Dr Rakesh Aggarwal

(President, INASL )
Non-alcoholic fatty liver is a common condition that is currently receiving a lot of attention. Importantly, the condition is heterogeneous and can vary from a very innocuous condition that needs only simple variations in life-style to a serious condition needing medical treatment. Given the high frequency and variable outcomes, a lay person is often faced with conflicting messaging and seeks answers. Unfortunately, these are often not easily available, particularly in developing country settings.

This Fatty Liver Support Group being launched by INASL is an attempt to fill this important public need. We hope to place here accurate information in a simple language to help guide the general public as well as patients with non-alcoholic fatty liver. We hope that this portal will go a long way to improve awareness about and care of this important condition. We plan to keep the information on the portal current by adding and changing the material over time, and also look forward to adding dynamic features at a future date.

We do look forward to input from our intended audience about the usefulness of the available information, and suggestions on how to improve it.

Non-alcoholic fatty liver disease

Dr Kaushal Madan
Director of Hepatology and Gastroenterology,
Max Hospitals, Saket, New Delhi, India

Non-alcoholic fatty liver disease (NAFLD) or fatty liver if continues for long time can cause fibrosis (scarring or shrinkage) in the liver which ultimately may damage the liver and can cause cirrhosis liver and even liver cancer. Hence it is very important to determine the presence and extent of fibrosis in patients with fatty liver as early as possible so as to treat it and to predict the outcome in those who already have advanced fibrosis and cirrhosis.

Introduction
Liver is a large organ present on the right, upper side of the abdomen. It has a large number of functions such as production of body proteins, filtration of toxins and ingested drugs, control of blood sugar, cholesterol and proteins.

What is fatty liver?
Fatty liver refers to the deposition of excessive fat in the liver.

What causes fatty liver?
Earlier, it was though that fatty liver used to occur only due to excessive alcohol intake. However it was recognized over last one decade, that patients who do not drink also develop fatty liver. These patients are labeled as having non-alcoholic fatty liver disease (NAFLD).
NAFLD is a life style disease. The risk factors for NAFLD are obesity, diabetes mellitus, abnormal lipid profile. Other causes of NAFLD include certain drugs, malnutrition, i.v nutrition and certain genetic diseases.

What are the symptoms of NAFLD?
Most patients with NAFLD do not have any symptoms at the time of diagnosis and they will come to light only by chance. Once the patients develop symptoms of liver disease, it suggests that the disease may be already quite advanced

How is NAFLD diagnosed?
As mentioned earlier most patients are detected by chance when they undergo ultrasonography or during investigation for abnormal blood tests (LFT).
What other tests should a patient with NAFLD undergo?
Once diagnosed, patients with NAFLD should undergo a fibroscan. The Fibroscan test gives two informations:
1. It tells us about the amount of fat in the liver. So there is an objective measure of the quantity of liver fat which can then be followed up over time in order to find if the fat is increasing or decreasing.
2. It also tells about the presence of scarring in the liver, also called fibrosis. Patients with long term fatty liver and with other risk factors have persistent liver inflammation which can lead to scarring and hardening of the liver. This can even lead to cirrhosis. This can be picked up easily by fibroscan
Some patients may have to under go a liver biopsy in order to determine the stage of the disease.

Is it a serious disease?
Although most patients tend to have a milder from of NAFLD. But, it is clear that NAFLD can cause all the complications associated with any chronic liver disease. So patients with uncontrolled NAFLD are at an increased risk of developing cirrhosis, liver cancer and liver failure. So if left untreated, NAFLD can have serious outcomes.
Not only liver complications, it has been seen that patients with NAFLD are also at an increased risk of later development of diabetes, hypertension, and heart disease.

Which patient with NAFLD develop serious complications?
Persons are risk of serious outcomes in presence of NAFLD are those with uncontrolled diabetes, those with sever obesity and those with a family history of advanced NAFLD

What is the treatment for NAFLD?
Since NAFLD is a lifestyle disease, the most effective treatment is ‘lifetyle interventions’. So the back bone of therapy in NAFLD patients is to increase physical activity along with dietary advice in order to achieve weight reduction in overweight individuals. If patients are able to reduce about 10% of their body weight, they are able to benefit immensely and have significant improvement in their liver complications.
This therapy not only reduces liver fat and inflammation due to fat, but also prevents other lifestyle conditions such as diabetes, hypertension and high cholesterol. Treatment with pills is required only in patients with advanced liver disease due to NAFLD.
In addition , other associated conditions such as diabetes, hypertension and high cholesterol should also be treated along side.

