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Fatty Liver

Fatty liver is the accumulation of triglycerides and other fats in the hepatocytes. It is commonly associated with alcohol, drugs, overnutrition or metabolic syndrome.


Presentation

Fatty liver will induce slow and increasing malaise, weakness and anorexia. Hepatomegaly is seen in cases of fatty liver. Jaundice will be seen in around 20% of the patients. Discomfort in the upper abdomen is commonly seen. Nausea, vomiting, abdominal pain are rare.

Liver function tests might show elevated transaminases. Fatty liver is reversible in the initial stages of the liver pathology, but continued alcohol consumption may result in alcoholic hepatitis or cirrhosis [4].

Fatigue
  • Researchers also speculate that changes in brain chemistry and hormone production contribute to feelings of fatigue and exhaustion.[activebeat.com]
  • CASE SUMMARY: A 61-year-old obese man presented with jaundice, nausea, fatigue, and an unintentional weight loss 2 weeks following initiation of metformin. Laboratory findings revealed aminotransferase values 10-15 times the upper limit of normal.[ncbi.nlm.nih.gov]
  • See your provider if you begin to have unusual symptoms such as fatigue or abdominal pain. To help prevent NAFLD: Maintain a healthy weight. Eat a healthy diet. Exercise regularly. Limit alcohol consumption. Use medicines properly.[nlm.nih.gov]
  • SYMPTOMS OF FATTY LIVER DISEASE Fatty liver disease frequently shows no symptoms, or mild symptoms such as: Fatigue; Weakness; Nausea; Abdominal pain.[barnesjewish.org]
  • Let your doctor know if you’ve been experiencing fatigue or loss of appetite. Also, tell your doctor about any history of alcohol, medication, and supplement use.[healthline.com]
Weight Gain
  • These improvements occurred despite a 4.5-kg weight gain since starting rosuvastatin and pioglitazone. DISCUSSION: Pharmacotherapy in NAFLD is not well validated, particularly combination therapy.[ncbi.nlm.nih.gov]
  • Although a fatty diet and weight gain is the main culprit, diabetes, hyperlipidemia (or elevated lipids in the blood), and alcohol abuse (with 90 to 100-percent of binge drinkers contracting fatty livers) will also increase the chances.[activebeat.com]
  • Sudden weight loss or sudden weight gain will lead to fatty liver.[symptoma.com]
  • Fat accumulates in the liver usually in connection with heavy use of alcohol, weight gain or diabetes.[herbalprovider.com]
  • gain is significant and weight loss maintenance is challenging in the long term. 43 A low carbohydrate diet may improve NAFLD more than other forms of dietary restriction; 23 however, evidence is mixed and studies comparing different dietary constituents[doi.org]
Short Stature
  • KEYWORDS: GPD1 deficiency; GPD1 gene; insulin resistance; novel variants; obesity; short stature[ncbi.nlm.nih.gov]
Turkish
  • Cognitive functions were evaluated using the Turkish version of the MoCA, with a cut-off score for mild cognitive impairment of less than 21 points.[ncbi.nlm.nih.gov]
Nausea
  • The treatment was well-tolerated any typical adverse reactions such as diarrhea, nausea, and hand-foot syndrome (HFS) were noted.[ncbi.nlm.nih.gov]
  • CASE SUMMARY: A 61-year-old obese man presented with jaundice, nausea, fatigue, and an unintentional weight loss 2 weeks following initiation of metformin. Laboratory findings revealed aminotransferase values 10-15 times the upper limit of normal.[ncbi.nlm.nih.gov]
  • SYMPTOMS OF FATTY LIVER DISEASE Fatty liver disease frequently shows no symptoms, or mild symptoms such as: Fatigue; Weakness; Nausea; Abdominal pain.[barnesjewish.org]
  • If the Liver has begun to be damaged then you may experience; Low appetite Weight loss Pain in the central or upper right stomach Weakness Some confusion or difficulty concentrating Nausea Swelling in the liver region Fatty liver is confirmed through[macmurray.co.nz]
  • Nausea, vomiting, abdominal pain are rare. Liver function tests might show elevated transaminases.[symptoma.com]
Vomiting
  • A 20-year-old woman, primigravida at 36( 4) weeks' gestation presented with malaise, vomiting for 1 week, yellowish discoloration of the eyes for 3 days and loss of fetal movements.[ncbi.nlm.nih.gov]
  • Nausea, vomiting, abdominal pain are rare. Liver function tests might show elevated transaminases.[symptoma.com]
  • In fatty liver of pregnancy there may be nausea, vomiting, abdominal pain and jaundice. How does fat get into the liver? Fat enters the liver from the intestines and from the tissues.[aucklandgastro.co.nz]
