Dr Chandika Liyanage MBBS, MPhil, MS, MRCS
Consultant Surgeon and Senior Lecturer in Surgery
North Colombo Teaching hospital and North Colombo Liver transplantation Service.
Fatty liver in lay terms can be simply defined as infiltration of the liver tissue with fat. In scientific terms this means abnormal retention of triglyceride vacuoles in the hepatocytes or the cells of the liver. Worldwide the incidence of fatty liver disease is on the rise. The incidence of fatty liver can range from about 10 to 25 %. However in the United States the incidence of fatty liver disease is about 33%. Alarmingly the incidence of fatty liver disease in Sri Lanka is significantly high. At the Ragama health study, which was a population-based study looking at the prevalence of fatty liver disease, showed that 30% of the population had fatty liver disease. This is further confirmed by our experience at the North Colombo transplant service where majority of the transplanted patients were cryptogenic cirrhosis (non alcoholic) patients. Further, as hepatobiliary surgeons undertaking laparoscopic gallbladder surgery, we see many patients who have fat infiltrated livers. Majority of these patients are females. This leaves us with an enormous health problem threatening our population. Interestingly more than 60% of these patients can have this condition reversed if they opt for a life style change.
The causes for Fatty liver disease could be alcohol or non-alcoholic. This is the basis for identifying the two conditions alcoholic fatty liver disease and non-alcoholic fatty liver disease (NAFLD). The causes for NAFLD include mainly obesity, which may be associated with insulin resistance and other metabolic problems. It could be a part of the metabolic syndrome, which is coined by obesity, diabetes, hypertension and high lipids. In addition nutritional problems and drugs and toxins also can result in this disease process. Unfortunately we see many females and some males who present with cirrhosis of liver requiring transplant. When we dig into their history we hear unfortunate stories of taking drug concoctions and liver toxins as form of therapy for long periods of time ,slowly destroying their livers.
Accumulation of fat can progress in to inflammation. This is the danger of fatty liver disease. This state is called Steatohepatitis, and in non-alcoholics it is called non alcoholic steatohepatitis (NASH). An alcohol consumption of less than two drinks per day (<20g for women and < 30g for men) will be a criterion to include them in to the NASH group. When there is extensive inflammation and high degree of steaotosis, it will lead to hepatocyte ballooning and necrosis with progression to fibrosis. This will eventually progress to the condition called cirrhosis. Though the transformation of alcoholic steaotohepatitis to cirrhosis is clear, the trigger for NASH to progress to cirrhosis is not very clear.
Most of these patients are diagnosed by elevated liver enzymes or due to liver enlargement and incidentally on ultra sound scan findings.
Generally liver function tests, vial hepatitis serology and imaging studies, mainly an abdominal ultra sound will help to diagnose this condition. Though not widely practiced, the confirmation is by a liver biopsy.
Though much research has been done on this subject there are no clear answers on treating this condition. Majority of fatty liver disease patients can reverse the condition by life style modification. The cardinal step is to avoid the causative factor. If it is alcohol it should be stopped. All hepato toxins should be avoided. High energy yielding refined carbohydrate and fat consumption should be minimized to cut down on the surplus of calories. Exercise helps in improving insulin resistance and to reduce excess body weight. Up-to-date the only un-debated form of remedy for fatty liver disease is to loose 10% of existing body weight.
It is important to have good glycaemic control and to achieve ideal body weight for your corresponding height. Patients should seek treatment for diabetes and hyperlipidaemias as early as possible and should screen themselves for this condition, as the prevalence is quite high in our population.
Alarmingly we now see this condition in the young adult population as well. When fatty liver sets in early in life there is a high probability that they will develop liver dysfunction later in life. This will mean people will require liver transplants unless this condition is taken seriously. The fact that it is reversible for most is encouraging. However the effort from the affected is still very discouraging.