Fatty Liver Disease

Nonalcoholic fatty liver disease is a condition in which fat accumulates in the liver. There are two types of nonalcoholic fatty liver disease:

• Non-alcoholic fatty liver disease, also known as NAFLD (non-alcoholic fatty liver disease): In patients with NAFLD, there is fat accumulation in the liver, but the liver is not inflamed.
• Nonalcoholic steatohepatitis (NASH) or nonalcoholic liver inflammation: Patients with NASH have fat buildup in the liver, and the liver is inflamed. NASH can lead to liver cirrhosis and liver cancer.

About 20 to 30% of people with nonalcoholic fatty liver disease (NAFLD) develop NASH.

NASH is a form of liver inflammation that is not caused by excessive alcohol consumption. Patients with NASH usually drink little or no alcohol, but they experience the same symptoms as patients who develop liver inflammation due to excessive alcohol consumption.

Most patients with NAFLD and NASH have few or no symptoms.

Liver diseases usually do not cause symptoms until a late stage. This is because the healthy part of the liver is able to perform its various functions adequately. By the time symptoms appear, the disease is usually already at an advanced stage.

Patients with NASH are often referred by their primary care physician to a hepatologist because of abnormal liver function test results in their blood.

If there are any symptoms of NASH, they are often the following:

• Fatigue
• Weight Loss
• Muscle weakness

By that point, the disease is often already at an advanced stage, and in most cases, liver cirrhosis has already developed.

NALFD and NASH are common in Western countries, particularly among the following patient groups:

• People who are overweight (obese)
• People who have diabetes (diabetes mellitus), specifically type 2 diabetes mellitus.
• People with metabolic syndrome.

Metabolic syndrome is a combination of five factors that can disrupt metabolism:

• Waist circumference
  • for men: >102 cm;
  • for women: > 88 cm.
• High blood pressure; Elevated blood fat levels (triglycerides)
• Low HDL cholesterol
• Elevated blood sugar levels

Non-alcoholic fatty liver disease results from an imbalance in fat metabolism and/or sugar metabolism in the liver, causing fat to accumulate in the liver cells. Fatty liver is a reversible condition. This means that the fat buildup will disappear once the underlying cause is addressed.

Blood Test

The liver specialist will perform various blood tests to rule out other underlying causes of liver disease. You will usually be tested for the following conditions: hepatitis C, hepatitis B, etc.

FIB 4 score

The FIB 4 score is a score calculated based on certain blood test results (AST, ALT, platelets) and your age. This allows us to classify patients into groups that are at higher risk of NAFLD progressing to fibrosis and cirrhosis.

During a blood test, a small tube of blood is drawn from a vein on the inside of the arm, usually in the crook of the elbow. To make it easier to see and feel this vein, a tourniquet is tightened around the upper arm. A needle is inserted into the vein, drawing the blood into the tube. The needle is used only once and then disposed of.

Radiological Examination

Images of the liver will be taken. This can be done using an ultrasound, a CT scan, or an MRI scan. These tests will give us a clear picture of the liver’s condition and the extent of fatty liver and/or inflammation.

Fibroscan

NAFLD and NASH cause scar tissue to form on the liver. A Fibroscan is a test that measures the stiffness of the liver. The more scar tissue there is, the stiffer the liver.
A Fibroscan is a test in which a type of ultrasound transducer is placed between the ribs on the right side of the body (where the liver is located). Small shock waves are sent to the liver. The test takes about 10 minutes and is painless.

Liver biopsy

A liver biopsy is the only test that can definitively determine whether you have fatty liver disease and whether it has caused inflammation of the liver. If the doctor is unsure whether you have fatty liver disease, wants to rule out other liver diseases, or needs to determine whether there is inflammation in the liver, a liver biopsy will be performed. A liver biopsy can provide clarity about the severity of the liver inflammation and the stage of the disease.
There are two types of liver biopsy:

• Percutaneous liver biopsy: In this procedure, the doctor inserts a needle through the skin, between the ribs, to remove a small sample of liver tissue. (link to brochure)
• Transjugular liver biopsy: When there is too high a risk of post-procedure bleeding (e.g., when the patient is taking a blood thinner that cannot be discontinued, when the patient has a coagulation disorder, etc.), a transjugular liver biopsy is performed. This involves removing a small sample of liver tissue through your blood vessels.

After these two biopsies, the tissue samples will be sent to the lab for further examination. You will receive the results at your next appointment, which will be scheduled shortly thereafter.

Fatty liver disease is a reversible condition. This means that the fat buildup disappears once the underlying cause is addressed. The liver’s condition can therefore improve if other conditions that often co-occur with NASH are treated.

Lifestyle Changes

Weight loss can be achieved by reducing calorie intake and increasing physical activity. A weight loss of 5 to 10% is already enough to reduce fatty liver.

Making these lifestyle changes not only helps improve liver function—and thus reduce fatty liver disease—but also reduces the risk of a heart attack, for example. This is important because patients with NASH often have an increased risk of a heart attack.

Treating High Blood Sugar Levels

Patients who have diabetes mellitus in addition to fatty liver disease are usually also seen by a doctor who specializes in this field (an endocrinologist). These doctors often prescribe medication for this condition.

Vitamin E

If you have a severe form of NASH and do not have diabetes or heart disease, you may be prescribed vitamin E. According to some scientific studies, vitamin E may help reduce the liver damage caused by NASH to some extent.

Preventing Further Damage to the Liver

If you have fatty liver disease, it is important to avoid other factors that can also damage the liver. For example: avoid excessive alcohol consumption, do not take medications that are harmful to the liver, get vaccinated against hepatitis B, etc.

Surgery

Sometimes bariatric surgery is recommended for patients who have difficulty losing 5 to 10% of their body weight. Bariatric surgery is a general term for all surgical procedures aimed at weight loss. Examples of such procedures include a “gastric sleeve” and a “gastric bypass.”

Future

Pharmaceutical companies are currently conducting extensive research into new medications to combat fat accumulation in the liver. These medications are currently being tested in advanced phases of clinical trials. The medications have already demonstrated their efficacy and safety, but now need to be tested on larger groups of patients. At AZ Delta, we are also participating in such studies that test this type of medication. If you are a patient with NAFLD or NASH and are interested in these studies, you can always contact the gastroenterology and hepatology study team:

• Lien Decaesteker: 051 23 75 12
• Elien De Cock: 051 23 75 34
• Ann D’Hondt: 051 23 75 33

Read more about fatty liver disease here [uptodate.com]

Read more about fatty liver disease here [mlds.nl]