  • The person may vomit blood or pass black stools. If you have any additional questions, please see our frequently asked questions page.[my.clevelandclinic.org]
  • […] weight, discomfort under the right rib cage, elevated cholesterol, coated tongue, poor immune health, increasing allergies, poor blood sugar control, lipomas (lumps of fat under the skin), digestive problems such as reflux, bloating, indigestion, nausea, vomiting[rebootwithjoe.com]
Loss of Appetite
  • If symptoms appear, they may include: A feeling of fullness in the middle or upper right side of the abdomen Abdominal pain Loss of appetite or weight loss Nausea Weakness Jaundice (yellowing of the skin and the whites of the eyes) Swelling of the abdomen[my.clevelandclinic.org]
  • However, you may experience the following: Tiredness Bloatedness Loss of appetite Pain in the right upper abdomen Late symptoms relate to the complications of liver cirrhosis and include nausea, jaundice, swollen abdomen and poor concentration.[healthxchange.sg]
  • When symptoms occur, the most common include: Fatigue Pain in the upper right abdomen In people with NASH who have liver damage (cirrhosis), symptoms may include: Weakness Loss of appetite Nausea Yellow skin and eyes (jaundice) Itching Fluid buildup and[nlm.nih.gov]
  • Typically, NAFLD presents with few or no symptoms, [ 3 ] but possible signs include: fatigue, weakness, weight loss or loss of appetite, nausea, abdominal pain, and jaundice. NAFLD is usually confirmed via blood tests and ultrasounds.[globalhealingcenter.com]
  • When the liver is very much enlarged, there will be gastro-intestinal disturbances, with loss of appetite, flatulence, nausea, and sometimes vomiting; diarrhea, 'alternating with constipation, occurs, and the stools contain mucus.[henriettes-herb.com]
Jaundice
  • Severe hepatopathy accompanied by jaundice used to be considered a rare complication.[ncbi.nlm.nih.gov]
  • CASE SUMMARY: A 61-year-old obese man presented with jaundice, nausea, fatigue, and an unintentional weight loss 2 weeks following initiation of metformin. Laboratory findings revealed aminotransferase values 10-15 times the upper limit of normal.[ncbi.nlm.nih.gov]
  • Jaundice - yellowing of the skin and the whites of the eyes. Tumor - an abnormal growth of cells which can be benign (non-cancerous) or malignant (cancerous). Varices - abnormally dilated and lengthened veins.[my.clevelandclinic.org]
  • The absence of jaundice, ascites, and splenic enlargement, would also render the diagnosis more positive. Prognosis .—This depends upon the condition.[henriettes-herb.com]
  • Patients who have abdominal swelling , jaundice, and easy bruising should seek medical care, though the cause may not necessarily be steatohepatitis or cirrhosis.[emedicinehealth.com]
Hepatomegaly
  • Furthermore, these cases of hepatomegaly and fatty liver have been also in the context of concomitant extrahepatic side effects.[ncbi.nlm.nih.gov]
  • Ultrasound of abdomen reveals a brighter echogenicity of the liver along with hepatomegaly. Fatty liver has lower density than spleen and hence can be easily identified on CT scans.[symptoma.com]
  • Hepatomegaly has been reported in a minority of patients. Elevated liver enzymes (such as AST/ALT) may be present, especially with NASH.[radiopaedia.org]
  • Examination Hepatomegaly is very common. Splenomegaly with or without portal hypertension may occur with cirrhosis. Signs of chronic liver disease may be seen in patients with cirrhosis (ascites, oedema, spider naevi).[patient.info]
  • […] likely ‡ Criteria for nonalcoholic fatty liver disease: consumption of ethanol less than 20 g/day for women and 30 g/day for men [21] Most individuals are asymptomatic and are usually discovered incidentally because of abnormal liver function tests or hepatomegaly[en.wikipedia.org]
Amenorrhea
  • LESSONS: Physicians should consider the possibility of PRLoma when diet and exercise fail to improve fatty liver disease in a patient with endocrine symptoms such as amenorrhea.[ncbi.nlm.nih.gov]

Workup

Broadly the disease may be differentiated from alcoholic Hepatitis, alcoholism, autoimmune hepatitis and cirrhosis [7]. 

Laboratory investigations include liver function tests which tend to be abnormal. Serum alanine levels are higher than serum aspartate levels in non alcoholic variant of fatty liver whereas it is the opposite in the alcoholic variant.

