Non-Alcoholic Fatty Liver Disease

One of the most common reasons for referral to a Gastroenterologist is abnormal blood tests of the liver, and the most common cause for this in the US is a fatty liver. Although alcohol and occasionally medicines can cause this damage, the most common cause is Non-Alcohol Fatty Liver Disease or NAFLD. Some doctors use “hepatic steatosis” to describe this, but it means the same thing.

What is it?

NAFLD occurs when the liver stores up fat in the working cells of the liver, called hepatocytes. This isn’t healthy for those cells, and it can damage them. If they are damaged, they may leak enzymes, which your doctor can measure in your blood. Some of the liver tests that your primary care provider may check routinely are enzymes released in small amounts naturally from the liver cells. Examples are AST and ALT. If the cells are damaged and leaking more enzymes, those blood test results become elevated. Sometimes, the immune system even becomes involved, causing a smaller number of people to develop a more serious condition called Non-Alcoholic Steatohepatitis, or NASH.

Who gets it?

We don’t know exactly why it happens. It is strongly associated with some risk factors:

• Being overweight
• Having Type 2 Diabetes
• Having high cholesterol
• Having high blood pressure

Sometimes, these risk factors are known as “metabolic syndrome.” Many American adults, even young adults, have some or all of these risk factors. Many of these people will develop NAFLD or even NASH. Occasionally, people with none of these risk factors may even develop NAFLD or NASH.

How is it diagnosed?

Usually, it starts with a doctor noticing abnormal blood tests of the liver that don’t return to normal right away. Sometimes, a fatty liver is noticed during evaluation for other problems, gallbladder disease. Most of the time, noninvasive tests like blood tests and ultrasound or MRI can make the diagnosis and tell you and your doctor how serious the issue is. Occasionally, a Gastroenterologist may recommend a liver biopsy if the doctor is uncertain about the diagnosis or is concerned that another liver problem may be present at the same time. Currently, a liver biopsy is the only way to diagnose NASH.

What does it do?

Often, it does nothing. Simply having fat in the liver typically causes no symptoms, and it may have been present for years before it is found. Although it’s sometimes found while investigating abdominal pain, it is rarely the cause of any significant pain. Most people with NAFLD will never develop a dangerous liver problem. However, a small number of people with NAFLD and a larger number of people with NASH will develop severe scarring of the liver, called cirrhosis. That higher risk of developing cirrhosis is what makes NASH more serious. If cirrhosis develops, a person might have fatigue, yellow skin and eyes, internal bleeding, swelling, and confusion. A person with cirrhosis can even die from this, even if they never drink alcohol.  Sometimes, people with cirrhosis have to get a liver transplant.

How can it be treated?

As of today, there is no specific treatment. Many studies are currently working on medicines to treat NAFLD. In the meantime, there are several lifestyle changes that a person can make to help their liver if they have NAFLD or NASH:

• If you are overweight, work on 5-10% weight loss
• Eat a diet high in fiber and protein, low in fats, sugars, and starches
• Exercise regularly
• If you have diabetes, high blood pressure, or high cholesterol, treat them
• Don’t drink alcohol
• If you smoke, stop smoking

Make sure you list a fatty liver with any other chronic health problems so that your doctors are aware. Be careful with new medicines, over-the-counter medicines, and especially herbal products. If you have a question about the safety of a medicine, ask your Gastroenterologist.

How is it monitored?

In patients with NAFLD or NASH, I recommend a yearly check-up with your primary care provider or Gastroenterologist. I obtain yearly blood tests of the liver, which include a complete blood count, liver panel, and blood clotting test. I ask questions about any symptoms and perform an exam to look for signs of worsening liver disease. Periodically, I may order a special type of ultrasound that measures the stiffness of the liver to estimate the amount of scar tissue. All of this allows me to monitor how the liver is doing, remain in tune with my patients’ other health concerns that may impact the liver, and teach my patients about the latest knowledge.