• Fatty Liver
• Diagnosis
• Treatment

Yellow appearance of a liver with excess fat

What is fatty liver?

• Answer : simply what the name suggests - too much fat in the liver!

• Some important facts:
  • Fatty liver is the accumulation of fat (mainly as triglycerides) within liver cells.
  • This happens when the fat coming into the liver is more than the fat going out (the liver makes and secretes fat).
  • This condition is becoming more common.
    • It is the commonest cause of abnormal liver enzyme tests(blood tests for the liver).
    • This is because fat in the liver may cause some inflammation.

• Excess alcohol intake may be the main underlying cause.
  • How much is too much?
    • Refer to section on alcohol and liver.

• There are an increasing number of people with fatty liver that is NOT caused by alcohol.
  • This condition has an association with:
    • Being overweight.
    • Having diabetes.
    • Having raised cholesterol or raised triglyceride levels in the blood.

• The underlying problem is considered to be "insulin resistance.
  • This means that the body is not responding normally to the insulin hormone.
  • This problem directly relates to the amount of fat tissue in the body.
  • Fatty tissue is not inert.
    • It secretes a range of hormones that control the body's metabolism.
  • Insulin resistance promotes increased rate of delivery of fat to the liver from the tissues.
  • Insulin resistance(and therefore fatty liver) is;
    • primarily determined by body weight.
    • and also the level of physical activity.

• Fatty liver is more common some ethnic groups.
  • That is, for a given weight there is more fatty liver in some groups.
    • It is more common with Indian and Chinese compared with European groups.
    • It is also more common in Pacific Islanders.

• About 10% of people with excess fat in the liver will develop inflammatory in the liver.
  • The medical term is called steatohepatitis.
  • This sometimes abbreviated as NASH - non-alcohol steatohepatitis.
  • Another abbreviation is NAFLD (non-alcoholic fatty liver disease).

• This inflammatory process, if sustained over a long period of time, can lead to significant liver fibrosis and eventually to cirrhosis (severe liver damage).
  • The risk is low (compared to other causes of liver disease).
  • Overall only 2% will progress to cirrhosis.

Abdominal fat is the main risk factor for fatty liver. The important test is the waist meaurement!! This should be less than 100cms for men.

• There are two main ways in which the diagnosis can come to light!
  • As a result of investigation of abnormal liver tests.
  • OR incidental finding at ultrasound performed for other reasons (e.g investigation of right–sided abdominal discomfort).

• Fatty liver is thought to cause no symptoms but fatigue and ill-defined discomfort in the right upper abdomen may be present (probably not a direct effect of the condition). The liver is usually of normal size.

• Fatty liver should be suspected if there are risk factors. They are :
  • Being overweight (BMI more than 30 - weight in kgs divided by height in metres²(squared).
  • High blood lipids or fats (raised blood cholesterol and/or trigylcerides).
  • Diabetes mellitus(or raised blood glucose but not quite diabetes - called impaired glucose tolerance).
  • Other features of the metabolic syndrome are;
    • Hypertension.
    • Increased waist circumference(100cms for men).
  • There is an association with polycystic ovary syndrome – this condition is also considered to be due to insulin resistance.
  • Excess alcohol intake.
    • Even 5-10 drinks per week may be significant if combined with other risk factors.

• Fatty liver can occur without any risk factors.

• Ultrasound is reasonably sensitive for detecting fatty liver.
  • This picks up 2/3 rds of cases - liver is echogenic or bright on ultrasound<.
  • Ultrasound is a useful screening test.
  • Fatty liver may be the cause of abnormal liver tests even if the ultrasound is normal.
  • Occasionally CT scan is required.

• The role of liver biopsy is controversial. There are some risks but also some potentially useful information will be obtained.
  • A liver biopsy may provide information about disease severity and some estimation of the future risk of serious liver disease.
    • If there is significant inflammation (steatohepatitis) then about 10-20% of people may eventually progress to cirrhosis.
    • If there is fat but no inflammation then there are rarely any problems with serious liver disease in the future (no progression to cirrhosis).

• It is common to have a raised serum ferritin with fatty liver.
  • This can cause confusion as ferritin is also elevated with haemochromatosis, a condition where there is an overload of iron in the body.

• The risk of progression to cirrhosis is higher if the fatty liver is caused by alcohol.
  • Particularly if alcohol intake is continued (at the same level of consumption).

• The decision to proceed to liver biopsy needs to be individualized.
  • Most of time it is better to wait for 6–12 months to see if the measures discussed below will lead to a reduction in the elevated liver enzyme tests.

• The treatment is simply weight loss.
  • Weight loss by liposuction or surgical removal of abdominal fat (apronectomy) does not work!!!
  • There is no shortcut - reduction in calorie intake is the only way.

• Risk factors should be reduced.
  • Diabetes tablet treatment may need to be started or increased.
  • Medication for raised cholesterol (Lipex) and trigycerides (Bezalip) may need to be started.
  • Alcohol intake must be reduced.
    • It is better to stop completely.
    • A possible safe limit is 2-3 standard drinks per week.

• Exercise is crucial to success.
  • Exercise has an important role in the treatment of fatty liver because it reduces insulin resistance – which is the underlying problem.
  • i.e the effect of exercise is not just mediated through weight loss.
  • This needs to be daily activity with a plan for gradual increase in activity levels.
  • Excercise needs to be aerobic.
    • This means "huffing and puffing" for more 30 mins three times a week!!
    • Weight training will not be helpful (not harmful either).

• Weight loss should be gradual.
  • About ½ kg per 1-2 weeks is ideal.
  • Rapid weight loss can aggravate fatty liver.
  • Slower rates of weight loss are more likely to be the norm.
    • A gradual and sustainable change in lifestyle is the goal.
  • Modest weight loss (less than 5%) can have a significant effect if combined with regular exercise.
    • But a 5-10% weight loss should be the goal.
  • There is no special diet.
    • This is no evidence to support specific claims of the "liver cleansing diet".
    • A reduction in fat intake and reduction in alcohol intake are going to be essential changes to achieve enough calorie reduction to lead to weight loss.
  • The "low carb" diet is probably detrimental in the longer term.
    • The impressive weight loss that can be achieved in the the first 6 months is not usually maintained.
  • Attention to the glycaemic index of foods could be important but as yet is not supported by any evidence.
    • Low glycaemic foods may be better.
  • Essentially the process is completely reversible with weight loss and special diets are not required.
  • Realistic goal setting and regular follow-up with your doctor helps.

• Weight – reduction surgerycould be considered in severe cases.
  • Gastric banding or gastric bypass has some proven efficacy for severe cases.
  • Weight loss after gastric bypass may be 40-50% of initial weight.
  • However this comes at a price.
    • There are post-operative problems and a risk of death (approx 1%).
    • There may be abdominal pain after meals.
    • Nutrient deficiencies can be a problem after several years.

• Other medications.
  • Metformin reduces insulin resistance and may be helpful but still limited information.
  • Antioxidants such as vitamin E may have a role.
  • Medications for diabetes and cholesterol (as discussed above).