Fasting insulin and glucose levels might be done to look out for underlying diabetes and treat accordingly.

Ultrasound of abdomen reveals a brighter echogenicity of the liver along with hepatomegaly. Fatty liver has lower density than spleen and hence can be easily identified on CT scans. A series of scans are helpful in evaluating the progress of fatty liver.

Increased serum ferritin levels are commonly seen along with decreased transferrin saturation levels. These indicate that simply reducing dietary iron will help reverse the increase in size of the liver.

Many a times a complete overall picture shows that there is obesity along with increased serum transaminases and also hypertriglyceridemia. All these when put together gives a diagnosis of fatty liver [8].

Histology reveals signet ring appearance of the liver cells with nucleus pushed on to the periphery of the liver cell. Macrocytosis is commonly seen in all patients with fatty liver and hence it is almost 75% specific.

Hypoketotic Hypoglycemia
  • hypoglycemia; the mother had a history of acute fatty liver in a previous pregnancy leading to fetal death at 34 weeks of gestation.[ncbi.nlm.nih.gov]
Treponema Pallidum
  • Our findings suggest that the occurrence of fatty liver can exacerbate the damage to the hepatic parenchyma due to a Treponema pallidum infection. [Indexed for MEDLINE] Free full text[ncbi.nlm.nih.gov]

Treatment

Proper diet along with curtailment of alcohol intake is the mainstay of treatment for fatty liver. There is no medicine that can reverse the fatty liver. Medications are indicated to control certain pathologies which lead to fatty liver. Alcohol abstinence will help to control fatty liver as it is the most important causative factor of fatty liver [9].

A balanced, low-carb and low fat diet should be taken by the patient. Sudden weight loss or sudden weight gain will lead to fatty liver.

Vitamin E should be taken at dosage of 800mcg/day and Vitamin C 60mg/day, if given in high risk patients, will reduce the chances of fatty liver and will also postpone the formation of fat globules in the cells of the liver [10]. 

Metformin may be indicated in patients who show hypertriglyceridemia and insulin resistance. Weight loss in obese patients will help in reducing the amount of fatty liver and progressively will return back to normal.

Prognosis

Fatty liver is a reversible condition [5]. It is considered to be a benign condition wherein changes can be reversed if there is weight loss and withdrawal of alcohol. The histologic changes return back to normal within 4 to 6 weeks.

If a patient continues to have alcohol despite having fatty liver, there are increased chances of him suffering from cirrhosis or alcoholic hepatitis [6]. This change in pathology will increase both morbidity and mortality.

Etiology

There are many causes giving rise to the fatty liver [3]:

  1. Alcohol intake beyond 60 grams per day.
  2. Diabetes which gives rise to insulin resistance and eventually, there is lipid deposition and storage in the liver.
  3. Impairment or inhibition of receptor molecules of fatty acids as well as imbalance of enzymes which monitor fatty acid oxidation.
  4. Obesity
  5. Genetic predisposition
  6. Corticosteroid intake
  7. Deranged metabolism of fatty acids and hence, increased formation along with decreased uptake.
  8. Drugs like tamoxifen, methotrexate, amiodarone.
  9. Metabolic abnormalities like glycogen storage diseases, galactosemia, tyrosiunemia.
  10. Nutritional status like total parental nutrition or starvation diet.

Epidemiology

Fatty liver is also called as steatosis and is seen in approximately 25 to 35 % of the population. Fatty liver develops in 90% of the heavy alcohol drinkers. People of all age group can have fatty liver.

Females are more easily affected than males. Females will be seen with fatty liver changes with lesser amount of alcohol intake over a shorter duration of time. Fatty liver is the commonest cause of abnormal liver tests in the United States.

Sex distribution
Age distribution

Pathophysiology

Fatty liver change is a slow and reversible process seen in the liver. It is basically seen due to imbalance between the fatty acid production and fatty acid oxidation. Initially, there are fat droplets being deposited around the nucleus of the liver cells. This process is called microvesicular fatty liver change [2]. There are plenty of fat droplets being placed around the nucleus and there is no displacement of the nucleus and hence, this stage is reversible.

Later on, there is progressively increasing fatty droplet deposition and there is displacement of the cell nucleus such that it is seen at the cell’s periphery. This is known as macrovesicular fatty liver change. On examination under the microscope, the fat vesicles are washed off and there is appearance of ‘signet ring’ like liver cells with the nuclei being pushed to the periphery [4]. Optically, the liver cell appears empty.

