what makes a liver “fatty”?
over 5% steatosis– more white space on histology
Lack of balance between energy in & out → disposal capacity (fructose, sucrose, glucose) → formation and accumulation of intrahepatic fat
hepatic steatosis
overarching term for >5% of liver with steatosis; absence of another causes (meds, starvation); little to no alcohol use; v common in DM2
NAFLD
what makes NASH diferent from NAFL?
NASH has steatosis, hepatocyte ballooning, lobular inflammation, perisinusoidal fibrosis that could progress to cirrhosis; its more severe
NASH= non-alcoholic steatohepatitis
4 stages of NAFLD disease progression. bold the step that is irreversibel
healthy liver →NAFLD → NASH → Cirrhosis
bloated hepatocyte, large fat droplets & displaced nucleus
NAFLD
inflamed dying hepatocyte, collagen fibers
NASH
remnants of dead cells, scarring
cirrhosis
5 conditions associated with NAFL & how?
obesity: associated w/ progression
T2DM: most impactful risk factor
HTN: higher incidence as NAFL progresses
dyslipidemia: statins could help
OSA: associated w/ more advanced NAFLD/NASH
which distribution of body fat has a higher risk of IR, CVD & fibrosis regardless of BMI? which is protective against NAFL?
- android has higher risk (includes waist, belly button)
- gynoid is protective (starts by bikini line?)
why is it important to diagnose? (2)
- increased overall mortality & CV death
- inreased risk of malignancy (GI, kidney, breast)
relationship between BMI and NASH & NAFL
higher BMI more likely to have NASH
lower BMI more likely to have NAFL
diagnosis of fatty liver (4)
- dx of exclusion; mostly asymptomatic
- elevated AST & ALT, glucose
- histology or US showing evidence of heatpic steatosis
- no other cause of hepatic fat accumulation
4 drugs that could cause hepatic fat accumulation
steroids
methotrexate
amiodarone
tamoxifen
6 d/o that could cause hepatic fat accumulation
Hep C
wilsons
lipodystrophy
starvation
parental nutrition
acute fatty liver
primary assessment used to look for patients at risk for advanced fibrosis; age, AST, ALT, platelet count
FIB-4 calculator– helps estimate amount of scarring
- secondary assessment that can be done in office or use US-based methods; fairly reliable for advanced fibrosis
- if advanced fibrosis (over 8) found, refer to GI/hepatology
vibration-controlled elastography (VCTE)
also used in risk stratification to detect over 5.5% hepatic fat but has limited availability
MRI– MR spectroscopy or Elastography
reference standard for risk stratification; reserved for diagnostic uncertainty but has limitations related to risk & cost
liver biopsy
3 general treatment options for fatty liver
liver protective behavior
bariatric surgery
medications
4 dietary changes to make
limit carbs
mediterranean diet
coffee
macronutrient composition
3 medication options for fatty liver
- pioglitazone
- vitamin E 800 IU plant based
- GLP-1 and SGLT-2i
medication that improves AST, ALT, fibrosis but causes weight gain
pioglitazone
medication that should not be used if at increased risk for prostate cancer or bleeding
Vitamin E
