Fatty Liver: a silent but a serious problem

By Dr. Ashok Rattan

Fatty liver is the accumulation of triglycerides and other fats in the liver cells. The amount of fatty acid in the liver depends on the balance between the processes of delivery and removal. In some patients, fatty liver may be accompanied by hepatic inflammation and liver cell death (steatohepatitis)

Liver and What it does:

The liver is located in the upper right-hand portion of the abdominal cavity, beneath the diaphragm, and on top of the stomach, right kidney, and intestines.

Shaped like a cone, the liver is a dark reddish-brown organ that weighs about 1.36 kilogram

There are 2 distinct sources that supply blood to the liver, including the following:

Oxygenated blood flows in from the hepatic artery
Nutrient-rich blood flows in from the hepatic portal vein

The liver holds about 13% of the body’s blood supply at any given moment. The liver consists of 2 main lobes. Both are made up of 8 segments that consist of 1,000 lobules (small lobes). These lobules are connected to small ducts (tubes) that connect with larger ducts to form the common hepatic duct. The common hepatic duct transports the bile made by the liver cells to the gallbladder and duodenum (the first part of the small intestine) via the common bile duct.

The liver regulates most chemical levels in the blood and excretes a product called bile. This helps carry away waste products from the liver. All the blood leaving the stomach and intestines passes through the liver. The liver processes this blood and breaks down, balances, and creates the nutrients and also metabolizes drugs into forms that are easier to use for the rest of the body or that are nontoxic. More than 500 vital functions have been identified with the liver. Some of the more well-known functions include the following:

Production of bile, which helps carry away waste and break down fats in the small intestine during digestion
Production of certain proteins for blood plasma
Production of cholesterol and special proteins to help carry fats through the body
Conversion of excess glucose into glycogen for storage (glycogen can later be converted back to glucose for energy) and to balance and make glucose as needed
Regulation of blood levels of amino acids, which form the building blocks of proteins
Processing of hemoglobin for use of its iron content (the liver stores iron)
Conversion of poisonous ammonia to urea (urea is an end product of protein metabolism and is excreted in the urine)
Clearing the blood of drugs and other poisonous substances
Regulating blood clotting
Resisting infections by making immune factors and removing bacteria from the bloodstream
Clearance of bilirubin, also from red blood cells. If there is an accumulation of bilirubin, the skin and eyes turn yellow.

When the liver has broken down harmful substances, its by-products are excreted into the bile or blood. Bile by-products enter the intestine and leave the body in the form of feces. Blood by-products are filtered out by the kidneys, and leave the body in the form of urine.

Liver health is an indication of overall wellbeing but very often ailments related to this organ go undiagnosed

Fatty liver:

Fatty liver, also known as hepatic steatosis, is a condition in which fat accumulates in the liver. This excess fat can interfere with liver function and lead to inflammation, scarring, and liver damage.

There are two types of fatty liver disease: alcoholic fatty liver disease (AFLD) and nonalcoholic fatty liver disease (NAFLD). As the name suggests, AFLD is caused by excessive alcohol consumption, while NAFLD occurs in people who do not consume large amounts of alcohol.

NAFLD is a common condition and is often associated with other health conditions such as obesity, insulin resistance, and high blood sugar. In some cases, NAFLD can progress to a more serious condition called nonalcoholic steatohepatitis (NASH), which can lead to liver cirrhosis and even liver failure.

Fatty liver develops when a person consumes more fat and sugars than his or her body can handle. This is more common in people who are overweight or obese but can also occur in adults with healthy body weights. If fat builds up to more than 5% of the liver, then the liver is a fatty liver. Although having this condition may not cause any immediate harm but extra fat in the liver can lead to inflammation and scarring

Classification:

Non-alcoholic fatty liver disease (NAFLD) affects people who drink little to no alcohol. If you just have fat but no damage to your liver, the disease is called nonalcoholic fatty liver disease (NAFLD). If you have fat in your liver plus signs of inflammation and liver cell damage, the disease is called nonalcoholic steatohepatitis (NASH).

