Deal­ing with fatty liver

The Star Malaysia - Star2 - - Healthy Liver - For more in­for­ma­tion, call 03-5639 1212.

FATTY liv­ers in geese are prized, but in hu­mans, they can cause se­ri­ous health com­pli­ca­tions.

A whop­ping 30% of the Asi­aPa­cific pop­u­la­tion is af­fected by non-al­co­holic fatty liver dis­ease (NAFLD) and the num­bers are only get­ting big­ger, ac­cord­ing to a 2012 study pub­lished in Hepa­tol­ogy In­ter­na­tional.

The same study re­ported an NAFLD preva­lence in Malaysia of 22.7% among in­di­vid­u­als at­tend­ing a health check at a sub­ur­ban med­i­cal fa­cil­ity and ob­served an in­or­di­nately high preva­lence of NAFLD among Malays and In­di­ans com­pared to that of other races.

Most peo­ple with fatty liver have sim­ple steato­sis or sim­ple fatty liver in which case the fat does not cause in­flam­ma­tion in the liver. Peo­ple with NAFLD do not con­sume sig­nif­i­cant amounts of al­co­hol.

How­ever, up to 25% of peo­ple with NAFLD ex­pe­ri­ence non­al­co­holic steato­hep­ati­tis (NASH), char­ac­terised by in­flam­ma­tion that can lead to fi­bro­sis (scar­ring), cir­rho­sis (se­verely scarred, hard­ened and shrunken liver), and even­tual liver fail­ure, whose only mode of treat­ment is liver trans­plan­ta­tion.

“There is an in­creas­ing num­ber of pa­tients with NAFLD who de­velop liver can­cer or re­quire liver trans­plants. In fact, NASH is now the sec­ond most com­mon cause for liver trans­plants in the United States and will likely over­take hep­ati­tis as the num­ber one cause for liver trans­plan­ta­tion in the fu­ture, as more hep­ati­tis C pa­tients to­day are be­ing treated with cu­ra­tive an­tivi­ral drugs,” says Dr Gane­salingam Kana­gasabai, con­sul­tant gas­troen­terol­o­gist at Subang Jaya Med­i­cal Cen­tre.

Only a small per­cent­age of NAFLD cases progress to cir­rho­sis, but it still makes a sig­nif­i­cant im­pact on the re­gional dis­ease bur­den.

A sub­tle dis­ease

NAFLD across the board is typ­i­cally asymp­to­matic. In rare cases, pa­tients com­plain of dis­com­fort, but by the time symp­toms are no­tice­able, it is usu­ally too late and the liver has be­gun fail­ing.

Tan­gi­ble symp­toms in­clude swollen an­kles due to fluid re­ten­tion, jaun­dice, con­fu­sion and in­ter­nal bleed­ing.

“The most com­mon way that peo­ple find out they have fatty liver is when they un­dergo an ul­tra­sound scan of the liver or rou­tine blood test that re­veals an ab­nor­mal read­ing of liver en­zymes,” says Dr Gane­salingam.

Ac­cord­ing to him, most peo­ple with fatty liver have metabolic syn­drome – a clus­ter of con­di­tions that in­cludes hyper­ten­sion, obe­sity, di­a­betes and el­e­vated choles­terol lev­els.

The dan­ger zone

“Peo­ple with fatty liver don’t of­ten die from liver dis­ease. The ma­jor­ity in­stead suc­cumb to car­dio­vas­cu­lar com­pli­ca­tions or stroke caused by metabolic syn­drome, which is as­so­ci­ated with fatty liver,” says Dr Gane­salingam.

“Can­cer-re­lated deaths are among the top three causes of death in peo­ple with NAFLD.”

He states that for the av­er­age per­son, liver dis­ease is the 12th most likely cause of death. For some­one with fatty liver, how­ever, the like­li­hood of liver dis­ease killing him goes up to third place.

De­tect­ing the cul­prit

A fatty liver is any liver with more than 5% fat. Cur­rently, only liv­ers with a sig­nif­i­cant amount of fat can be picked up through ul­tra­sounds.

The draw­back with ul­tra­sounds is that if the scar­ring is not se­vere, the ra­di­ol­o­gist will be un­able to tell if the liver is dam­aged.

“The dif­fi­cult part is de­tect­ing which pa­tient with fatty liver has NASH with on­go­ing in­flam­ma­tion and scar­ring in the liver. A pa­tient can have nor­mal liver test re­sults yet have sig­nif­i­cant in­flam­ma­tion and scar­ring,” says Dr Gane­salingam.

