Non-alcoholic fatty liver disease (NAFLD)
Most people learn of this diagnosis by accident: an abdominal ultrasound done for something else comes back with a line about fatty change in the liver.
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Most people learn of this diagnosis by accident: an abdominal ultrasound done for something else comes back with a line about fatty change in the liver. Nothing hurts, so the report goes into a drawer. Yet this is a condition that in most people really will stay harmless, while in a minority it will scar the liver over the years. Which of the two happens is decided not by luck but by what is going on with weight, blood sugar and blood pressure. In recent years the disease has acquired a new name — metabolic dysfunction-associated steatotic liver disease — which is the better one, because it names the cause.
What is happening inside the liver
The liver is constantly processing fats and sugars. When more arrives than it can put to use, the surplus is stored inside its own cells. That is steatosis: fat in the liver.
The key player is the tissues' loss of responsiveness to insulin. Muscle and fat tissue stop obeying the hormone, the pancreas answers by releasing more and more of it, and under that pressure the liver both stores fat and manufactures new fat itself. This is why the disease travels in company with excess weight, type 2 diabetes, high blood pressure and disordered cholesterol: they share a root.
From there, two paths are possible. In most people the fat simply stays fat for decades. In some it provokes inflammation: liver cells are damaged and die, and connective tissue is laid down in their place. That is fibrosis, scar tissue that filters nothing. It is the amount of scar, not the amount of fat, that decides how the story ends.
Why it is noticed so late
The liver has no pain endings inside it, so it can work at half capacity for years and say nothing about it. Hence the defining feature of the disease: usually there are no complaints at all.
Sometimes there are:
- heaviness or a dull discomfort on the right under the ribs, more often after eating;
- tiredness that rest does not lift and effort does not explain;
- less stamina, a sense of the battery running flat.
The signs that really do speak of a diseased liver — yellow skin and whites of the eyes, dark urine, itching, a swollen abdomen, bruises from the lightest knock — appear only at the stage of cirrhosis. They cannot be used as the cue to act: by then some of the change is beyond reversing.
Who develops it
Non-alcoholic fatty liver disease is very common, and most of those who have it do not know.
- Excess weight, particularly around the middle. Waist measurement says more here than the figure on the scales: fat around the internal organs is the more active kind.
- Type 2 diabetes and prediabetes. The strongest combination: with diabetes the disease is not only commoner but moves on to fibrosis appreciably faster.
- High blood pressure, raised triglycerides, low "good" cholesterol.
- Polycystic ovary syndrome.
- Pauses in breathing during sleep and an underactive thyroid.
- Age. The proportion of people with fibrosis rises over the years.
- Inherited make-up. There are gene variants in which the liver stores fat even without marked excess weight.
One point deserves separate mention: the disease occurs in slim people too. A normal weight does not rule out the diagnosis where there is raised blood sugar, high triglycerides or a family predisposition. These are the people most often missed.
The four steps the disease climbs
The course is conventionally described in four stages. Decades usually separate the first from the last, and the progression is not compulsory.
- Steatosis — fat has accumulated but the liver cells are intact. There is no damage. This is where most people stay.
- Steatohepatitis — inflammation has joined the fat and cells are being damaged. The liver is still coping, but this is where scarring begins.
- Fibrosis — part of the tissue has been replaced by scar. The liver usually keeps working and the person still feels nothing. Early fibrosis can be reversed if the cause is removed.
- Cirrhosis — there is so much scar that the structure of the organ changes and blood flow through it is obstructed. Hence the complications: enlarged veins in the gullet that can bleed, fluid collecting in the abdomen, confusion, a raised risk of liver cancer.
An important correction to the usual picture: in this disease liver cancer occasionally arises before cirrhosis. That is why follow-up is set by the stage of fibrosis rather than by how well a person feels.
How it is found, and why an ultrasound alone is not enough
Investigation has two jobs: to confirm that fat is the issue, and to establish whether scarring has already begun. The second matters more, and it is the one most often skipped.
- Liver ultrasound sees fat well when there is a lot of it, and does not see fibrosis at all. A report of fatty liver is the start of the conversation, not the end of it.
- Blood tests: liver enzymes, bilirubin, a full blood count with platelets, glucose and glycated haemoglobin, lipids. Normal enzymes do not rule out fibrosis — a widespread and dangerous misconception. In some people with marked scarring the tests stay normal for years.
- Simple fibrosis scores. From tests already taken — age, two enzymes and the platelet count — the doctor works out a figure that sorts patients into those who need nothing further and those who need a closer look. It costs nothing and takes a minute.
