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].

• Inflammation

  This inflammation may develop into scarring (fibrosis) and cirrhosis. [msdmanuals.com]

  Cirrhosis occurs in response to liver injury, such as the inflammation in nonalcoholic steatohepatitis. As the liver tries to halt inflammation, it produces areas of scarring (fibrosis). [mayoclinic.org]

  Mediators Inflamm. 2018 Jan 31;2018:9321643. doi: 10.1155/2018/9321643. eCollection 2018. [ncbi.nlm.nih.gov]

  Inflammation of the liver due to fatty liver is called steatohepatitis. This inflammation may develop into scarring ( fibrosis ). Fibrosis often progresses to cirrhosis (scarring that distorts the structure of the liver and impairs its function). [merckmanuals.com]

  The mildest form is defined as an accumulation of fat in the liver with little or no associated inflammation. But if chronic inflammation ensues, the diagnosis becomes NASH. [doi.org]

• Weight Loss

  Treatment Doctors recommend weight loss to treat nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH). Weight loss can reduce fat in the liver, inflammation, and fibrosis. [niddk.nih.gov]

  The promotion of gradual weight loss in obese patients is the most widely recommended therapy but, unfortunately, this is very difficult to achieve. [ncbi.nlm.nih.gov]

  Orlistat is a lipase inhibitor that reduces fat absorption and promotes weight loss. [dx.doi.org]

• 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]

  Frequently, FLHS and cage layer fatigue are diagnosed at a time. 456.457. Clinically healthy birds in the flock could also exhibit liver haematomas, dark red (fresh) or green to brown (old). [thepoultrysite.com]

  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]

  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

  He was started on nutrition support along with supportive therapy, which resulted in weight gain and improvement in his condition. [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]

  gain Get your Copy of The Liver Cleansing Diet Here via top 10 remedies As mentioned previously, fatty liver is completely reversible. [thewhoot.com]

• Swelling

  When it does, they may include: Enlarged liver Fatigue Pain in the upper right abdomen Possible signs and symptoms of nonalcoholic steatohepatitis and cirrhosis (advanced scarring) include: Abdominal swelling (ascites) Enlarged blood vessels just beneath [mayoclinic.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

  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]

  These can include: appetite loss nausea vomiting abdominal pain jaundice Most cases of NASH are detected in people between ages 40 and 60, according to the American Liver Foundation. [healthline.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]

  The differentials in the postpartum period of fever and jaundice could include sepsis which was ruled out by appropriate investigations in the index case. The viral aetiology of her jaundice was also ruled out. [sjmms.net]

  […] and metabolic diseases (E00-E88) injury, poisoning and certain other consequences of external causes (S00-T88) neoplasms (C00-D49) symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94) From Section K70-K77: jaundice [icdcodelookup.com]

  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]

• 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]

  […] 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]

  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]

• Hypertension

  In both cases hypertension and diabetes mellitus showed no exacerbation during follow-up; hepatitis C antibody and hepatitis B surface antigen were negative; ultrasound (US) and computed tomography (CT) revealed fatty liver (moderate in one patient and [ncbi.nlm.nih.gov]

  Causes Diabetes Obesity (BMI>25 kg/m2 in Asian people) Increased belly fat (Central obesity) »» waistline >90cm in Asian men or >80cm Asian women Cholesterol problems Hypertension Metabolic syndrome Other associated conditions like Obstructive Sleep Apnea [singhealth.com.sg]

  Obesity, and medical conditions such as hypertension, hypercholesterolemia, and diabetes, are risk factors for the development of NAFLD. [hopkinsmedicine.org]

• Thrombosis

  Portal vein thrombosis and hepatic artery thrombosis seemed to be important factors for development of de novo fatty liver after transplantation. Copyright © 2011 Elsevier Inc. All rights reserved. [ncbi.nlm.nih.gov]

  Brandes, Soluble Epoxide Hydrolase Deficiency Attenuates Neointima Formation in the Femoral Cuff Model of Hyperlipidemic Mice, Arteriosclerosis, Thrombosis, and Vascular Biology, 10.1161/ATVBAHA.110.204099, 30, 5, (909-914), (2010). A. Tannapfel, H. [doi.org]

• Palmar Erythema

  Patients with fatty liver disease should be seen regularly by a primary care physician, who may be able to detect disease progression through physical examination findings (eg, spider telangiectasia, palmar erythema, or splenomegaly), laboratory findings [emedicine.com]

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.

• Dyslipidemia

  In addition to worsening control of diabetes and dyslipidemia, severe NAFLD was confirmed. Rosuvastatin was started, which induced short-term elevations in aminotransferases resulting in patient discontinuation. [ncbi.nlm.nih.gov]

  Cases were more likely than controls to be obese, to have diabetes, dyslipidemia, hypertension, and metabolic syndrome, and to be smokers. [medpagetoday.com]

  NAFLD has been associated with dysmetabolic conditions: diabetes mellitus obesity (particularly central obesity) dyslipidemia hypothyroidism The pathogenesis of NAFLD is not well understood. [radiopaedia.org]

• Hypoglycemia

  Hospitalario Universitario de Albacete, Universidad de Castilla La-Mancha, Albacete, Spain. [email protected] Abstract Here we report a 7-month-old girl with long-chain 3-hydroxyacyl-coenzyme A dehydrogenase (LCHAD) deficiency with hypoketotic hypoglycemia [ncbi.nlm.nih.gov]

  Hypoglycemia is considered a very important feature in this rare disorder and should help in deciding the diagnosis in an appropriate setting, but there was no hypoglycemia in our case. [sjmms.net]

  The results were used to titrate the infusion rate of a 20% glucose solution to prevent hypoglycemia and to maintain blood glucose at levels within ± 0.5 mmol/l of the fasting value or at a predetermined value of 5.0 mmol/l whenever glucose levels were [doi.org]

• Transaminases Increased

  Furthermore, recent clinical studies have shown that increased circulating levels of gamma-glutamyl transpeptidase (GGT) and liver transaminase increase the risk of new-onset atrial fibrillation (AF) [4-5]. [doi.org]

  It is also associated with hormonal disorders (panhypopituitarism, hypothyroidism, hypogonadism, polycystic ovary syndrome), persistently elevated transaminases, increasing age and BMI and hypoxia caused by obstructive sleep apnea, with some of them predicting [en.wikipedia.org]

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.

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.

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.

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.

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.

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.

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.

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.

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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.