Ac­cord­ing to him, the most ac­cu­rate way to test for NASH is to do a liver biopsy – an in­va­sive pro­ce­dure with po­ten­tial risks.

The di­ag­nos­tic time­line

“When a pa­tient is di­ag­nosed with NAFLD, the next course of ac­tion is to ex­am­ine his risk po­ten­tial and de­ter­mine con­tribut­ing fac­tors such as di­a­betes, high blood pres­sure, obe­sity, high choles­terol, smok­ing and lack of ex­er­cise. Af­ter that, we have to as­sess whether the fat is caus­ing the liver harm,” says Dr Gane­salingam.

A non-in­va­sive, quick and sim­ple way of as­sess­ing whether or not the fatty liver is harm­ful is with a tran­sient elas­tog­ra­phy of the liver that can de­ter­mine the de­gree of fi­bro­sis and the amount of fat in the liver. A tran­sient elas­tog­ra­phy is per­formed with a Fi­broscan ma­chine.

“The Fi­broscan uses shear waves that are pro­jected at the liver. The rate at which they travel through the liver is mea­sured.

“If there is sig­nif­i­cant scar­ring within the liver due to fat-in­duced in­flam­ma­tion, the waves travel faster through the denser tis­sue and re­sults in a higher read­ing,” says Dr Gane­salingam.

A Fi­broscan is use­ful in as­sess­ing the se­ri­ous­ness of fatty liver cases, but is un­for­tu­nately not widely avail­able in Malaysia.

A low tran­sient elas­tog­ra­phy read­ing in­di­cates sim­ple fatty liver with no scar­ring. A high read­ing is cause for con­cern as these pa­tients prob­a­bly have NASH and an in­creased risk of cir­rho­sis, liver fail­ure or liver can­cer.

Pa­tients with high read­ings need to be mon­i­tored for po­ten­tial com­pli­ca­tions due to their fatty liver. It is be­lieved to­day that pa­tients pre­vi­ously thought to have cir­rho­sis of un­known cause (called cryp­to­genic cir­rho­sis) prob­a­bly had NASH.

Treat­ment and preven­tion

Life­style in­ter­ven­tion con­sist­ing of diet ad­just­ments, ex­er­cise and weight loss is the cor­ner­stone of treat­ment for fatty liv­ers. It is ad­vis­able to aim for at least 5% weight loss, but the rec­om­mended rate is around 7% to 10%.

Ac­cord­ing to Dr Gane­salingam, it is gen­er­ally be­lieved that a 10% weight loss leads to as much as 80% re­duc­tion of liver fat, which in turn re­duces in­flam­ma­tion and can re­verse scar­ring in the liver.

If a pa­tient loses more than 5% of his to­tal weight, a sig­nif­i­cant amount of fat, in­flam­ma­tion and scar­ring in the liver is re­duced. Equal em­pha­sis should be given to proper con­trol of di­a­betes, blood pres­sure and choles­terol lev­els.

Other strate­gies in­volve drug treat­ment. Non-di­a­betic NASH pa­tients with sig­nif­i­cant liver scar­ring are pre­scribed vi­ta­min E, while di­a­betic NASH pa­tients are pre­scribed pi­ogli­ta­zone.

More new drugs emerge ev­ery day, but even promis­ing ones such as the glucagon-like pep­tide-1 re­cep­tor ag­o­nist are still in test­ing or trial stages, which means the only treat­ment for NAFLD is still life­style in­ter­ven­tion. In pa­tients who are mor­bidly obese where life­style in­ter­ven­tion has failed, bariatric surgery is an op­tion.

“A med­i­cal con­sul­ta­tion for NAFLD should em­pha­sise life­style in­ter­ven­tion con­sist­ing of diet change, ex­er­cise and weight loss. It is im­por­tant to re­mem­ber that most pa­tients with NAFLD die from heart dis­ease and stroke, not liver dis­ease.

“It is fu­tile to take a liver sup­ple­ment dili­gently with­out watch­ing your diet, ex­er­cis­ing and quit­ting smok­ing. Liver sup­ple­ments should not be used as the cure-all for NAFLD,” adds Dr Gane­salingam.

A tran­sient elas­tog­ra­phy is used to di­ag­nose liver trou­ble.

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