fibrosis
≥ 7.7 to 9.8 indicates moderate fibrosis
≥ 9.8 indicates severe fibrosis

Question 6

what is the second line investigation of choice when EFL blood test is not available?

Answer 6

NAFLD fibrosis score is the second line

It is based on an algorithm of age, BMI, liver enzymes, platelets, albumin and diabetes and is helpful in ruling out fibrosis but not assessing the severity when present.

Question 7

what is the conservative management?

Answer 7

Weight loss
Exercise
Stop smoking
Control of diabetes, blood pressure and cholesterol
Avoid alcohol

Question 8

what are targeted therapies used?

Answer 8

efer patients with liver fibrosis to a liver specialist where they may treat with vitamin E or pioglitazone.