What not to do, if you have fatty liver?
• You should avoid herbal medications since they can also cause unpredictable harms to the liver.
• You should not self medicate
• You should not eat foods which can make you gain weight, like sweets and saturated fats.
• You should avoid alcohol intake

Whom should you contact if you have NAFLD
For more and specific advice on Fatty liver disease, you should contact a Hepatologist or a liver specialist near you. In addition, if you have other risk factors, like diabetes or hypertension or high cholesterol, then you should meet the concerned specialists also.

FIBROSCAN IN NON-ALCOHOLIC FATTY LIVER DISEASE (NAFLD)

Prof. Ajay Duseja (MD, DM, FAASLD, FACG, FAMS, FSGEI)
Department of Hepatology, PGIMER, Chandigarh, India

Importance of fibrosis (scarring) in fatty liver

Non-alcoholic fatty liver disease (NAFLD) or fatty liver if continues for long time can cause fibrosis (scarring or shrinkage) in the liver which ultimately may damage the liver and can cause cirrhosis liver and even liver cancer. Hence it is very important to determine the presence and extent of fibrosis in patients with fatty liver as early as possible so as to treat it and to predict the outcome in those who already have advanced fibrosis and cirrhosis.


Limitations of doing liver biopsy
Traditionally liver biopsy (taking liver piece from the liver by a needle) remains the gold standard for determination of hepatic fibrosis in NAFLD. However, liver biopsy is an invasive procedure (putting needle in the liver) and may be associated with complications like pain and bleeding. Moreover, the sample obtained with liver biopsy is very small and sometimes, may not represent the disease process going on in the whole liver. Liver biopsy sample has to be sent to pathology lab and the whole process of interpretation of the biopsy takes few days before the final report, which may also be associated with some inter- and intra-observer variation among the pathologists analysing the liver biopsy. In addition, because of the invasive nature of the liver biopsy, it is difficult to do it repeatedly in order to assess the effect of various treatment modalities in NAFLD.

Fibroscan for the assessment of liver fibrosis (scarring)
Hence there has always been a need for various non-invasive test which are simple, accurate, less time consuming and could act as an alternative to liver biopsy for the assessment of liver fibrosis in patients with fatty liver. Fibroscan or Transient Elastography is one such alternative to liver biopsy and has the advantage of being purely non-invasive, safe, accurate, operator-independent and can be repeated any number of times.

Technique of Fibroscan
Patient needs to come for the Fibroscan test with 2-3 hours of fasting and the test is done with a machine similar to ultrasound machine and the examination takes less than five minutes and the report is given immediately to the patient. The principle of Fibroscan is to measure the hepatic fibrosis by assessment of liver stiffness by assessing the speed of the travelling shear waves generated by the transducer (probe) of the machine. Higher the liver stiffness or hepatic fibrosis, higher would be the Fibroscan value which is measured in kilopascals (kPa) and varies from 2.5 to 75 kPa. In patients with overweight and obesity and with high fat below the skin of the right side of the chest (where probe is kept for examination), the values may not be accurate with the standard probe (M probe) and may require the use of the XL probe. Similarly, there is a separate probe for doing Fibroscan test in children (S probe).
Sometimes patients with NAFLD or fatty liver can have various other reasons which can falsely elevate the Fibroscan value which may not be truly representative of hepatic fibrosis. Hence the Fibrocan interpretation should be done by the treating doctor in the clinical context.

Estimation of liver fat with Fibroscan
Another advantage of Fibroscan is that, in addition to measuring fibrosis in the liver, it can simultaneously also measure the presence and severity of the fat in the liver by a built-in software called controlled attenuation parameter (CAP).

Other tests for liver fibrosis
In addition to Fibroscan, various blood tests and other elastography techniques are also available these days to assess the presence and extent of hepatic fibrosis in patients with NAFLD.

Lean NAFLD

Q: Can NAFLD occur in Lean people, i.e. persons who are not obese?
A: Yes NAFLD [Fatty Liver] can occur in Lean people, i.e. persons who are not obese.

Q: What proportion of NAFLD patients are lean NAFLD?
A: Upto about one sixth of NAFLD patients may not be obese.

Q: Why does NAFLD [Fatty Liver] occur in Lean people, despite than not being obese?
A: Most of the persons who are not obese and yet have NAFLD are metabolically abnormal. Like overweight or obese NAFLD, they also generally have resistance to action of insulin at different levels inside the body. What this means is that most of them have either central obesity without excess weight [their waist or central part of body at around level of navel is more than normal], or they have lipid abnormalities like high bad cholesterols or low good cholesterol [HDL] and may often have disturbances in their glucose metabolism. Uncommonly this may even be due to certain genetic disorders.

Q: How does one treat NAFLD in patients who are lean?
A: In Lean NAFLD patients who are not obese, unlike obese/overweight NAFLD patients, reduction of weight is not a target for treatment. However these patients should also exercise regularly and avoid fatty food, because this can ameliorate their fatty liver without weight reduction. Besides, other accompaniments like diabetes, high blood pressure and abnormalities of lipids have to be treated appropriately too.