Severity:

Nonalcoholic fatty liver disease (NAFLD) is typically classified into four grades:

Grade 1: Steatosis, or simple fatty liver, which is the mildest form of NAFLD and involves only the accumulation of fat in the liver without inflammation or fibrosis.
Grade 2: Steatosis with mild inflammation, which involves the accumulation of fat in the liver along with mild inflammation.
Grade 3: Steatosis with moderate inflammation and fibrosis, which involves the accumulation of fat in the liver along with moderate inflammation and fibrosis (scarring) in the liver.
Grade 4: Steatosis with severe inflammation and fibrosis, which involves the accumulation of fat in the liver along with severe inflammation and fibrosis in the liver.

In addition to these grades, nonalcoholic steatohepatitis (NASH) is a more severe form of fatty liver disease that is characterized by inflammation and fibrosis in the liver, and can progress to cirrhosis and liver failure if left untreated.

Alcoholic fatty liver disease (AFLD) can also vary in severity, with mild forms causing minimal liver damage and more severe forms causing inflammation, fibrosis, and even cirrhosis.

The severity of fatty liver disease can be determined through imaging tests, such as ultrasound or MRI, as well as through liver function tests and other blood tests that evaluate liver function and inflammation. Treatment and management of fatty liver disease will depend on the severity of the condition and may include lifestyle changes, medication, and in severe cases, liver transplant

Clinical features:

Fatty liver disease is sometimes called a silent liver disease. This is because it can happen without causing any symptoms. Most people with NAFLD live with fat in their liver without developing liver damage. A few people who have fat in their liver develop NASH.

If you have NASH, you may have symptoms that could take years for them to develop. If liver damage from NASH leads to permanent scarring and hardening of your liver, this is called cirrhosis.

Symptoms from NASH may include:

Severe tiredness
Weakness
Weight loss
Yellowing of the skin or eyes
Spider Like blood vessels on the skin
Long-lasting itching

NASH that turns into cirrhosis could cause symptoms like fluid retention, internal bleeding, muscle wasting, and confusion. People with cirrhosis over time may develop liver failure and need a liver transplant.

Who is at risk:

Risk factors include:

Being overweight
Having high blood fat levels, either triglycerides or LDL (“bad”) cholesterol
Having diabetes or prediabetes
Having high blood pressure

Pathophysiology:

The pathophysiology of fatty liver disease involves the accumulation of excess fat (triglycerides) in liver cells, known as hepatocytes. In normal liver function, hepatocytes process and store fats, but when there is an imbalance between fat accumulation and fat removal, fatty liver can occur.

The accumulation of fat in the liver can be caused by a variety of factors, including obesity, insulin resistance, high levels of triglycerides in the blood, and excessive alcohol consumption. In nonalcoholic fatty liver disease (NAFLD), the most common type of fatty liver disease, the accumulation of fat is not caused by alcohol consumption.

The excess fat in the liver can cause damage and inflammation, leading to a condition called steatohepatitis. Steatohepatitis is characterized by inflammation, cell injury, and fibrosis (scar tissue formation) in the liver. This can ultimately progress to cirrhosis, a condition in which the liver becomes severely scarred and can no longer function properly.

The pathophysiology of fatty liver disease also involves insulin resistance and metabolic dysfunction. Insulin resistance can lead to the accumulation of fat in the liver by impairing the breakdown of fats and increasing the production of new fats. Metabolic dysfunction, including dyslipidemia and oxidative stress, can further contribute to the development of fatty liver disease.

Overall, the pathophysiology of fatty liver disease is complex and involves multiple factors. Understanding these factors is important for developing effective treatments and preventative measures for this increasingly common condition.

Diagnosis:

Fatty liver disease can be diagnosed through various methods, including:

Physical exam: A healthcare provider may perform a physical exam to check for signs of liver disease, such as an enlarged liver or spleen.
Blood tests: Blood tests can be used to assess liver function and check for elevated levels of liver enzymes, which can indicate liver damage or inflammation.
Imaging tests: Imaging tests such as ultrasound, CT scan, or MRI can be used to visualize the liver and detect the presence of fatty deposits.
Biopsy: A liver biopsy involves taking a small sample of liver tissue for examination under a microscope. This test can help to determine the extent of liver damage and the presence of inflammation or fibrosis.
Fibroscan: A fibroscan is a noninvasive test that measures the stiffness of the liver, which can help to detect the presence of fibrosis.

