Non- alcoholic fatty liver disease

Contents

• What is fatty liver?
• Who gets fatty liver?
• What tests might I have to diagnose fatty liver?
• What happens if my tests indicate that I just have fatty liver?
• What if I am found to have non-alcoholic steatohepatitis (NASH)?
• What are the symptoms of fatty liver/NASH?
• What is cirrhosis?
• What can I do if I have fatty liver or NASH?

What is fatty liver?

Fatty liver is a condition where fat accumulates in the liver. Whilst some people with fatty liver do not get severe liver damage, for other people the fat in the liver causes inflammation and scarring over a period of time resulting in a condition called NASH (Non-alcoholic steatohepatitis).

Who gets fatty liver?

Fatty liver is now the most common cause of liver disease and it is estimated that about one in every four people in the UK have it.

People who get fatty liver are commonly, but not always, overweight. For all people, the heavier we are, especially when weight goes on the stomach, the more likely we are to develop type 2 diabetes, high blood pressure, high cholesterol and fatty liver. This is also linked to an increased risk of developing heart disease. Where you carry your extra weight may put you at more risk of liver disease and indeed other health problems too. If your body is an “apple” shape, you will carry extra fat around your abdominal area.

Some drugs such as steroids, Sodium Valproate, Methotrexate, Tamoxifen and Amiodarone can cause fatty liver and we can advise you regarding these.

What tests might I have to diagnose fatty liver or NASH?

A number of different sorts of tests are used to assess whether a person has fatty liver and, if so, whether it is causing significant damage to the liver

Blood tests

These allow us to look for a number of causes of liver disease and also other health conditions (for example, diabetes and high cholesterol).

Fibroscan

This is very similar to an ultrasound, the probe does not take pictures of the liver, but instead gives a pulse of vibration to the skin over the liver and measures the stiffness of the liver to estimate the degree of scarring (or fibrosis). We will do this at your clinic appointment. If this test indicates increased liver stiffness it may mean you have some liver damage.

Liver ultrasound

This is used to assess whether there may be fatty liver and also whether there is evidence of severe scarring to the liver. This is a procedure very similar to the one used for pregnant women to look at their unborn baby. Gel will be put on your abdominal area and a probe will be applied this will allow the radiologist to look at your liver. The procedure will last around ten minutes.

MRI Elastography

This is MRI based technology that uses imaging with sound waves to create a detailed picture of your liver. MRI Elastography gives a good indication of how severe the scarring is and is often used when a fibroscan is not possible.

Liver biopsy11

This is a procedure whereby a tiny sample of liver tissue is taken under local anaesthetic, using ultrasound-guidance. This procedure is carried out if we suspect you have inflammation and scarring on the liver or we are concerned about your blood results and the possibility that something else is affecting your liver. It is currently the best way of assessing the nature and the degree of liver damage. This test is carried out in our Radiology Day Unit. You will be injected with a local anaesthetic to numb the area where the biopsy will be taken. A small hollow needle will then be inserted into the liver to get a small sample of liver tissue. You will then be asked to lie on your right side for about two hours and be on bed rest for around a further four hours. Your blood pressure and pulse will be checked on a regular basis as there is a small risk of bleeding. The liver tissue is then looked at by a specialist, which takes around two to three weeks. You will be asked to attend clinic for your biopsy result. If you have not received an appointment for clinic follow up please contact your hepatology Clinical Nurse Specialist on 01223 217591. You can of course decide not to have a liver biopsy and we are happy to discuss this with you.

What if my test results indicate that I just have fatty liver, without scarring?

If your tests suggest that you just have fatty liver, we may refer you back to your GP and ask them to monitor your blood tests in 2-3 years. If they have any concerns following these tests we will ask them to refer you back for a further assessment with a Fibroscan. If needed from there, we may arrange a liver ultrasound and blood tests.

As the following advice will explain it is essential for your overall health to address your diet and levels of physical activity.

What if I am found to have non-alcoholic steatohepatitis (NASH) - what does it mean?

The specialist who looks at your liver biopsy will be able to determine the level of liver damage that you have. This may be:

• Mild scarring linked to fatty liver - we will see you every two years. We will repeat your liver blood tests and Fibroscan and if there is some suggestion that your liver damage has progressed we may need to repeat your liver biopsy.
• Moderate scarring linked to fatty liver – this means that the scarring is at a moderate stage, but there is a risk that the scarring may get worse over a period of a few years. Because of the increased risk of the disease worsening, we see people with this stage of liver disease every year. We will carry out a liver ultrasound scan, a fibroscan and special blood tests. We like to repeat the liver biopsy at three years to see whether the scarring is worsening.
• Severe scarring linked to fatty liver or Cirrhosis – this means that there is extensive scarring, which is distorting the structure of the liver. There is an increased risk of liver cancer in people with cirrhosis and therefore people with this stage of liver disease have an appointment in the Liver Clinic every six months, or more frequently if needed and check their liver blood tests, as well as six monthly liver scans.

What are the symptoms of fatty liver/NASH?

Most people do not have any symptoms from their fatty liver but this does not mean that there is not damage occurring in your liver, it is still important to make the changes suggested to prevent further deterioration.

