Non-alcoholic fatty liver disease (NAFLD)

Question 1

Define primary NAFLD.

Answer 1

Refers to excess fat (triglyceride) deposition and accumulation in the liver cells (steatosis), where triglycerides are present in more than 5% of hepatocytes, which is not the result of excessive alcohol consumption or other secondary causes

NAFLD does not cause problems initially, however it can progress to hepatitis and cirrhosis.

Question 2

What is secondary NAFLD?

Answer 2

May be caused by drug treatments such as amiodarone or tamoxifen, hepatitis C virus infection, and endocrine conditions such as polycystic ovary syndrome

Question 3

What are the 4 stages of NAFLD?

Answer 3

Stages:
1. Non-alcoholic Fatty Liver Disease
2. Non-Alcoholic Steatohepatitis (NASH)
3. Fibrosis
4. Cirrhosis

Question 4

Give 3 causes of non-alcoholic fatty liver disease.

Answer 4

1. Type 2 diabetes mellitus.
2. Hypertension.
3. Obesity.
4. Hyperlipidaemia.

Question 5

What is non alcoholic steatohepatitis (NASH)?

Answer 5

An advanced form of non-alcoholic fatty liver disease.

Question 6

What is the path of damage that NAFLD follows?

Answer 6

Healthy - steatosis - steatohepatitis - fibrosis - cirrhosis

Question 7

Give 3 risk factors for NAFLD.

Answer 7

NAFLD shares the same risk factors as for cardiovascular disease and diabetes.

• Obesity
• Poor diet and low activity levels
• Type 2 diabetes
• High cholesterol
• Middle age onwards
• Smoking
• High blood pressure

Question 8

Investigation for NAFLD 1: History taking

Answer 8

1. History taking
   - Risk factors
   - Any symptoms such as fatigue and RUQ abdominal pain
   - Alcohol intake
   - Any co-morbidities and drug history

Question 9

Investigation for NAFLD 2: Clinical examination

Answer 9

2. Clinical examination
   - Height and weight - BMI
   - Blood pressure
   - Assess for signs of advanced liver disease (such as jaundice, spider naevi, palmar erythema, ascites, hepatomegaly, splenomegaly, hepatic encephalopathy)

Question 10

Investigation for NAFLD 3: Blood tests

Answer 10

3. Blood tests
   ( To exclude co-existing liver disease)
   - LFTs: raised bilirubin, AST:ALT ratio, low albumin
   - FBC: unexplained low platelets
   - Clotting factors
   - Hep B + C viral serology - HBsAg and anti-HCV levels
   - Auto-antibodies: ASMA + ANA = AI hepatitis; AMA = PBC
   - Ferritin (screen for hereditary haemochromatosis)
   - RFTs (screen for CKD)
   - TFTs (screen for hypothyroidism)
   - A1A deficiency (If + Fx)
   - Serum caeruloplasmin (Wilson’s disease if <40 YO)
   - Lipid profile (screen for hyperlipidaemia)
   - HbA1c (screen for impaired glucose regulation or TIIDM)
   - tTGA test (screen for Coeliac disease)

Question 11

Investigation for NAFLD 4: Non-invasive scoring system

Answer 11

4. Non-invasive scoring system
   (assess the risk of advanced liver fibrosis)

(1) Enhanced Liver Fibrosis (ELF) test: first-line

(2) NAFLD Fibrosis Score (NFS): second-line

(3) Fibroscan: third-line
- Particular Ultrasound that measures liver stiffness to give an indication of fibrosis

(4) Fibrosis (FIB)-4 Score (FIB-4)

Question 12

Management for NAFLD.

Answer 12

1. Lifestyle modification advice
   - Diet
   - Physical activity
   - Regular exercise
   - Stop smoking
   - Encourage gradual sustained weight loss
2. Advise on drinking alcohol within national recommended limits
3. Ensure that associated conditions such as hypertension, hyperlipidaemia, and type 2 diabetes mellitus are optimally managed.

Question 13

When to refer a person with NAFLD?

Answer 13

Refer people with suspected or confirmed NAFLD to a hepatology specialist for further assessment and management if:

• The person is at high risk of advanced liver fibrosis.
• There are signs of advanced liver disease on examination.
• There is uncertainty about the diagnosis.