Thursday, April 30, 2009

Understanding and Managing Fatty Liver

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Fatty liver

It has been suggested that Steatohepatitis be merged into this article or section. (Discuss)

Fatty liver
Classification and external resources
ICD-10 K70., K76.0
ICD-9 571.0, 571.8
DiseasesDB 18844
eMedicine med/775
MeSH C06.552.241

Different stages of liver damageFatty liver, also known as fatty liver disease (FLD), steatorrhoeic hepatosis, or steatosis hepatitis, is a reversible condition where large vacuoles of triglyceride fat accumulate in liver cells via the process of steatosis.

Despite having multiple causes, fatty liver can be considered a single disease that occurs worldwide in those with excessive alcohol intake and those who are obese (with or without effects of insulin resistance). The condition is also associated with other diseases that influence fat metabolism[1]. Morphologically it is difficult to distinguish alcoholic FLD from non alcoholic FLD and both show micro-vesicular and macrovesicular fatty changes at different stages.

Contents [hide]
1 Causes
2 Pathology
3 Diagnosis
4 Treatment and prevention
5 Complication
6 Epidemiology
7 See also
8 References
9 External links

Fatty liver is commonly associated with alcohol or metabolic syndrome (diabetes, hypertension and dyslipidemia) but can also be due to any one of many causes[2][3]:


Abetalipoproteinemia, glycogen storage diseases, Weber-Christian disease, Wolman disease, acute fatty liver of pregnancy, lipodystrophy

Malnutrition, total parenteral nutrition, severe weight loss, refeeding syndrome, jejuno-ileal bypass, gastric bypass, jejunal diverticulosis with bacterial overgrowth

Drugs and toxins
Amiodarone, methotrexate, diltiazem, highly active antiretroviral therapy, glucocorticoids, tamoxifen, environmental hepatotoxins (e.g. phosphorus, toxic mushroom)

Inflammatory bowel disease, HIV, Hepatitis C especially genotype 3.

Fatty change represents the intra-cytoplasmic accumulation of triglyceride (neutral fats). At the beginning, the hepatocytes present small fat vacuoles (liposomes) around the nucleus - microvesicular fatty change.

In this stage liver cells are filled with multiple fat droplets that do not displace centrally located nucleus. In the late stages, the size of the vacuoles increases pushing the nucleus to the periphery of the cell giving characteristic signet ring appearance - macrovesicular fatty change. These vesicles are well delineated and optically "empty" because fats dissolve during tissue processing.

Large vacuoles may coalesce, producing fatty cysts - which are irreversible lesions. Macrovesicular steatosis is the most common form and is typically associated with alcohol, diabetes, obesity and corticosteroids. Acute fatty liver of pregnancy and Reye's syndrome are examples of severe liver disease caused by microvesicular fatty change[4]. The diagnosis of steatosis is made when fat in the liver exceeds 5–10% by weight[5][6][1].

Mechanism leading to hepatic steatosisDefects in fat metabolism are responsible for pathogenesis of FLD which may be due to imbalance in energy consumption and its combustion resulting in lipid storage or can be a consequence of peripheral resistance to insulin, whereby the transport of fatty acids from adipose tissue to the liver is increased[7][1].

Impairment or inhibition of receptor molecules (PPAR-α, PPAR-γ and SREBP1) that control the enzymes responsible for the oxidation and synthesis of fatty acids appears to contribute towards fat accumulation.

In addition alcoholism is known to damage mitochondria and other cellular structure further impairing cellular energy mechanism. On the other hand non alcoholic FLD may begin as excess of unmetabolised energy in liver cells. Hepatic steatosis is considered reversible and to some extent nonprogressive if there is cessation or removal of underlying cause.

Severe fatty liver is sometimes accompanied by inflammation, a situation that is referred to as steatohepatitis. Progression to alcoholic steatohepatitis (ASH) or non-alcoholic steatohepatitis (NASH) depend on persistence or severity of inciting cause. Pathological lesions in both conditions are similar.

However, the extent of inflammatory response varies widely and does not always correlate with degree of fat accumulation. Steatosis (retention of lipid) and onset of steatohepatitis may represent successive stages in FLD progression[8].

Liver with extensive inflammation and high degree of steatosis often progresses to more severe forms of the disease[9]. Hepatocyte ballooning and hepatocyte necrosis of varying degree are often present at this stage. Liver cell death and inflammatory responses lead to the activation of stellate cells which play a pivotal role in hepatic fibrosis.

The extent of fibrosis varies widely. Perisinusoidal fibrosis is most common, especially in adults, and predominates in zone 3 around the terminal hepatic veins[10].

The progression to cirrhosis may be influenced by the amount of fat and degree of steatohepatitis and by a variety of other sensitizing factors. In alcoholic FLD the transition to cirrhosis related to continued alcohol consumption is well documented but the process involved in non-alcoholic FLD is less clear.