Some people will complain of mild discomfort around the upper right-hand side of their abdomen where the liver is located. Your liver is encased in a capsule and if you have fat in your liver this can causes the capsule to stretch causing discomfort

Some people complain of tiredness and fatigue.

Some people have symptoms from the health conditions that are linked to fatty liver, including diabetes, high blood pressure, sleep apnoea and heart disease.

One of the problems with liver disease is that the liver does not usually give symptoms as it is being damaged, and therefore people can develop severe liver disease with cirrhosis without any liver-related symptoms. The absence of symptoms therefore does not mean that there is no liver disease.

Some people who have NASH with cirrhosis, can over time develop other specific symptoms of liver disease, such as jaundice (yellow eyes and/or skin), or swelling of the ankles and abdomen with fluid and bleeding from the gut. These issues will be discussed with people who are found to have cirrhosis.

What is cirrhosis?

Cirrhosis is caused by continuous long-term damage to the liver leading to scarring. Cirrhosis can be due to a number of things, including alcohol, viral infections, damage from the immune system and also hereditary causes, but is also commonly seen in people with obesity and type 2 diabetes. A healthy liver has a smooth outline and is soft in texture but cirrhosis causes the liver to become hard with irregular bumps, called nodules. Over time in cirrhosis the liver can run out of healthy cells to support its normal functions, and people can start to develop signs of liver failure.

What can I do if I have fatty liver or NASH?

If you are overweight, it is really important to make lifestyle changes. There is evidence to suggest that gradual weight loss and the introduction of regular exercise reduces fat in your liver. If you are able to lose 10% of your body weight, the fat, inflammation and scarring in your liver will improve.

We can advise you about diet and exercise programs available in your area and offer you written information regarding recommended national guidelines on exercise and a booklet on diet.

If you are eligible, we can also offer a referral to our colleagues in the Obesity Service or if you live outside the Cambridge area we will ask your G.P. to refer you locally.

How do I lose weight?

Eating regular meals, including a healthy breakfast will help you lose weight, your diet should include plenty of fruit and vegetables and high fibre foods (for example oats, wholegrain bread, brown rice and pasta). You should drink plenty of water as thirst can often be confused with hunger and ensure that your portion sizes are not too large, eating from smaller plates may help with this. You do not need to ban foods from your diet but we would suggest not having a stock of junk food at home and opting for healthier snacks such as fruit, unsalted nuts, rice cakes and unsalted or unsweetened popcorn. Looking at food labels is a good way of understanding whether the food you choose is healthy and there is a link at the bottom of this page that will explain this further.

If you are diabetic it is really important that your diabetes is well controlled. One of the blood tests we check is your Hba1c. This tells us how well your diabetes has been controlled over the last few weeks. If this is elevated, we will suggest to your GP that your medication may need to be reviewed. If appropriate you may benefit from a referral to a specialist diabetic clinic. If you are not diabetic, we will check your glucose (sugar) levels at each of your clinic appointments to make sure that you have not developed diabetes.

If you have a high cholesterol level, we may ask your G.P. to consider starting you on medication. A lot of people think that you should not be started on medication such as statins or fibrates if you have liver disease. If you have a heart disease risk that suggests you should be on a statin (this will be being monitored at your GP surgery) we would recommend that you do take one, unless you have other health problems that mean that you cannot take this sort of medication. Your cholesterol levels will be monitored as part of keeping an eye on your liver disease.

If you are on medication that causes fatty liver, we may ask your GP or another specialist doctor to consider stopping this and changing to an alternative drug if possible.

If you have a high blood pressure it is important that this is well controlled. If you are already on medication your blood pressure will be checked at your GP surgery as advised. We will measure your blood pressure at your clinic visits, if we find your reading is elevated, we will ask you to make an appointment with your GP or practice nurse to have this monitored. They may start you on medication if indicated.

If you drink alcohol - if people have cirrhosis we recommend complete abstinence from alcohol, given the degree of liver damage. For people with a moderate degree of scarring we would recommend that consumption is less than 10 units of alcohol/week. Alcohol has not caused your liver disease, but having liver damage from another cause increases the sensitivity of the liver to damage from alcohol.

There is no medication at present that is definitively proven to improve fatty liver or NASH long term. There are, however, a number of new treatments that have shown promising results in treating people with NASH and we are involved in a number of studies involving these medications. As such, you may be approached and asked if you would like to be involved in one of these studies. Your treatment will not be affected in any way if you decide you do not want to be involved.

We hope this information has helped you understand your liver disease

If you have any questions or concerns, please do not hesitate to discuss them with us.

Where can I find more information?

Fatty Liver

NHS Non-alcoholic fatty liver disease (NAFLD) (opens in a new tab)

British Liver Trust Non-alcoholic fatty liver disease (NAFLD) (opens in a new tab)

Diet

Start the NHS weight loss plan (opens in a new tab)

Myfitnesspal.com (opens in a new tab)

Food labels (opens in a new tab)

Exercise

Exercise (opens in a new tab)

Couch to 5K: week by week (opens in a new tab)

Dr Michael Allison Consultant Hepatologist
Donna Goodge Clinical Nurse Specialist