Prevention

The only way to prevent fatty liver is to avoid alcohol completely or indulge only rarely. The other causes like diabetes are not truly preventable. Maintaining good Body Mass Index (BMI) and having a well-balanced, low fat diet are important to prevent diabetes and thereby metabolic syndrome and fatty diabetes which are important associations of fatty liver.

Summary

Fatty liver is collection of triglycerides and fats in the cells of the liver. The fatty acids are normally maintained within normal limits by striking a balance between accumulation and removal of fatty acids. Fatty liver is seen as a result of two processes namely deficient fatty acid beta oxidation and simultaneously, increased production of fatty acid [1].

Both these processes lead to increased endogenous fatty acid deposits causing precipitation of fatty liver.
Fatty liver is commonly seen in alcoholic patients, those consuming over 60g alcohol each day for a period of more than 1 year. Fatty liver is a reversible pathology usually seen as a result of increased alcohol consumption.

Patient Information

Fatty liver is infiltration of fats in liver cells. When there is imbalance between fatty acid oxidation and fatty acid intake in the body, it leads to accumulation of fats in the liver cells.

Sometimes this fatty liver may be caused by ingestion of drugs, obesity, hypertriglyceridemia (increased levels of triglyceride in the blood), starvation, prolonged parental nutrition (dietary intake by nasogastric tube), prolonged intake of alcohol etc. Alcohol intake is the most common cause for fatty liver.

Females will be affected with lesser levels of alcohol as compared to males. A minimum quantity of 20gm of alcohol per day for a prolonged period will cause fat deposition in the liver. The liver cannot function when there is excess of fat accumulated in the liver cells, leading to a rise in the titres of the enzymes produced by liver.

Liver function will be abnormal and there will elevated levels of transaminases and bile. All these changes will cause nausea (feeling of vomiting), anorexia (loss of appetite), discomfort in the upper abdomen, weakness and prostration and enlargement of the liver. There is hepatomegaly (increased size of the liver) in almost 70% of the cases.

This condition of fatty liver can be diagnosed by blood tests like liver function test, Ultrasonography, CT scan and MRI. This is otherwise a very benign condition that can be reversed easily. If a person stops drinking alcohol there will be reversal of fatty liver in a period of 4 to 6 weeks. Complete abstinence of alcohol is the best way to treat fatty liver. Secondly, proper diet and nutrition will help obese persons reduce weight and will help reduce the excess fat in the liver cells. Prognosis is very good if cirrhosis and hepatitis does not set in.

References

Article

  1. Guy CD, Suzuki A, Zdanowica M Abdelmalek M et al. Hedgehog pathway activation parallels histologic severity of injury and fibrosis in human nonalcoholic fatty liver disease. Hepatology. 2012 June; 55(6):1711-21..
  2. Reddy JK, Rao MS. Lipid metabolism and liver inflammation. II. Fatty liver disease and fatty acid oxidation. Am J Physiol Gastrointest Liver Physiol. 2006 May;290 (5): G852–8.
  3. Day CP, James OF. Steatohepatitis: a tale of two "hits"? Gastroenterol. 1998 Apr; 114 (4): 842–5.
  4. Medina J, Fernández-Salazar LI, García-Buey L, Moreno-Otero R. Approach to the pathogenesis and treatment of Non-alcoholic steatohepatitis. Diabetes Care. 2004 Aug;27 (8): 2057–66.
  5. Daniel J. DeNoon (September 26, 2008) et al. Fatty Liver Disease: Genes Affect Risk. WebMD. Retrieved April 6, 2013.
  6. Hamaguchi M, Kojima T, Takeda N, Nakagawa T, et al. The metabolic syndrome as a predictor of nonalcoholic fatty liver disease. Ann Intern Med. 2005 Nov 15;143 (10): 722–8.
  7. Qian Y, Fan JG. Obesity, fatty liver and liver cancer. Hepatobiliary Pacreat Dis Int. 2005 May; 4 (2): 173–7.
  8. Adams LA, Lymp JF, St Sauver J, Sanderson SO, et al. The natural history of nonalcoholic fatty liver disease: a population-based cohort study. Gastroenterology. 2005 Jul;129 (1): 113–21.
  9. Sleisenger M. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. Philadelphia: W.B. Saunders Company. 2006
  10. Adams LA, Angulo P, Lindor KD, et al. Nonalcoholic fatty liver disease. CMAJ. 2005 Mar 29; 172 (7): 899–905.

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Last updated: 2017-08-09 17:36