Fatty Liver

Non-alcoholic fatty liver disease (NAFLD) has become common with the rising incidence of obesity and diabetes. The disease affects around 9 to 32 % of the Indian population and is greater amongst obese and diabetic populations. The disease is more common amongst the older age groups. In a study conducted on Indian population, it was found that 61.8 % of patients with non-alcoholic fatty liver disease belong to the age group of 61 to 70 years. Management of NAFLD is unique because lifestyle changes such as weight loss, increase in physical activity, and dietary changes are the usually recommended management options. There are no recommended medications for the condition. Even a minimal increase in physical activity has shown to have a beneficial effect on the condition. Aerobic activity and resistance training or strength training are also helpful. 

What Is Fatty Liver Disease?

The liver is one of the largest internal organs. It helps us to digest the food, remove toxins and poisons from our body and to store energy in our body. A build-up of fat in the liver leads to a condition called fatty liver disease. Our liver normally has some fat in it by itself and this causes no symptoms. However, excess accumulation of fat in the liver, can lead to inflammation. This condition is termed as the fatty liver disease. 

Fatty liver disease is of two main types:

• Non-alcoholic fatty liver disease (NAFLD)
  NAFLD is a build-up of fat in the liver that is not related to excessive intake of alcohol. NAFLD can be of two kinds:
  • Simple fatty liver
    This is a condition where there is a build-up of fat in the liver, but, it is not accompanied by any damage to the liver cells. There is no associated inflammation due to fat accumulation. This condition generally does not cause any damage to the liver and does not cause any problems. 
  • Non-alcoholic steatohepatitis (NASH)
    In this condition, there is an accumulation of fat in the liver, along with, inflammation and damage to the liver cells. The inflammation and liver cell damage can cause many complications such as fibrosis, scarring, cirrhosis, and even liver cancer. (Read more - Cystic fibrosis treatment)
• Alcoholic fatty liver disease
  Alcoholic fatty liver disease occurs due to excessive intake of alcohol. Alcohol is broken down in the liver and leads to the release of certain harmful substances that can damage the liver cells and promote inflammation. As a result, the body's natural defense system is slowly weakened. When a person continues to consume more and more alcohol, the liver damage increases.

The fatty liver disease is a silent disease and does not cause any significant symptoms. General tiredness and a slight discomfort in the upper right side of the abdomen may be present in a person with this condition, most in most people there are no noticeable symptoms that indicate the presence of the disease.  

When fatty liver begins to show signs of inflammation and damage, only then the condition can present with symptoms. These symptoms may indicate signs of cirrhosis (liver damage with irreversible scarring of the liver) like jaundice. The skin and the whites of the eyes may turn yellow indicating the presence of the disease. Another sign of liver damage is ascites and edema, which is an abnormal accumulation of fluids within the tissues of the body.

Your doctor may also notice stiffness of the liver during a physical examination. The stiffness may be indicative of fibrosis or scarring of the liver.
A person with liver damage may also have increased bruising and mental confusion.

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Causes

Excessive alcohol intake is one of the main causes of alcoholic fatty liver disease. Alcohol is a toxin for the liver and causes inflammation. The exact cause of non-alcoholic fatty liver disease (NAFLD) and NASH is unknown. Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) may be caused by a number of factors that lead to an accumulation of fat cells in the liver. These include:

• Diet
  An unhealthy diet is one of the major reasons for accumulation of fat in the liver. Intake of excessive calories subdues the capacity of the liver to metabolise fat cells and leads to fat build up in the liver.
• Pre-existing diseases
  Certain diseases such as type 2 diabetes, obesity or excessive weight, makes a person more prone to the condition. Excessive levels of triglycerides, a certain kind of fat cells, also predispose individuals to the disease.
• Medications
  Certain medicinal drugs such as tamoxifen, amiodarone, and methotrexate are known to cause side-effects that may lead to the condition. 
• Insulin resistance
  There are indications that insulin resistance may be linked to NAFDL. The cells are unable to adequately utilise the insulin produced to metabolise glucose which leads to fat accumulation in the liver. 

Risk Factors

The exact reason for NAFLD is not known. It is seen that individuals with certain medical conditions and of certain ethnic backgrounds are more prone to the condition and are at a higher risk of getting the disease. Type 2 diabetes or prediabetes, obesity, older individuals, high levels of fats such as triglycerides and cholesterol in the blood, high blood pressure, certain cancer drugs, infections such as hepatitis C and exposure to toxins increase a person’s chances of developing the disease.

Fatty liver disease does not have a specific medical treatment or surgical treatment, but, the damage caused by it can be prevented and even reversed to some extent if the person with fatty liver disease takes proper preventive care. Prevention is particularly effective in people with non-alcoholic steatohepatitis (NASH). 