Flow chart for diagnosis, modified from[3]
Elevated liver enzyme

Serology to exclude viral hepatitis

Imaging study showing
fatty infiltrate

Assess alcohol intake

Less than 2 drinks per day‡ More than 2 drinks per day‡

Non-alcoholic fatty liver disease likely Alcoholic liver disease likely

‡ Criteria for nonalcoholic fatty liver disease:
consumption of ethanol less than 20g/day for woman and 30g/day for man[11]

Most individuals are asymptomatic and are usually discovered incidentally because of abnormal liver function tests or hepatomegaly noted in unrelated medical condition. Elevated liver biochemistry is found in 50% of patients with simple steatosis[12]. The serum ALT level usually is greater than the AST level in non-alcoholic variant and the opposite in alcoholic FLD ( AST:ALT more than 2:1).

Imaging studies are often obtained during evaluation process. Ultrasonography reveals a "bright" liver with increased echogenicity.

Medical imaging can aid in diagnosis of fatty liver; fatty livers have lower density than spleen on computed tomography (CT) and fat appears bright in T1-weighted magnetic resonance images (MRIs). No medical imagery, however, is able to distinguish simple steatosis from advanced NASH. Histological diagnosis by liver biopsy is sought when assessment of severity is indicated.

[edit] Treatment and prevention
The treatment of fatty liver depends on what is causing it, and generally, treating the underlying cause will reverse the process of steatosis if implemented at early stage.


Up to 10% of cirrhotic alcoholic FLD will develop hepatocellular carcinoma. Overall incidence of liver cancer in non-alcoholic FLD has not yet been quantified, but the association is well established[13].


The prevalence of FLD in the general population ranges from 10% to 24% in various countries[2]. However, the condition is observed in up to 75% of obese people, 35% of whom will progress to non-alcoholic FLD[14], despite no evidence of excessive alcohol consumption. FLD is the most common cause of abnormal liver function test in the US[2].

Hispanic-Americans and European-Americans have higher frequencies of unexplained serum aminotransferase elevations than those reported in African-Americans (, but prevalence of FLD among different racial groups is not known.

Non-alcoholic fatty liver disease
Metabolic syndrome
Alcoholic liver disease
Focal fatty liver

^ a b c Reddy JK, Rao MS (2006). "Lipid metabolism and liver inflammation. II. Fatty liver disease and fatty acid oxidation". Am. J. Physiol. Gastrointest. Liver Physiol. 290 (5): G852–8. doi:10.1152/ajpgi.00521.2005. PMID 16603729.
^ a b c Angulo P (2002). "Nonalcoholic fatty liver disease". N. Engl. J. Med. 346 (16): 1221–31. doi:10.1056/NEJMra011775. PMID 11961152.
^ a b Bayard M, Holt J, Boroughs E (2006). "Nonalcoholic fatty liver disease". American family physician 73 (11): 1961–8. PMID 16770927.
^ Goldman, Lee (2003). Cecil Textbook of Medicine -- 2-Volume Set, Text with Continually Updated Online Reference. Philadelphia: W.B. Saunders Company. ISBN 0721645631.
^ Adams LA, Lymp JF, St Sauver J, Sanderson SO, Lindor KD, Feldstein A, Angulo P (2005). "The natural history of nonalcoholic fatty liver disease: a population-based cohort study". Gastroenterology 129 (1): 113–21. doi:10.1053/j.gastro.2005.04.014. PMID 16012941.
^ Crabb DW, Galli A, Fischer M, You M (2004). "Molecular mechanisms of alcoholic fatty liver: role of peroxisome proliferator-activated receptor alpha". Alcohol 34 (1): 35–8. doi:10.1016/j.alcohol.2004.07.005. PMID 15670663.
^ Medina J, Fernández-Salazar LI, García-Buey L, Moreno-Otero R (2004). "Approach to the pathogenesis and treatment of nonalcoholic steatohepatitis". Diabetes Care 27 (8): 2057–66. doi:10.2337/diacare.27.8.2057. PMID 15277442.
^ Day CP, James OF (1998). "Steatohepatitis: a tale of two "hits"?". Gastroenterology 114 (4): 842–5. doi:10.1016/S0016-5085(98)70599-2. PMID 9547102.
^ Gramlich T, Kleiner DE, McCullough AJ, Matteoni CA, Boparai N, Younossi ZM (2004). "Pathologic features associated with fibrosis in nonalcoholic fatty liver disease". Hum. Pathol. 35 (2): 196–9. doi:10.1016/j.humpath.2003.09.018. PMID 14991537.
^ Zafrani ES (2004). "Non-alcoholic fatty liver disease: an emerging pathological spectrum". Virchows Arch. 444 (1): 3–12. doi:10.1007/s00428-003-0943-7. PMID 14685853.
^ Adams LA, Angulo P, Lindor KD (2005). "Nonalcoholic fatty liver disease". CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne 172 (7): 899–905. doi:10.1503/cmaj.045232. PMID 15795412.
^ Sleisenger, Marvin (2006). Sleisenger and Fordtran's Gastrointestinal and Liver Disease. Philadelphia: W.B. Saunders Company. ISBN 1416002456.
^ Qian Y, Fan JG (2005). "Obesity, fatty liver and liver cancer". HBPD INT 4 (2): 173–7. PMID 15908310.
^ Hamaguchi M, Kojima T, Takeda N, Nakagawa T, Taniguchi H, Fujii K, Omatsu T, Nakajima T, Sarui H, Shimazaki M, Kato T, Okuda J, Ida K (2005). "The metabolic syndrome as a predictor of nonalcoholic fatty liver disease". Ann. Intern. Med. 143 (10): 722–8. PMID 16287793.

