3.11. Liver + Biliary Tree Disease - Non-Alcoholic Fatty Liver Disease

Question 1

Which group of conditions is Non-Alcoholic Fatty Liver Disease (NAFLD) associated with?

Answer 1

Metabolic Syndromes - e.g. Diabetes, Obestity, Hypertension, Hypertriglyceridaemia

Question 2

What other factors effect Non-Alcoholic Fatty Liver Disease (NAFLD)?

Answer 2

1. The frequency increases with age
2. There is a genetic factor (e.g. the PNPLA3 gene)
3. It is more prevalent in the Hispanic Community

Question 3

What is the Pathology of Non-Alcoholic Fatty Liver Disease (NAFLD)?

Answer 3

The Hepatocytes become infiltrated with fat (Steatosis) associated with a disturbance in metabolism - but not associated with Alcohol intake.

Question 4

What can this Steatosis lead to?

Answer 4

1. Hepatomegaly - known as Non-Alcoholic Steatohepatitis (NASH)
2. The inflammatory response, resulting in fibrosis of the liver

Question 5

What can the Inflammatory Response, causing Fibrosis, lead to?

Answer 5

Liver Cirrhosis

Question 6

What are the Clinical Signs of Non-Alcoholic Fatty Liver Disease (NAFLD)?

Answer 6

1. Hepatomegaly
2. Obesity
3. Weight Loss
4. Jaundice

Question 7

Why is Obesity a Clinical Sign?

Answer 7

As this is the Major Risk Factor

Question 8

Why might there be Weight Loss?

Answer 8

Due to the potential Malabsorption of Fat, due to the Malfunctioning Liver

Question 9

What Type of Jaundice will be present?

Answer 9

Intrahepatic (Conjugative) Jaundice

Question 10

What are the Symptoms of Non-Alcoholic Fatty Liver Disease (NAFLD)?

Answer 10

1. Asymptomatic (in most cases)
2. Pain
3. Fatigue / Weakness
4. Pruritus

Question 11

What type of Pain might occur?

Answer 11

A dull, aching pain in the Right Hypochondriac Region

Question 12

Why might Pain occur?

Answer 12

Due to the damage of hepatocytes and the associated Hepatomegaly

Question 13

Why might Fatigue / Weakness be present?

Answer 13

Due to Malabsorption

Question 14

Why might Pruritus?

Answer 14

Due to the Hyperbilirubinaemia associated with the Jaundice and Liver Failure

Question 15

What investigations are neccessary in Non-Alcoholic Fatty Liver Disease (NAFLD)?

Answer 15

1. Staging
2. Liver Function Test (and Biochemistry)
3. Enhanced Liver Fibrosis (ELF) Panel
4. Abdominal Ultrasound / CT Scan
5. Fibroscan
6. MRI Spectroscopy
7. Biopsy

Question 16

When must Staging occur?

Answer 16

Before treatment begins

Question 17

What is taken into account for the Staging?

Each of these being High Risk will score 1 point

Answer 17

1. Age
2. Diabetes
3. BMI
4. Aminotransferase Ratio (AST/ALT)
5. Platelet Count
6. Albumin Count

Question 18

How many points must there be before the patient is deemed High Risk of developing Non-Alcoholic Fatty Liver Disease (NAFLD)?

Answer 18

3

Question 19

What is the Age Component of the Scoring System?

Answer 19

Low Risk - Less than 45

High Risk - Older than 45

Question 20

What is the Diabetes Component of the Scoring System?

Answer 20

Low Risk - Absent

High Risk - Present

Question 21

What is the BMI Component of the Scoring System?

Answer 21

Low Risk - Less than 30

High Risk - Greater than 30

Question 22

What is the Aminotransferase Ratio (AST/ALT)Component of the Scoring System?

Answer 22

Low Risk - Less than 1 (ASTALT)

Question 23

What is the Platelet Count Component of the Scoring System?

Answer 23

Low Risk - Normal (>150)

High Risk - Low (<150)

Question 24

What is the Albumin Count Component of the Scoring System?

Answer 24

Low Risk - Normal (>34)

High Risk - Low (<34)

Question 25

What is the Liver Function Test (and Biochemistry) looking for?

Answer 25

The ratio of Aspartate Aminotransferase to Alanine Aminotransferase (AST:ALT)

Question 26

What results from the Liver Function Test (and Biochemistry) are suggestive of Non-Alcoholic Fatty Liver Disease (NAFLD)?

Answer 26

1. Both are less than 4 x the limit of normal

2. The ratio of Aspartate Aminotransferase to Alanine Aminotransferase (AST:ALT) is greater than 1 - AST>ALT

Question 27

What is the purpose of the Enhanced Liver Fibrosis (ELF) Panel?

Answer 27

This is a blood test to find the Biomarkers of Liver Fibrosis - Hyaluronic Acid, TIMP-1 and PIIINP

Question 28

What else would you look for in the blood?

Answer 28

A biomarker of Chronic Liver Disease - Caspase-Cleaved Fragments of Cytokeratin 18

Question 29

What is the purpose of the Abdominal Ultrasound / CT?

Answer 29

To visualize the Liver so any inflammation can be detected

Question 30

What is a Fibroscan? And what is its purpose?

Answer 30

This is a special type of Ultrasound which can measure Fibrosis or Fatty Deposits in the Liver

Question 31

What is the purpose of the MRI Spectroscopy?

Answer 31

To quantify the presence of the Fat in the Liver

Question 32

Why is a biopsy needed?

Answer 32

For a final definitive diagnosis

Question 33

What is the treatment of Non-Alcoholic Fatty Liver Disease (NAFLD)?

Answer 33

1. Lifestyle Changes

2. Controlling the Aetiology

Question 34

What lifestyle changes would be recommended?

Answer 34

1. Reduce Weight via Exercise
2. Improve Diet
3. Alcohol Cessation (although not the cause)

Question 35

What can be used to control the Aetiology?

Answer 35

1. Vitamin E
2. Insulin Sensitizers
3. Glucagon-Like Peptide - 1 analogues