Non-Alcoholic Fatty Liver Disease

Question 1

Definition

Answer 1

Excess fat accumulation in the liver (steatosis) in the absence of excess alcohol consumption (<20g per day women, 30g men)

Question 2

Epidemiology

Answer 2

Ethnicity: Hispanic and Asian people, lower in black people
Diabetics

Question 3

Metabolic Risk factors

Answer 3

Central obesity > 90% of patients with a BMI > 30kg/m2
Impaired glucose regulation or type 2 diabetes
Hypertension
Hyperlipidaemia

Question 4

Non-metabolic risk factors

Answer 4

Obstructive sleep apnoea
Endocrine disorders: PCOS, hypothyroidism
Family History
Nutritional: TPN, rapid weight loss, jejunoileal bypass surgery
Drugs: NSAIDS, amiodarone, corticosteroids, diltiazem, methotrexate, tamoxifen

Question 5

Pathophysiology

Answer 5

Hepatocyte Insulin resistance
Increased fat storage + decreases fatty acid oxidation = STEATOSIS
Liver is large, yellow, fat and greasy
Double bond in fat vulnerable to degradation by free radicals
Fatty acid radical and water = react with non-radicals (e.g. O2,other fatty acids) = damages cell membranes = cell death = inflammation + neutrophil infiltration = non alcoholic steatohepatitis (NASH)
Over time stellate cells to lay down fibrous tissue = fibrous -> cirrhosis

Question 6

Stages of NAFLD

Answer 6

1. Hepatic steatosis
2. Non-alcoholic steatohepatitis (NASH)
3. Fibrosis and cirrhosis

Question 7

Signs

Answer 7

Hand signs:
- Palmer erythema
- Dupuytren’s contracture
Jaundice
Ascites
Spider Naevi
Confusion and asterixis
Caput medusae
Haematemesis
Hepatosplenomegaly
Raised BMI

Question 8

Symptoms

Answer 8

Non specific:
- Malaise
- Weakness
- Weight loss
Abdominal discomfort: RUQ
Pruritus
Easy bruising

Question 9

Diagnosis

Answer 9

FIRST LINE = abdominal USS abdomen
GOLD STANDARD = LIVER BIOPSY (avoid unless absolutely necessary)
LFTs: Raised bilirubin, ALT, AST (raised ALT:AST ratio), low albumin
Lipid panel: high cholesterol, LDL, HDL
FBC = thrombocytopaenia, hyperglycaemia

Question 10

Treatment

Answer 10

FIRST LINE = Diet and exercise
- Weight loss
- Reduced calorie intake (statins, metformin, ACE-i)
- ORLISTAT = fat from GI tract
- Vit E = antioxidant clears up free radical
END STAGE = LIVER TRANSPLANT

Question 11

Scoring

Answer 11

Non invasive tool to assess the level of fibrosis, such as Fibrosis-4 (FIB-4) or NAFLD Fibrosis score. Patients with low score can be managed in primary care
> 2.67 = advanced

Question 12

Complication

Answer 12

HE,
Ascites,
HCC,
Portal HTN,
Oesophageal varices