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Fatty Liver Disease Information

Non-alcoholic fatty liver disease (NAFLD) is fatty inflammation of the liver when this is not due to excessive alcohol use. It is related to insulin resistance and the metabolic syndrome, and may respond to treatments originally developed for other insulin resistant states (e.g. diabetes mellitus type 2), such as weight loss, metformin and thiazolidinediones. Non-alcoholic steatohepatitis (NASH) is the most extreme form of NAFLD, which is regarded as a major cause of cryptogenic cirrhosis of the liver.

Most patients with NAFLD have no or few symptoms. Infrequently patients may complain of fatigue, malaise and dull right upper quadrant abdominal discomfort. Mild jaundice can rarely be noticed. More commonly it is diagnosed as a result of abnormal liver function tests during routine blood tests. By definition, alcohol consumption of over 20 g/day excludes the condition.

NAFLD is associated with insulin resistance and the metabolic syndrome (obesity, combined hyperlipidemia, diabetes mellitus (type II) and high blood pressure).

Disturbed liver enzymes are common, and liver ultrasound may show steatosis; it may also be used to exclude gallstone problems (cholelithiasis). A biopsy (tissue examination) of the liver is the only widely accepted test which can distinguish NASH from other forms of liver disease, and can be used to assess the severity of the inflammation and resultant fibrosis.

Other tests generally performed are other blood tests (erythrocyte sedimentation rate, glucose, albumin, renal function etc.) As the liver is important in coagulation, some coagulation studies will generally be done, especially the INR (international normalized ratio). To distinguish this disease from viral hepatitis, blood tests (serology) are generally done (hepatitis A, B, C, EBV, CMV and herpes viruses, as well as rubella) to ensure these are not playing a role. Additionally, autoimmune causes are ruled out with serology. TSH is warranted, as hypothyroidism is more prevalent in NASH patients.

Trials are presently being conducted to optimise treatment of NASH. No standard treatment has yet emerged as the "gold standard". General recommendations include improving metabolic risk factors and reducing alcohol intake.

A large number of treatments have been studied for NAFLD. While many may improve biochemical markers, such as alanine transaminase levels, most have not been shown to reverse the histological abnormalities or reduce clinical endpoints:

*Weight loss: gradual weight loss, and possibly bariatric surgery, may improve the process in obese patients.

* Insulin sensitisers (metformin and rosiglitazone but more markedly pioglitazone) have shown efficacy in some studies.

* Antioxidants and ursodeoxycholic acid, as well as lipid-lowering drugs, have little benefit.

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