Fatty Liver Fatty LiverDiagnosisTreatment Yellow appearance of a liver with excess fatWhat is fatty liver? Answer : simply what the name suggests - too much fat in the liver! Some important facts: Fatty liver is the accumulation of fat (mainly as triglycerides) within liver cells. This happens when the fat coming into the liver is more than the fat going out (the liver makes and secretes fat). This condition is becoming more common.It is the commonest cause of abnormal liver enzyme tests(blood tests for the liver). This is because fat in the liver may cause some inflammation.What causes fatty liver? Excess alcohol intake may be the main underlying cause. How much is too much?Refer to section on alcohol and liver. There are an increasing number of people with fatty liver that is NOT caused by alcohol. This condition has an association with being overweight, having diabetes (or pre-diabetes - also called impaired glucose tolerance - and having raised cholesterol or raised triglyceride levels in the blood. The underlying problem is considered to be "insulin resistance". This means that the body is not responding normally to the insulin hormone. This problem directly relates to the amount of fat tissue in the body. Fatty tissue is not inert. It secretes a range of hormones that control the body's metabolism. Insulin resistance promotes increased rate of delivery of fat to the liver from the tissues. Insulin resistance (and therefore fatty liver) is primarily determined by body weight and also the level of physical activity. Fatty liver is more common some ethnic groups. That is, for a given weight there is more fatty liver in some groups.It is more common with Indian and Chinese compared with European groups. It is also more common in Pacific Islanders. About 10% of people with excess fat in the liver will develop inflammatory in the liver. The medical term is called steatohepatitis. This sometimes abbreviated as NASH - non-alcohol steatohepatitis. Another abbreviation is NAFLD (non-alcoholic fatty liver disease). This inflammatory process, if sustained over a long period of time, can lead to significant liver fibrosis and eventually to cirrhosis (severe liver damage). The risk is low (compared to other causes of liver disease). Overall only 2% will progress to cirrhosis. This is a much smaller risk than for fatty liver caused by alcoholAbdominal fat is the main risk factor for fatty liver. The important test is the waist meaurement!! This should be less than 100cms for men.How is the diagnosis made? There are two main ways in which the diagnosis can come to light! As a result of investigation of abnormal liver tests. OR incidental finding at ultrasound performed for other reasons (e.g investigation of right–sided abdominal discomfort). Fatty liver is thought to cause no symptoms but fatigue and ill-defined discomfort in the right upper abdomen may be present (probably not a direct effect of the condition). The liver is usually of normal size. Fatty liver should be suspected if there are risk factors. They are : Being overweight (BMI more than 30 - weight in kgs divided by height in metres2(squared). High blood lipids or fats (raised blood cholesterol and/or trigylcerides). Diabetes mellitus (or raised blood glucose but not quite diabetes - called impaired glucose tolerance). Other features of the metabolic syndrome are hypertension and increased waist circumference (100cms for men; 90cms for women). There is an association with polycystic ovary syndrome – this condition is also considered to be due to insulin resistance. Excess alcohol intake. Even 5-10 "standard" drinks per week may be significant if combined with other risk factors. Fatty liver can occur without any risk factors. Ultrasound is reasonably sensitive for detecting fatty liver. This picks up 2/3 rds of cases - liver is echogenic or bright on ultrasound. Ultrasound is a useful screening test. Fatty liver may be the cause of abnormal liver tests even if the ultrasound is normal. Occasionally CT scan is required.What can a liver biopsy show? The role of liver biopsy is controversial. There are some risks but also some potentially useful information will be obtained. A liver biopsy may provide information about disease severity and some estimation of the future risk of serious liver disease.If there is significant inflammation (steatohepatitis) then about 10-20% of people may eventually progress to cirrhosis.If there is fat but no inflammation then there are rarely any problems with serious liver disease in the future (no progression to cirrhosis). It is common to have a raised serum ferritin with fatty liver. This can cause confusion as ferritin is also elevated with haemochromatosis, a condition where there is an overload of iron in the body. The risk of progression to cirrhosis is higher if the fatty liver is caused by alcohol. Particularly if alcohol intake is continued (at the same level of consumption). The decision to proceed to liver biopsy needs to be individualized. Most of time it is better to wait for 6–12 months to see if the measures discussed below will lead to a reduction in the elevated liver enzyme tests.Liver biopsy is often avoided by using a Fibroscan. This is a non-invasive machine that measures the elasticity of the liver. A loss of elasticity suggests increasing fibrosis which is an important warning that the fatty liver may become a more serious condition Treatment The treatment is weight loss. Weight loss by liposuction or surgical removal of abdominal fat (apronectomy) does not work!!! There is no shortcut - reduction in calorie intake is the only way. Risk factors should be reduced. Diabetes tablet treatment may need to be started or increased. Medication for raised cholesterol (statins) and trigycerides (Bezalip) may need to be started. Alcohol intake must be reduced. It is better to stop completely.A possible safe limit is 2-3 standard drinks per week. Exercise is crucial to success. Exercise has an important role in the treatment of fatty liver because it reduces insulin resistance – which is the underlying problem. i.e the effect of exercise is not just mediated through weight loss. This needs to be daily activity with a plan for gradual increase in activity levels. Exercise needs to be aerobic. This means "huffing and puffing" for more 30 mins three times a week!! Weight training will not be helpful (not harmful either). Weight loss should be gradual. About ½ kg per 1-2 weeks is ideal. Rapid weight loss can aggravate fatty liver. Slower rates of weight loss are more likely to be the result of lifestyle changes that can be maintained for the long term. There is no quick fix!A gradual and sustainable change in lifestyle is the goal. Modest weight loss (less than 5%) can have a significant effect if combined with regular exercise but a 5-10% weight loss should be the goal.The traditional advice has been that there is no special diet. This is no evidence to support specific claims of the "liver cleansing diet".A reduction in fat intake and reduction in alcohol intake are going to be essential changes to achieve enough calorie reduction to lead to weight loss. Recent evidence supports a low carbohydrate diet. In particular, it appears that excess fructose causes fatty liver. Fructose is used in a lot of commercially prepared foods especially soft drinks. Low carbohydrate diets are the most effective way to lose weight. There is interest in the role of probiotics - it appears that gut bacteria have a role in mediating body metabolism - this is an emerging area. Realistic goal setting and regular follow-up with your doctor helps. Weight – reduction surgery could be considered in severe cases. Gastric banding or gastric bypass has some proven efficacy for severe cases.The weight loss after gastric banding is less (maybe 15-20%) and there have been some long term concerns particularly erosion of the band into the stomach.Weight loss after gastric bypass may be 40-50% of initial weight. However this comes at a price. There are post-operative problems and a risk of death (approx 1%).There may be abdominal pain after meals.Nutrient deficiencies can be a problem after several years. Other medications. Metformin reduces insulin resistance and may be helpful but still limited information. Antioxidants such as vitamin E may have a role. Medications for diabetes and cholesterol (as discussed above).