- Elastography measures the stiffness of the liver. The scan is painless, takes a few minutes and spares most people a biopsy. Liver biopsy is now done rarely, in cases that remain unclear.
- Ruling out other causes. Hepatitis B and C are checked, alcohol intake is discussed honestly, the list of medicines and supplements is gone through, iron handling is looked at and, in younger people, copper. Fat in the liver does not exclude a second disease running alongside it and worsening the outlook.
What genuinely changes the course
There is no medicine here that can simply be taken instead of making changes. The changes themselves, though, act directly on the liver, and their effect is measurable.
- Weight loss. The landmarks are these: 5 % of body weight lost reduces liver fat, 7 to 10 % clears the inflammation, and a larger loss can shrink the scar as well. Whether the result holds matters more than how fast it came.
- What is on the plate. More vegetables, pulses, fish, nuts and olive oil; fewer sweet drinks, less baking and less heavily processed food. Fizzy drinks and juices hit the liver harder than people expect, because fructose is processed precisely here.
- Movement. Two and a half to five hours of moderate activity a week plus strength work twice a week. Exercise reduces liver fat even when the weight has not shifted.
- Alcohol. At the stage of steatosis it is kept to a minimum; with fibrosis or cirrhosis it is not drunk at all. The word "non-alcoholic" in the name means alcohol was not the cause, not that it is now safe.
- Smoking speeds up fibrosis and adds to the cardiac risk, which in this disease is the leading one anyway.
A separate word on painkillers. Paracetamol at a dose agreed with a doctor remains an acceptable option in liver disease; over-the-counter anti-inflammatory painkillers such as ibuprofen are not suitable once cirrhosis has developed. Any herbal remedy "for the liver" should be shown to a doctor before it is taken: a number of supplements damage the liver themselves.
What the doctor does
A doctor is needed not to prescribe "something for the liver", but to take charge of what is destroying it.
First, metabolism. Blood sugar and blood pressure are brought to target, and in diabetes and obesity there are now medicines that reduce weight and improve the state of the liver at the same time. The doctor selects them from the whole picture, not from one ultrasound.
Second, the heart and blood vessels. People with this disease die of heart attack and stroke more often than of their liver, so cholesterol here is lowered rather than the liver "spared". Statins are not forbidden in fatty liver disease and are usually needed; abandoning them because of the diagnosis is a common and expensive mistake. The decision belongs to the doctor, looking at the blood tests.
Third, a liver specialist where fibrosis is marked. Specialists have medicines used where inflammation with scarring has been demonstrated, including treatments introduced in recent years that act on the liver directly. In severe obesity weight-loss surgery is discussed, and where cirrhosis is the end point, transplantation.
Fourth, follow-up. The stage of fibrosis is reassessed every few years, and more often in diabetes. Vaccination against hepatitis A and B is recommended for people with chronic liver disease. With cirrhosis, regular ultrasound to catch a tumour early and inspection of the gullet for enlarged veins are added.
Signs that cannot wait
Call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine on the single number 112) if there is:
- vomiting of blood, or of dark clots resembling coffee grounds;
- black, tarry stools;
- confusion, disorientation, sudden drowsiness, behaviour out of character;
- severe abdominal pain with a high temperature in someone whose abdomen is swollen.
See a doctor the same day if the skin or the whites of the eyes turn yellow, the urine darkens and the stools go pale, the abdomen swells quickly, the legs swell, persistent itching appears, or bruises come up from the slightest knock.
Online consultation
This disease consists almost entirely of questions that are settled by a conversation and some paperwork. In an online appointment the doctor can go through your discharge letter and blood results, explain what lies behind the phrase in the ultrasound report, judge from the figures you already have how likely fibrosis is, and say whether elastography and a hepatologist are needed.
It is equally suited to what actually determines the outcome: how to build meals around your routine, what sort of exercise suits you, what to do about blood pressure and blood sugar, whether your medicines and supplements are safe. What an online appointment does not replace: examination, ultrasound, elastography and the blood tests themselves. And with the urgent signs listed in the previous section, the place to start is emergency care.
This material is for information only and does not replace medical advice.
Consult with a doctor about Non-alcoholic fatty liver disease (NAFLD)
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Online doctors for Non-alcoholic fatty liver disease (NAFLD)
Discuss your symptoms and possible next steps for Non-alcoholic fatty liver disease (NAFLD) with a doctor online.