Measures that help stop and even reverse the damage are as follows:

• Losing weight
  Weight loss helps in managing fatty liver as long as one loses weight safely. A safe weight loss is a weight loss of no more than half or one kilogram in a week.
• Staying away from alcohol
  When alcohol is broken down in the liver, it produces substances that are harmful to the liver. Stopping alcohol intake gives the liver a chance to remove the accumulated toxins and heal itself.
• Controlling diabetes
  Managing diabetes helps to improve NAFLD.
• Making dietary changes
  Diet plays a key role in treating and managing NAFLD. Add fresh fruits, vegetables and whole grains to your diet and avoid excessive sugar and salt intake.
• Increasing your physical activity
  Even a small amount of increase in physical activity is seen to be therapeutic and helpful in NAFLD.
• Being regular with your follow-ups
  Regular check-ups by a liver specialist are important to assess the liver health.
  
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As the condition does not have any specific symptoms, diagnosis of fatty liver generally occurs if your doctor notices an enlarged liver during a routine check-up or notices something distinctive in your blood test that indicates the presence of fatty liver. In such a case, your doctor may advice certain blood tests, liver function tests, an ultrasound, a CT scan or an MRI to ascertain the condition of your liver. 
If most of the tests are negative and you do not have any other liver diseases, then you may be diagnosed with non-alcoholic steatohepatitis (NASH). Only a liver biopsy can confirm the disease. In liver biopsy, a small sample of the liver tissue is removed and examined under a microscope.
If the doctor suspects fatty liver disease, he will take a detailed medical history and ask questions about your alcohol consumption and the medicines you are taking to determine if a medication may be causing a problem.

Depending on the type, the management of the fatty liver disease is as follows:

Non-alcoholic fatty liver disease

There is no fixed medication for non-alcoholic steatohepatitis (NASH) or for Non-alcoholic Fatty Liver Disease (NAFLD).

• Weight loss is recommended to those diagnosed with the condition. Weight loss helps to reduce the accumulation of fat in the liver, diminishes inflammation and fibrosis.
• Increase in physical activity helps to lose overall body fat, including fat in the liver and helps with the condition. Studies have shown that simply being active has a beneficial effect on NALDF, even if the level of activity is below the recommended level. 
• Doctors may evaluate the medicines you are taking and ask you to switch or stop certain medicines. Do not stop taking any medicines by yourself without the approval of your doctor as it can lead to other complications and prove dangerous to your health. 
• It is important to understand that there are no approved medicines to treat (NAFLD) but there is growing evidence that suggests that certain medicines that are used to treat diabetes and vitamins may help with the condition. However, further research is needed before drawing any conclusion.

Alcoholic fatty liver disease

• Complete abstinence from alcohol is one of the most important components of treating alcoholic fatty liver disease. Therapy may be recommended for people who have issues with stopping alcohol intake. 
• Certain medicines help to stop alcohol consumption by either reducing cravings or making you feel sick if you drink alcohol.

Lifestyle management

If you are diagnosed with fatty liver disease, there are some lifestyle changes that you can incorporate to manage the condition more effectively. These include:

• Include 3-4 portions of fresh fruits and vegetables into your diet. Avoid excessive sugar and salt intake and opt for whole grains instead of processed foods. 
• Cut down the intake of foods with saturated fats and trans fats and replace them with monounsaturated fats and polyunsaturated fats, especially omega - 3 fatty acids to reduce chances of heart diseases associated with NAFLD.
• Exercise regularly to keep your weight in check and to reduce the accumulated fat in the liver.
• If you are taking food supplements such as vitamins, or alternative herbal medicines then it is very important to talk to your doctor about it and take his/her advice. Certain herbal medicines can cause damage to your liver.
• People with liver damage are more prone to certain infections and pneumococcal diseases. It is important that people with fatty liver disease get the vaccination for hepatitis A and B, flu, and pneumococcal diseases. Hepatitis can be very dangerous for individuals with fatty liver and may even lead to liver failure.

Prognosis

A healthy liver has a great ability to heal itself, even grow back and regenerate if it is injured. Timely diagnosis and treatment ensure that fatty liver disease is stopped, and the damage is reversed which is seen in many cases. Inflammation and fibrosis are the first signs of liver damage. If fatty liver disease is diagnosed at this early stage, there are high chances that your liver may heal itself over a period. Healthy lifestyle and dietary changes need to be incorporated to help the liver in healing itself. Fibrosis progresses to cirrhosis where there is less of healthy tissue in the liver. Treatment at this stage is targeted at stopping the progression of the disease and protecting the healthy liver tissue.  

Complications

The end stage of fatty liver disease is liver failure. Liver failure occurs due to cirrhosis or due to malnutrition. If liver failure is due to cirrhosis, it indicates that the liver failure has been gradual and that the liver function has deteriorated slowly over a period, possibly years. Liver failure due to malnutrition can be sudden and can occur in as little as 48 hours. A liver transplant may be the only treatment option in such cases.