Non Alcoholic Fatty Liver Disease (NAFLD)

Question 1

Aetiology of NAFLD

Answer 1

Overweight or obesity. Insulin resistance, in which your cells don’t take up sugar in response to the hormone insulin. High blood sugar (hyperglycemia), indicating prediabetes or type 2 diabetes.

Question 2

Pathophysiology of NAFLD?

Answer 2

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 tohepatitis andcirrhosis.

4 stages:

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

Question 3

Risk factors of NAFLD?

Answer 3

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 4

Clinical presentation of NAFLD?

Answer 4

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

Question 5

Investigating abnormal liver function tests with unknown cause:

Answer 5

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

• Ultrasound Liver → picks up fatty changes
• Hepatitis B andCserology
• Autoantibodies (autoimmune hepatitis, primary biliary cirrhosisandprimary sclerosing cholangitis)
• Immunoglobulins (autoimmune hepatitisandprimary biliary cirrhosis)
• Caeruloplasmin (Wilsons disease)
• Alpha 1 Anti-trypsin levels (alpha 1 anti-trypsin deficiency)
• Ferritin and Transferrin Saturation (hereditary haemochromatosis)

Question 6

Investigating non-alcoholic fatty liver disease

Answer 6

Liver ultrasoundcan 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 thefirst linerecommended 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 indicatesnone to mild fibrosis
• ≥ 7.7 to 9.8 indicatesmoderate fibrosis
• ≥ 9.8 indicatessevere fibrosis

NAFLD fibrosis scoreis thesecond linerecommended 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 inruling outfibrosis but not assessing the severity when present.

Fibroscanis 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.

Question 7

Management: NAFLD?

Answer 7

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

Question 8

Complications of NAFLD?

Answer 8

increase risk of heart disease, stoke and diabetes

• hepatitis and cirrhosis