Name
FATTY LIVER
DESCRIPTION
DETAIL
CAUSES : - ALCOHOL OR ALCOHOLIC LIVER DISEASE - NON-ALCOHOLIC STEATO HEPATITIS ( NASH ) - DIABETES MALLITUS - OBESITY - PROTEIN CALORIE MALNUTRITION - TOTAL PARENTERAL NUTRITION - JEJUNOILIAL BYPASS - DRUGS LIKE METHOTREXATE, ASPIRIN, VIT A , GLUCOCORTICOIDS, AMIODARONE, SYNTHETIC OESTROGENS, VALPROIC ACID, TETRACYCLINE, NUCLEOSIDE ANALOGUES ( DDL, AZT ) - REYE SYNDROME - ACUTE FATTY LIVER OF PREGNANCY - JAMAICAN VOMITING SICKNESS -------------------------------------------------------------------------- DIFFERENTIAL DIAGNOSIS β’ Viral hepatitis β’ Drug induced hepatitis β’ Occupational exposure β’ Metabolic liver diseaseβ’ CBC is normal β’ Sedimentation rate normal β’ Liver tests (albumin, bilirubin, prothrombin time, alkaline phosphatase, GGPT) normal but both ALT and AST enzymes elevated with ALT>AST β’ Lipids almost always abnormal. Cholesterol elevated 60%. 45% decreased HDL, 58% increased LDL. 50 to 80% elevated triglycerides. β’ 30-100 % are diabetic with elevated insulin β’ Leptin elevated more than expected for obesity IMAGING β’ Ultrasound often detects hepatomegaly with bright irregularities which is usual finding in fat β’ CT scan can be diagnostic of fat for it has decreased density in Hounsfi eld Units compared to all other conditions of the liver. Focal fat deposits usually represents a transient change when marked weight loss occurs and is not related. DIAGNOSTIC PROCEDURES : β’ Liver biopsy . Patients with unexplained hepatomegaly and elevation of the ALT, AST enzymes persisting for at least 3 months . Liver biopsy separates benign fatty liver from NASH, thereby helping to establish prognosis
TYPENOTES
GENERAL MEASURES : β’ Obesity; when body mass index (BMI) greater than 30, should be treated. Weight loss to ideal body weight is the single most evaluated and effective treatment. Fully half of obese NASH patients will normalize the ALT, AST enzymes and loose fat on CT scan. β’ Diabetes should be tightly regulated β’ Other identifi ed risk factors should be corrected if possible β’ All alcohol use should be discontinued permanently SURGICAL MEASURES β’ Weight reduction operations such as gastric bypass are frequently utilized with reduction of obesity and improvement in NASH ACTIVITY : β’ No restrictions β’ Daily regimen of physical activity recommended DIET: β’ Weight, diabetes, and blood lipid control are the goals β’ Regular visits to a dietitian are useful β’ Usually restriction of both total energy (calories), simple carbohydrates, and alcohol are required to control diabetes, weight and lipids PATIENT EDUCATION Planning for lifelong change in eating, exercise, and alcohol use is required. As such, regular education and motivation sessions are of value. DRUG(S) OF CHOICE : β’ General: . Drugs to control diabetes and elevated lipid levels are required if those conditions are present . Drugs to facilitate weight loss may be used on a temporary basis β’ Specific, used only in biopsy proven NASH when weight reduction, diabetes and lipid control have failed. These treatments are considered experimental but have normalized ALT and AST and reduced fat in the liver in pilot studies: . Troglitazone . Metformin . Pioglitazone PATIENT MONITORING : β’ Repeat liver tests (ALT, AST) each 2 to 4 months β’ Yearly US or CT scan to show diminution in fat β’ Changes toward normal provide major motivation to continue life style changes PREVENTION/AVOIDANCE: β’ Avoid alcohol β’ Avoid unessential medications including health food and OTC agents β’ Obtain hepatitis A and B vaccination if not immune β’ Obtain Pneumovax and yearly infl uenza vaccination POSSIBLE COMPLICATIONS: β’ Limited to patients with NASH: . Progression of liver fi brosis to cirrhosis. Believed to be the major cause of cryptogenic cirrhosis. . Liver failure with ascites, encephalopathy, and bleeding varices . Hepatocellular carcinoma . Consideration of transplantation EXPECTED COURSE/PROGNOSIS : β’ Goals of treatment: . Fatty liver without NASH (no fibrosis, no hepatitis): non-progressive disease, treat to control symptoms . Fatty liver with NASH: progressive disease, treat to normalize ALT, AST and to diminish fat in liver as verifi ed by yearly ultrasounds β’ NASH form of fatty liver : . Slowly progressive . Normalization of AST, ALT with treatment slows progression but does not stop it . Diminution of fat on serial images or biopsy slows progression but does not stop it . Cirrhosis develops in about 25% of patients after 20-30 years . Liver failure from cirrhosis occurs in 1-5%. Transplantation is effective. NASH has infrequently recurred after transplantation.
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
BLOOD SUGAR ( FASTING ), ULTRA SOUND WHOLE ABDOMEN - MALE, BLOOD SUGAR ( AFTER MEALS ), COMPLETE BLOOD COUNT, CT SCAN ABDOMEN, LIPIDS PROFILE, LIVER FUNCTION TEST, BIOPSY