Nonalcoholic Fatty Liver Disease (NFLD)
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Nonalcoholic fatty liver disease (NAFLD) is a prevalent liver condition that primarily affects individuals who consume little to no alcohol. The condition is characterized by an excessive accumulation of fat in the liver and is most commonly observed in individuals who are overweight or obese. The global incidence of NAFLD is on the rise, particularly in Middle Eastern and Western nations, paralleling the increasing prevalence of obesity.
In some cases, NAFLD can progress to a more severe condition known as nonalcoholic steatohepatitis (NASH). NASH represents an advanced stage of fatty liver disease, leading to inflammation and damage to the liver due to the accumulation of fat deposits. This progression may result in worsening conditions, potentially leading to significant liver scarring, known as cirrhosis, and even the development of liver cancer. The damage inflicted by NASH is comparable to the harm caused by prolonged heavy alcohol consumption.
Currently, there is a movement to rename nonalcoholic fatty liver disease to metabolic dysfunction-associated steatotic liver disease (MASLD). Additionally, experts are recommending a similar name change for nonalcoholic steatohepatitis to metabolic dysfunction-associated steatohepatitis (MASH). This shift in nomenclature reflects a broader recognition of the underlying metabolic factors contributing to these liver conditions, aiming to enhance understanding and treatment approaches for these increasingly prevalent health issues.
Symptoms
NAFLD often presents without noticeable symptoms. When symptoms do manifest, they might include:
- Fatigue.
- Malaise
- Pain or discomfort in the upper right abdomen.
Potential symptoms associated with NASH (nonalcoholic steatohepatitis) and cirrhosis (advanced liver scarring) include:
- Itchy skin.
- Abdominal swelling, referred to as ascites.
- Shortness of breath.
- Leg swelling.
- Spider-like blood vessels just beneath the skin’s surface.
- Enlarged spleen.
- Red palms.
- Jaundice – yellowing of the skin and eyes.
Causes
The factors leading to the accumulation of fat in specific livers and the progression from non-alcoholic fatty liver disease (NAFLD) to non-alcoholic steatohepatitis (NASH) remain unclear to experts. Both NAFLD and NASH are linked to:
- Genetic factors.
- Excess weight or obesity.
- Elevated levels of fats, especially triglycerides, in the blood.
- Type 2 diabetes, characterized by high blood sugar or hyperglycemia.
- Insulin resistance, where cells do not efficiently respond to insulin, affecting sugar uptake.
While these health issues together may play a role in the development of a fatty liver, it’s important to note that some individuals can still develop non-alcoholic fatty liver disease (NAFLD) even without these specific risk factors.
Risk factors
Various diseases and health conditions can elevate the risk of non-alcoholic fatty liver disease (NAFLD). These include:
- Family history: A familial predisposition to fatty liver disease or obesity.
- Growth hormone deficiency: Insufficient production of growth hormones in the body.
- High cholesterol: elevated levels of cholesterol in the blood.
- Insulin resistance: The body’s reduced responsiveness to insulin.
- Type 2 diabetes: A condition marked by elevated blood sugar levels.
- High triglycerides: Increased levels of triglycerides in the bloodstream.
- Obesity: Particularly when excess fat accumulates around the waist.
- Metabolic syndrome: A cluster of conditions like high blood pressure, elevated triglycerides, and central obesity.
- Polycystic ovary syndrome (PCOS): A hormonal disorder affecting individuals with ovaries.
- Obstructive sleep apnea: A sleep disorder characterized by interrupted breathing during sleep.
- Underactive thyroid (hypothyroidism): Insufficient production of thyroid hormones.
- Underactive pituitary gland (hypopituitarism): Reduced function of the pituitary gland.
Additionally, non-alcoholic steatohepatitis (NASH) is more likely in certain groups:
- Individuals above the age of 50.
- People grappling with obesity.
- Those with specific genetic risk factors.
- Individuals dealing with diabetes or high blood sugar.
- Those exhibiting symptoms of metabolic syndrome, such as high blood pressure, elevated triglycerides, and an enlarged waist size.
Distinguishing between NAFLD and NASH necessitates a clinical evaluation and appropriate testing.
Diagnosis
NAFLD often remains asymptomatic, and its detection commonly occurs incidentally during tests conducted for unrelated reasons that indicate a potential liver issue. For instance, elevated liver enzyme levels revealed in a routine blood test during an annual examination may prompt further investigations, ultimately leading to the diagnosis of NAFLD.
Tests conducted for diagnosing NAFLD, excluding other diseases, and assessing the extent of liver damage include:
- Blood tests:
- Complete blood count, providing insights into the composition of your blood.
- Iron studies to determine the levels of iron in both your blood and cells.
- and liver function tests for assessing liver health.
- Screening tests for chronic viral hepatitis, including hepatitis A, hepatitis C, and others.
- Celiac disease screening to identify potential gluten-related issues.
- Fasting blood sugar test to evaluate glucose levels after a period of fasting.
- Hemoglobin A1C test, indicating the stability of your blood sugar over time.
- Lipid profile, measuring blood fats such as cholesterol and triglycerides.
- Imaging procedures
- Abdominal ultrasound, which is frequently the initial test when liver disease is suspected.
- Magnetic resonance imaging (MRI) or computerized tomography (CT) scanning, which are more effective in detecting mild liver fibrosis but cannot differentiate between non-alcoholic steatohepatitis (NASH) and NAFLD.
- Transient elastography, a modern ultrasound variant that measures liver stiffness as an indicator of fibrosis or scarring.
- Magnetic resonance elastography, a combination of MRI and sound waves that produces a visual map, known as an elastogram, illustrating tissue stiffness.
- Liver biopsy: If additional tests indicate advanced liver disease or non-alcoholic steatohepatitis (NASH), or if your test results are inconclusive, your doctor may recommend a liver biopsy. This procedure involves obtaining a small tissue sample from the liver using a needle inserted through the abdominal wall. The extracted tissue is then examined in a laboratory for signs of inflammation and scarring, providing the most accurate diagnosis of NASH and a clear assessment of the extent of liver damage. While a liver biopsy can be uncomfortable and carries associated risks, your healthcare team will thoroughly discuss these considerations with you before proceeding.
Treatment
The initial approach to treating non-alcoholic fatty liver disease (NAFLD) often involves weight loss, achieved through a combination of adopting a healthy diet, managing portion sizes, and engaging in regular exercise. Improving overall health through weight loss can address underlying issues contributing to NAFLD, with a recommended target of losing at least 10% of body weight. Benefits can still be realized with a weight loss as modest as 3% to 5% of the initial weight. In specific cases, weight-loss surgery or medications may be considered. However, for individuals with cirrhosis resulting from non-alcoholic steatohepatitis (NASH), a liver transplant may be necessary.