The specific diagnostic approach used may depend on the severity of the suspected fatty liver disease and the healthcare provider’s clinical judgement. In some cases, additional testing may be needed to rule out other causes of liver disease or to determine the extent of liver damage. It’s important to work closely with a healthcare provider to determine the best approach to diagnosis and management for your specific case of fatty liver disease.

The diagnosis of fatty liver disease is typically made through imaging tests such as ultrasound, CT scan, or MRI. However, certain laboratory tests may also be useful in screening for the condition. These tests include:

Liver function tests (LFTs): LFTs measure levels of certain enzymes and proteins in the blood that indicate liver function. Elevated levels of these enzymes may indicate liver damage or inflammation, which can be caused by fatty liver disease.
Lipid panel: A lipid panel measures levels of cholesterol, triglycerides, and other fats in the blood. Elevated levels of these fats can indicate an increased risk for fatty liver disease.
Fasting blood glucose: Fasting blood glucose measures the level of sugar in the blood after an overnight fast. High blood sugar levels may indicate insulin resistance, which is a risk factor for fatty liver disease.
Hemoglobin A1c (HbA1c): HbA1c is a measure of average blood sugar levels over the past two to three months. Elevated HbA1c levels can indicate insulin resistance and an increased risk for fatty liver disease.
Ferritin: Ferritin is a protein that stores iron in the body. Elevated levels of ferritin may indicate iron overload, which can contribute to the development of fatty liver disease.

It’s important to note that these tests are not specific to fatty liver disease and may be abnormal for other reasons as well. Imaging tests are typically necessary for a definitive diagnosis of fatty liver disease. If you are concerned about fatty liver disease or have risk factors for the condition, speak with a healthcare professional about appropriate screening tests.

Management:

The management of fatty liver disease depends on the severity of the condition and underlying causes. Here are some general approaches to management based on severity:

Grade 1 (simple fatty liver): Management typically involves lifestyle modifications such as weight loss, a healthy diet, regular exercise, and avoiding alcohol and other toxins.
Grade 2 (steatosis with mild inflammation): Lifestyle modifications are typically recommended, and medications to manage diabetes or high cholesterol may also be prescribed.
Grade 3 (steatosis with moderate inflammation and fibrosis): Lifestyle modifications are strongly recommended, and medications may be prescribed to manage diabetes or high cholesterol. In some cases, a liver biopsy may be performed to determine the extent of fibrosis, and treatment may involve medications to reduce inflammation and slow the progression of fibrosis.
Grade 4 (steatosis with severe inflammation and fibrosis): Treatment may involve medications to manage inflammation and fibrosis, and in some cases, liver transplant may be necessary

For both alcoholic and nonalcoholic fatty liver disease, the most effective treatment is to identify and address the underlying causes. This may include quitting alcohol or managing conditions such as diabetes, obesity, and high cholesterol. Lifestyle modifications such as weight loss, a healthy diet, regular exercise, and avoiding alcohol and other toxins are also essential for managing and potentially reversing fatty liver disease.

If you have NAFLD without any other medical problems, you don’t need any special treatment. But making some lifestyle changes can control or reverse the fat buildup in your liver. These may include:

Losing weight
Lowering your cholesterol and triglycerides
Controlling your diabetes
Avoiding alcohol

If you have NASH, no medication is available to reverse the fat buildup in your liver. In some cases, the liver damage stops or even reverses itself. But in others, the disease continues to progress. If you have NASH, it’s important to control any conditions that may contribute to fatty liver disease. Treatments and lifestyle changes may include:

Losing weight
Medication to reduce cholesterol or triglycerides
Medication to reduce blood pressure
Medication to control diabetes
Limiting OTC drugs
Avoiding alcohol
Seeing a liver specialist

Prevention:

Fatty liver disease can be prevented or its progression can be slowed through lifestyle modifications and medical management. Here are some ways to prevent fatty liver disease:

