Fatty liver disease – Potentially a ticking time bomb

Anecdotal evidence strongly suggests that up to 35% of adults referred for an abdominal ultrasound have fatty liver disease (FLD). So much so, that I considered it incumbent to dedicate this Physician’s Weekly instalment to this prevalent, poorly understood, yet potentially life-threatening condition.

The anatomy of the liver

The liver is a dark reddish-brown wedge-shaped organ, snugly located in the right upper quadrant of the abdominal cavity. Its average weight is three pounds or 1.36 kilograms. A protective fibrous capsule covers the liver, which in turn is encapsulated by the peritoneum. It consists primarily of a large right and a smaller left lobe. These lobes are separated by the falciform ligament. The liver is divided into eight segments. These segments contain a total of 1,000 smaller lobules.

Function of the liver

Over 500 functions of the liver have been identified. Some of the most notable include:

• Processing all the blood leaving the stomach and intestine.
• Helping to regulate the body’s temperature.
• Producing bile which is secreted into the small intestine to help with the digestion of fat.
• It makes a range of proteins, including clotting factors, which are released into the blood.
• Manufactures cholesterol, which is an integral building block for cell membranes, bile acids, vitamin D, glucocorticoids, steroid hormones, and sex hormones.
• Stores excess blood glucose in the form of glycogen. If and when needed, glycogen can be reconverted into glucose and released into the blood.
• Plays an integral role in blood clotting.
• Regulates the essential building blocks for circulating proteins – amino acids.
• Breaks down and eliminates alcohol, drugs, toxins, and other substances.
• Clears the blood of bilirubin which is a by-product of the haemoglobin released from destroyed red blood cells.
• Manufactures immunoglobulins to attack viruses, bacteria, and other microbes entering the body.
• Stores a range of vitamins and minerals – e.g. A, D, E, K, B12, as well as iron and copper.

Types of fatty liver disease (FLD)

A build-up of fat in the liver cells (hepatocytes) is referred to as FLD. There are two types of FLD – Alcohol Fatty Liver Disease (AFLD) and Non-Alcohol Fatty Liver Disease (NAFLD). It is estimated that 25% of adults have NAFLD. AFLD is common in persons who are heavy alcohol consumers over a protracted period.

How the build-up of fat in the liver cells causes damage

The excess fat accumulating in the liver cells over time essentially overcrowds the cell. If progressive, this results in significant damage to the cell and by extension liver, over time. Initially, there are inflammatory changes in the liver (steatohepatitis). Once persistent, this is followed by scarring (hepatofibrosis). Over time, the liver’s functions can be significantly compromised (cirrhosis).

About 3-5% of persons with NAFLD will develop cirrhosis. AFLD progresses to cirrhosis in 10-25% of individuals who have been drinking heavily for 10 years or more. AFLD progresses more rapidly in females than males, all other variables being equal.

Stages and progression of FLD

• Grade 1 (simple steatosis): This has an excellent prognosis and can be reversed with lifestyle intervention. See the treatment of FLD below.
• Grade 2 (steatohepatitis): If not treated can lead to cirrhosis, liver failure, and liver cancer.
• Grade 3 (hepatofibrosis): This leads to premature death if not aggressively managed.
• Cirrhosis: In the early stages, the life expectancy is 12-15 years. In advanced stages, life expectancy is less than two years.

Causes of a NAFLD

• Being overweight/ obese
• Type 2 diabetes or insulin resistance
• Elevated blood fats – cholesterol and triglycerides
• Metabolic syndrome
• Large waist size
• Hypothyroidism
• Poly Cystic Ovarian Syndrome (PCOS)
• Medicines – amiodarone, diltiazem, tamoxifen, corticosteroids, methotrexate, azathioprine, certain antidepressant/ antipsychotic medications, some anti-seizure/ epileptic medications, niacin, ketoconazole, anabolic steroids
• Hypertension
• Advancing age
• Menopause
• Rapid weight loss
• Infections – Hepatitis B & C
• Toxins – dry cleaning solvents, herbicides, and industrial chemicals.

Early symptoms of FLD

FLD is not associated with any symptoms until the disease is quite advanced.

How is the diagnosis made?

• A thorough medical history may raise the doctor’s index of suspicion.
• An enlarged liver may be detected on physical examination.
• Abnormal liver function tests.
• Via an abdominal ultrasound or MRI.

Potential complications from progressive FLD

•  Hepatitis
• Type 2 diabetes
• Hypertension
• Kidney disease
• Cirrhosis
• Liver failure
• Liver cancer
• Premature death

Treatment of FLD

There are no specific medications for NAFLD. In some instances, the condition may spontaneously disappear. However, everyone with FLD can benefit from the following interventions.

• Loss of weight if overweight.
• Ceasing alcohol consumption.
• Quitting smoking/ avoiding second hand smoke.
• Strict control of diabetes.
• Tight control of abnormal lipid levels.
• Increasing physical exercise.
• Avoiding saturated and trans fats.
• Increased consumption of fibre, fruits, complex carbohydrates, vegetables, and nuts.
• Avoiding medications that contribute to NAFLD.
• Minimize sugar consumption.
• Correcting hypothyroidism.
• Managing PCOS.
• Controlling hypertension.
• Once there are no contraindications, drinking coffee.
• Avoiding red meats and processed foods.

Author: Dr. C. Malcolm Grant – Family Physician – Family Care Clinic, Arnos Vale – Former Tutor, Faculty of Medical Sciences, UWI, Cave Hill, Barbados. For appointments: clinic@familycaresvg.com, 1(784)570-9300 (Office), 1(784)455-0376 (WhatsApp)

Disclaimer: The information provided in the above article is for educational purposes only and does not substitute for professional medical advice. Please consult a medical professional or healthcare provider if you are seeking medical advice, diagnoses, or treatment. Dr. C. Malcolm Grant, Family Care Clinic or The Searchlight Newspaper or their associates, respectively, are not liable for risks or issues associated with using or acting upon the information provided above.