Non Alcoholic Fatty Liver Disease

Non alcholic fatty liver disease (NAFLD) forms part of the “metabolic syndrome” group of chronic health conditions relating to processing and storing energy that increase risk of heart disease, stroke and diabetes. It is estimated that up to 30% of adults have NAFLD. It is characterised by fat deposited in liver cells. These fat deposits can interfered with the functioning of the liver cells. NAFLD does not cause problems initially, however it can progress to hepatitis and cirrhosis.

Stages

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

 

Risk factors

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

 

Investigating Abnormal Liver Function Tests

Where someone presents with abnormal liver function tests without a clear cause then you will often be advised to perform a non-invasive liver screen. This is used to assess for possible underlying causes of liver pathology:

  • Ultrasound Liver
  • 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)

 

Autoantibodies

  • Antinuclear antibodies (ANA)
  • Smooth muscle antibodies (SMA)
  • Antimitochondrial antibodies (AMA)
  • Antibodies to liver kidney microsome type-1 (LKM-1)

 

Investigation in Non-Alcoholic Fatty Liver Disease

Liver Ultrasound can confirm the diagnosis of hepatic steatosis (fatty liver). It does not indicate the severity, the function of the liver or whether there is liver fibrosis.

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. It measures three markers (HA, PIIINP and TIMP-1) and uses an algorithm to provide a result that indicates the fibrosis of the liver:

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

NAFLD fibrosis score is the second line recommended assessment for liver fibrosis where the ELF test is not available. 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.

Fibroscan is the third line investigation. It involves a particular ultrasound that measures the stiffness of the liver and gives an indication of fibrosis. This is performed if the ELF blood test or NAFLD fibrosis score indicates fibrosis.

 

Management

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

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

 

Last updated January 2019
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