Maintain a healthy weight: Being overweight or obese is a significant risk factor for developing fatty liver disease. Maintaining a healthy weight through regular exercise and a balanced diet can help to prevent the condition.
Eat a healthy diet: Consuming a diet that is high in fruits, vegetables, and whole grains and low in saturated fats, trans fats, and added sugars can help to prevent fatty liver disease.
Exercise regularly: Regular exercise, such as aerobic activity and strength training, can help to reduce the risk of developing fatty liver disease and improve liver function.
Manage underlying health conditions: Conditions such as diabetes, high cholesterol, and high blood pressure can increase the risk of fatty liver disease. Managing these conditions through medication and lifestyle modifications can help to prevent or manage fatty liver disease.
Limit alcohol consumption: Alcohol consumption is a significant risk factor for developing fatty liver disease. Limiting alcohol consumption or abstaining from alcohol altogether can help to prevent the condition.
Avoid exposure to toxic substances: Exposure to toxic substances such as pesticides, chemicals, and drugs can increase the risk of developing fatty liver disease. Avoiding or limiting exposure to these substances can help to prevent the condition.

It’s important to work closely with a healthcare provider to determine the best approach to preventing or managing fatty liver disease based on individual risk factors and medical history.

The way to prevent non-alcoholic fatty liver disease is to follow the same lifestyle advice given to people who already have the condition, including:

eating a healthy diet that is rich in fruit and vegetables, whole grains and healthy fats
maintaining a healthy weight
being physically active on most days of the week — check with your GP first if you haven’t been exercising regularly

Prevalence in the World and in India:

Fatty liver disease is a common health condition worldwide, and its prevalence has been increasing over the past few decades due to the rise in obesity, diabetes, and metabolic syndrome. The exact prevalence of fatty liver disease varies depending on the population studied and the diagnostic criteria used, but here are some general statistics:

In India, the prevalence of fatty liver disease is estimated to be around 20-30% of the general population, with higher rates in people who are obese, have diabetes, or consume alcohol excessively.
Worldwide, the prevalence of fatty liver disease is estimated to be around 25%, with higher rates in Western countries where rates of obesity and diabetes are higher.
Nonalcoholic fatty liver disease (NAFLD) is the most common form of fatty liver disease, and it is estimated to affect 20-30% of the general population worldwide.
Alcoholic fatty liver disease (AFLD) is the second most common form of fatty liver disease, and it is estimated to affect 10-20% of heavy drinkers.

It’s important to note that many cases of fatty liver disease are asymptomatic, and the condition may go undiagnosed until it progresses to more severe stages. It’s also important to address risk factors such as obesity, diabetes, and excessive alcohol consumption to prevent the development and progression of fatty liver disease.

The ultimate effect of fatty liver disease on quality of life and life expectancy can vary depending on the severity of the condition and the presence of other underlying health conditions.

In its early stages, fatty liver disease may not cause any symptoms and may not have a significant impact on quality of life. However, as the condition progresses and inflammation and fibrosis develop, symptoms such as fatigue, abdominal pain, and jaundice may occur, and quality of life may be affected.

In more severe cases of fatty liver disease, such as advanced fibrosis or cirrhosis, there is an increased risk of liver failure, liver cancer, and other complications that can significantly impact life expectancy and quality of life. Liver failure can be life-threatening, and a liver transplant may be necessary in some cases.

It’s important to note that lifestyle modifications such as weight loss, regular exercise, and a healthy diet can help to prevent or manage fatty liver disease and improve quality of life.

Additionally, addressing underlying health conditions such as diabetes and high cholesterol can also help to reduce the risk of complications and improve overall health and longevity.

Overall, the effect of fatty liver disease on quality of life and life expectancy can be significant, particularly in advanced stages of the condition. However, early diagnosis and management can help to slow or prevent disease progression and improve outcomes

(The author is Chairman Medical Committee & Quality. The article is for informational purposes only. Please consult medical experts and health professionals before starting any therapy, medication and/or remedy. Views expressed are personal and do not reflect the official position or policy of the FinancialExpress.com.)