-Dr. Sanjay Khanna – Director & HOD – Gastroenterology / Hepatobilliary Sciences, Fortis Hospital Shalimar Bagh.
What is it?
The liver is one of the most vital organs of the body in addition to the heart, lungs, brain, and kidneys. It weighs about 1.5 kilograms and is placed in the right upper abdomen, separated from the lungs by the diaphragm. One of the most important tasks of the liver is that it to act as a filter, to clean the blood, before it passes this deoxygenated blood onto the heart and the lungs to get oxygenated, and finally the peripheral circulation. The liver also acts as a factory for manufacturing proteins, especially albumin. Albumin is required for providing immunity to the body and building the muscle mass. If the liver is injured because of any reason, then these important functions are also compromised.
Liver injury, as we commonly come across in clinical practice, can be caused by various water-borne infections like hepatitis A and E and blood-borne infections like hepatitis B and C. Liver injury can also occur because of toxic agent injection like alcohol and intake of complementary alternate medicines. Obesity is the current pandemic and is also a part of metabolic syndrome. It is one of the most common reasons which can involve the liver, as is also seen in diabetes, hypothyroidism and hyperlipidemias. Fatty liver, as the name suggests is the deposition of fat in the liver and is picked on a routine ultrasound. When fatty liver is not because off alcohol consumption, it is labelled as Non-alcoholic fatty liver disease (NAFLD) and is a part of this metabolic syndrome. Fatty liver is the starting or the first phase of liver involvement in alcoholic and non-alcoholic patients. In NAFLD patients it can subsequently progress to the second phase of mild liver injury or Non-alcoholic steatohepatitis (NASH) and further onto stage of severe liver injury or stage of fibrosis and finally the last stage of liver injury and shrinkage or cirrhosis. Cirrhosis is a stage of irreversible liver damage and these cirrhotic patients can have various complications secondary to compromised liver functions and they also have an increased risk of liver cancers.
How to pick up non-alcoholic fatty liver disease?
Almost all patients of NAFLD are asymptomatic and are usually picked up incidentally while doing an ultrasound for some other reason. Some patients might have a dragging discomfort in the right upper abdomen or dyspeptic symptoms. Careful history for alcohol intake, presence of comorbidities like diabetes, hypertension, cardiac illness and hypothyroidism should be taken. Obesity needs to be assessed. Blood tests should be ordered to rule out diabetes, hypothyroidism, hyperlipidemias and to assess the liver functions (LFT), especially liver enzymes i.e., SGOT and SGPT, which may be deranged. If liver tests are abnormal, then all causes which can lead to LFT derangement need to be ordered i.e., viral hepatitis B and C and ruled out as multiple causes of LFT derangement can occur in the same patient. In NAFLD the LFT’s are normal but in the setting off NASH and more advanced liver injury, they are going to be abnormal. Ultrasound shows fatty liver only in the early stages but shows shrinking and irregular liver with advancing stages of the disease. Currently, a newer investigation, Fibroscan of the liver, is becoming an integral part of management of patients of NAFLD and advancing liver disease. In the early stage of NAFLD, Fibroscan values are usually less than 6.1 kPa, and more than 13.5 kPa in the stage of cirrhosis. Values in between these are seen in the intermediate stages and these Fibrosis scores help us in the management of these patients. It is important that treatment be started early in these patients as the disease can be reversed till the third stage of illness with decent outcomes. Stage of cirrhosis is irreversible, and the disease process may be halted to some extent. NAFLD is totally reversible, and all efforts should be in to achieve this. All this is important as early identification of NAFLD and intervention will prevent the progression to the advanced stage of cirrhosis and cancer, thus saving lots of manpower and money.
How do we treat NAFLD?
Early treatment is imperative for these patients of NAFLD. Most important part of treatment is lifestyle change which include a change in the diet and exercise. Weight reduction diet in obese, a diet which is a diet low in carbohydrates and fats and high in fruits and salads. This will reduce the calorie intake to preferably 1200 Kcal/day. Patients should also be advised at least 45 minutes of exercise or brisk level work and this should be over and above all the routine activities of these patients. Target is to achieve 7%-10% weight loss in these patients and then to maintain it. Benefits of both these measures are backed by enough data to support them for treatment of NAFLD. Drug treatment should be used to control diabetes, hypertension, hyperlipidemias and hypothyroidism. In patients of NASH, who are not controlled with diet and exercise alone, some drugs can be used which reduce the liver injury in these patients. Oral vitamin E formulations are being used in these patients for 6-12 months and they have shown some benefit to reverse NASH in majority of the patients. Other newer medicines like Saroglitazar are also being selectively used as adjunct to diet and exercise therapy. However, sustainable, and best results for NAFLD and NASH treatment have been seen with dietary modifications and exercise.
I would conclude by saying that non-alcoholic fatty liver is a part of the metabolic syndrome. All efforts should be directed to rule out other causes for NAFLD and then treat accordingly. Diet and exercise in all and in some selected patients, vitamin E may be used with good outcomes. Alcohol should be stopped in all patients and diabetes, hypertension and hypothyroidism should be strictly controlled. NAFLD and NASH is a potentially reversible disease, and all efforts should be directed to halt its progress to the more advanced cirrhosis. Prevention is better than cure and aptly applies in this scenario where we want to prevent the progress of NAFLD to cirrhosis.