[edit] External links
American Association for the Study of Liver Disease
American Liver Foundation
00474 at CHORUS
Photo at Atlas of Pathology
[hide]v • d • eDigestive system · Digestive disease · Gastroenterology (primarily K20-K93, 530-579)

Upper GI tract Esophagus Esophagitis (Candidal) · rupture (Boerhaave syndrome, Mallory-Weiss syndrome) · UES (Zenker's diverticulum) · LES (Barrett's esophagus) · Esophageal motility disorder (Nutcracker esophagus, Achalasia, Diffuse esophageal spasm, GERD) · Esophageal stricture · Megaesophagus

Stomach Gastritis (Atrophic, Ménétrier's disease, Gastroenteritis) · Peptic (gastric) ulcer (Cushing ulcer, Dieulafoy's lesion) · Dyspepsia · Pyloric stenosis · Achlorhydria · Gastroparesis · Gastroptosis · Portal hypertensive gastropathy · Gastric antral vascular ectasia · Gastric dumping syndrome · Gastric volvulus

enteropathy Small intestine/
(duodenum/jejunum/ileum) Enteritis (Duodenitis, Jejunitis, Ileitis) — Peptic (duodenal) ulcer (Curling's ulcer) — Malabsorption: Coeliac · Tropical sprue · Blind loop syndrome · Whipple's · Short bowel syndrome · Steatorrhea · Milroy disease

Large intestine
(appendix/colon) Appendicitis · Colitis (Pseudomembranous, Ulcerative, Ischemic, Microscopic, Collagenous, Lymphocytic) · Functional colonic disease (IBS, Intestinal pseudoobstruction/Ogilvie syndrome) — Megacolon/Toxic megacolon · Diverticulitis/Diverticulosis

Large and/or small Enterocolitis (Necrotizing) · IBD (Crohn's disease) — vascular: Abdominal angina · Mesenteric ischemia · Angiodysplasia — Bowel obstruction: Ileus · Intussusception · Volvulus · Fecal impaction — Constipation · Diarrhea (Infectious)

Rectum Proctitis (Radiation proctitis) · Proctalgia fugax · Rectal prolapse

Anus Anal fissure/Anal fistula · Anal abscess · Anal dysplasia · Pruritus ani

Accessory Liver Hepatitis (Viral hepatitis, Autoimmune hepatitis, Alcoholic hepatitis) · Cirrhosis (PBC) · Fatty liver (NASH) · vascular (Hepatic veno-occlusive disease, Portal hypertension, Nutmeg liver) · Alcoholic liver disease · Liver failure (Hepatic encephalopathy, Acute liver failure) · Liver abscess (Pyogenic, Amoebic) · Hepatorenal syndrome · Peliosis hepatis

Gallbladder Cholecystitis · Gallstones/Cholecystolithiasis · Cholesterolosis · Rokitansky-Aschoff sinuses · Postcholecystectomy syndrome

Bile duct/
other biliary tree Cholangitis (PSC, Secondary sclerosing cholangitis, Ascending) · Cholestasis/Mirizzi's syndrome · Biliary fistula · Haemobilia · Gallstones/Cholelithiasis
common bile duct (Choledocholithiasis, Biliary dyskinesia)

Pancreatic Pancreatitis (Acute, Chronic, Hereditary) · Pancreatic pseudocyst · Exocrine pancreatic insufficiency · Pancreatic fistula

Hernia Diaphragmatic: Congenital diaphragmatic · Hiatus — Abdominal hernia: Inguinal (Indirect, Direct) · Umbilical · Incisional · Femoral — Obturator hernia · Spigelian hernia · Internal hernia

Peritoneal Peritonitis (Spontaneous bacterial peritonitis) · Hemoperitoneum · Pneumoperitoneum

GI bleeding/BIS Upper (Hematemesis, Melena) · Lower (Hematochezia)

1 comment:

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