Q: What other precautions are needed for Lean NAFLD patients? A: Lean NAFLD patients should avoid overeating and putting on weight. Besides they should avoid cola drinks in particular. They should not smoke and should not drink too. They should also avoid medications which are harmful to liver, and ideally be vaccinated against Hepatitis B and Hepatitis A.

Prof. Dr S.P. Singh, MBBS, MD, DM, FSGEI, FACG, AGAF, FRCP [Edin], FRCPS [Glasgow].
Chairman, Kalinga Gastroenterology Foundation [KGF],
President, South Asian Association for Study of the Liver [SAASL],
Chairman, Kalinga Gastroenterology Foundation [KGF].

Common Myths about Fatty Liver disease

Dr Akash Shukla (G.C Member INASL)

Myth 1: Fatty liver is nothing to worry about
A: Fact: Most people with fatty liver don’t get any symptoms.In a proportion of patients, fatty liver can progress to significant liver damage in the form of steatohepatitis, fibrosis, cirrhosis (scarring of the liver) andliver cancer. This happens because prolonged fat deposition in the liver cells causes inflammation and then scarring. The scar tissue builds up, causing fibrosis which may progress to cirrhosis. In rare cases it may cause liver cancer also. Presence of fatty liver is associated with increased risk of heart disease, different cancers in the body, diabetes, hypertension, obstructive sleep apnea syndrome etc. Therefore, diagnosis of fatty liver should not be ignored and thorough evaluation for liver and non-liver related complications should be done.

Myth 2: “there’s nothing that can be done for treatment NAFLD”
A: Fact : Many treatment options are available today for management of NAFLD. Lifestyle modifications like (proper diet and weight loss) and various medical and surgical treatments are effective in the management of NAFLD. All patients with NAFLD should be try to lose weight. Even a 5-7% weight loss can have beneficial effects. In addition, appropriate management of co-morbid metabolic conditions like dyslipidemia and diabetes is of paramount importance.

Myth 3: “The patients of NAFLD don’t need to see a liver specialist?”
A: Fact: A consultation with a liver specialist is an important step in the management of NAFLD. The liver specialist will first distinguish patients with simple steatosis (who have a good liver related prognosis but needs close monitoring for other organs) from those who have NASH and are at risk for progressive liver injury. He will also ensure that there is no alternative / additional disease in the liver. Based upon the staging of NAFLD he will be able to provide valuable prognostic information and suggest appropriate line of treatment.
This staging is often done by a combination of blood tests, imaging and elastography based (like MR Elastography, ARFI, Fibroscan etc) methods. Although liver biopsy remains the gold standard for NAFLD diagnosis and staging, determining which patient requires liver biopsy is another important aspect of specialist evaluation of NAFLD.

Myth 4: “There are no drugs for patients with NAFLD”
Fact: There are several drugs which have shown benefits in patients with NAFLD. The most commonly used medicine is Vitamin E. Recently, newer drugs like saroglitazar and obeticholic acid have shown improvement in liver biopsies of patients with NAFLD. There are many drugs like pioglitazone, GLP-1 inhibitors like liraglutide, SGLT 2 inhibitors (gliflozins) which when given for diabetes treatment, help improve the liver also. It should be noted that these drugs are more effective when combine with life-style modification, diet and exercise.

Myth 5: Fatty liver disease cannot be reversed Fact: In the early stages of the disease, fatty liver can be reversed completely. This can be achieved by the following measures:
• Avoid alcohol
• Reduce sugar intake
• Cut out saturated fats in diet
• Exercise regularly (Aerobic and Isometric)
• Maintain a healthy weight
• Control blood sugar levels
• Eating a healthy diet with plenty of fresh fruits, vegetables, whole grains and lean meats like chicken and fish
Even in those patients who have fibrosis, there is some hope of halting the disease and possibly reversing the damage with appropriate management.

Myth 6: Fatty liver disease is only seen in the rich and those who are obese
Fact: NAFLD is common across all socio-economic strata and in rural as well as urban population. While, it is more common in the obese, it may also be seen even in a proportion of people with normal BMI and is referred to as ‘lean NASH’. This is likely to be due to excessive visceral fat without significant increase in body weight. Lean NASH appears to be more common in India as compared to the west.

Myth 7: If the liver function tests (LFT) are normal, the liver does not have disease Fact: Most people with fatty liver will have a normal or near normal LFT. Often, the LFT remain normal till the liver disease becomes very advanced. A normal LFT does not rule out significant liver disease. A combination of blood tests, imaging and elastography-based (like MR Elastography, ARFI, Fibroscan etc) tests and sometimes liver biopsy is used for assessment of liver status.