First, we must define what are the diseases mentioned in this title, and we’ll help you understand the magnitude of their importance when a person suffers from them, their causes as well as their treatment and/or prevention of progression. Throughout this article, we will take you by the hand explaining the terms and the progressive sequence of this disease to help you avoid confusion with the terms and abbreviations.
What is fatty liver, liver steatosis or non-alcoholic fatty liver disease?
Non-alcoholic fatty liver disease (hepatic steatosis or NAFLD) is a generic term for multiple and varied liver disorders that affect people who drink very little or no alcohol. As its name implies, the main characteristic of the disease is a significant accumulation of fat in the cells of the liver.
Non-alcoholic fatty liver disease (NAFLD) is a potentially severe form of the disease, characterized by possible inflammation of the liver, which can progress towards scarring and irreversible damage. In this disease, the damage is similar to that caused by excessive alcohol consumption. In its most severe form, nonalcoholic fatty liver disease may progress toward cirrhosis and liver failure.
Non-alcoholic fatty liver disease (NAFLD) is becoming the most common cause of liver disease in the world, especially in Western countries, it is estimated that it affects approximately 80 to 100 million people worldwide. In the United States, it is the most frequent form of chronic liver disease, it is estimated that in the United States only, it already affects one-third of the population and more than 75% of patients suffering from obesity. Non-alcoholic fatty liver disease (NAFLD) ranges from steatosis only (fat cells between liver cells) to nonalcoholic steatohepatitis (NASH) which implies the presence of inflammation and presence of toxic substances between the liver cells; and at its most severe end it involves fibrosis, cirrhosis and even an increased risk of liver cancer (hepatocellular carcinoma).
It is estimated that approximately 6 million individuals in the US have progressed to NASH (non-alcoholic steatohepatitis) and about 600,000 to cirrhosis linked to NASH. There are significant cultural and geographic differences in the prevalence of obesity.
It is considered that fibrosis occurs in a third of patients who suffer from NAFLD only four years after the diagnosis if no treatment is received. So since obesity and metabolic syndrome are considered one of the main risk factors to develop it, this topic has a place in this obesity surgery blog. It is already well known, and it is proven that, unfortunately, in most cases, the medical or nonsurgical measures to control weight, in case of severe obesity, are not effective or they are only for a short period of time. Some studies have even considered this liver disease as a primary indication to admit a patient as a candidate for bariatric surgery.
The progression sequence of fatty liver disease is as follows:
1. Fatty liver or nonalcoholic fatty liver disease (NAFLD)
2. Nonalcoholic steatohepatitis (NASH)
3. Liver fibrosis
4. Hepatic cirrhosis or liver cancer
5. Hepatic failure and need for liver transplantation
Who suffers from non-alcoholic fatty liver disease?
Non-alcoholic fatty liver disease (NAFLD) occurs in all ethnic groups although it is more frequent in Hispanics and Asians, especially in people between 40 and 60 years of age with a high risk of heart disease due to risk factors such as obesity and type 2 diabetes. The condition is also closely linked to the metabolic syndrome, a group of abnormalities that include increased abdominal fat, reduced ability to produce insulin, high blood pressure, and high triglyceride levels.
What are the causes of non-alcoholic fatty liver disease?
It is unknown why some people with obesity and metabolic syndrome are more likely than others to develop this condition, while it is also unknown why some of the patients suffering from fatty liver develop progressive inflammation that leads to non-alcoholic liver cirrhosis and others don’t.
Both non-alcoholic fatty liver disease (NALFD) and non-alcoholic fatty liver steatohepatitis (NASH) are related to the following factors:
- Overweight or obesity
- Insulin resistance and carbohydrate intolerance
- An elevated blood glucose level (hyperglycemia) that indicates prediabetes or type 2 diabetes. LINKS TO ARTICLES (prediabetes and diabetes)
- High levels of blood fat, mainly triglycerides
These combined health problems seem to stimulate the emergence of fatty deposits in the liver and for some people, this excess of fat acts as a toxin in the cells of the liver: 1 which causes inflammation and nonalcoholic steatosis, 2 which leads to the accumulation of scar tissue (fibrosis) in the liver, and then in turn progresses, if not treated in time, to 3 liver cirrhosis and ultimately to 4 liver failure .
What are the risk factors for non-alcoholic fatty liver disease?
There are a wide variety of diseases and conditions that can increase your risk of suffering from this disease and include:
- Hypercholesterolemia (high blood cholesterol levels)
- Hypertriglyceridemia (high levels of triglycerides in the blood)
- Metabolic syndrome
- Obesity, especially when fatty tissue is concentrated in the abdomen (android obesity)
- Polycystic ovarian syndrome
- Sleep apnea
- Type 2 diabetes
- Positive family history of the disease
- Use of medications and toxins (amiodarone, methotrexate, tamoxifen, synthetic estrogens, etcetera.)
While the simple steatosis observed in NAFLD does not represent an increase in morbidity or mortality in the short term, the progression of this condition to NASH (non-alcoholic steatohepatitis) dramatically increases the risk of cirrhosis, liver failure, and hepatocellular carcinoma (HCC). Cirrhosis due to NASH is an increasingly common reason for liver transplantation.
How is nonalcoholic fatty liver disease (NAFLD) diagnosed?
Because nonalcoholic fatty liver disease does not cause symptoms in most cases, it is usually detected when tests that indicate a liver problem are done for other reasons.
The tests that are done to try to identify the diagnosis and determine the severity of the disease include the following:
- Blood work or tests
- Complete blood count
- Liver function tests
- Fasting blood glucose test
- Glycosylated hemoglobin (A1C) that shows the stability of your blood glucose
- Lipid profile, which measures fats in the blood, such as cholesterol and triglycerides
- Complete ultrasound
- Computed tomography (CT) or magnetic resonance imaging (MRI) of the abdomen.
- Transitional elastography, by ultrasound or magnetic resonance
* Specifying the details of each study goes beyond the purpose of the article, so we only list them.
Liver biopsy: this test is considered the gold standard and confirms the degree and severity of the problem since the tissue sample is examined in a laboratory for signs of inflammation and scarring.
Treatment for fatty liver
The treatment, in general, is summarized in the solution to many diseases, and this is weight loss, depending on your degree of obesity will be the percentage of ideal weight loss for you, seeking to stay away from this disease.
However, due to what we have previously described in other articles, when the patient's obesity is severe, the chances of losing a considerable amount of weight and sufficient to resolve or stop the progression of the disease are low, it is estimated that only 20% of people with severe obesity achieve to lose enough weight and more importantly, maintain this weight loss in the long term to avoid this and the many other diseases that go hand in hand with obesity.
This is why weight loss surgery much sense as the answer in cases of severe or morbid obesity.
There are already multiple scientific studies where the beneficial effect of bariatric surgery has been evaluated in these liver diseases and it has been proven that when it comes to fatty liver disease and non-alcoholic steatohepatitis (the first two phases of the disease NAFLD and NASH) surgery achieves a regression of the disease with statistically significant histological changes (in the cells) as well as general improvement of the levels of liver enzymes, in other studies a complete resolution of the disease has been proven in up to 82% of the cases!
Even so, to date bariatric surgery, has not been approved as a sole or primary indication for the treatment of this disease.
When the disease is already in the phase of fibrosis, there has not been a complete regression of the disease, but it has stopped its the progression with weight loss surgery.
Finally, in the case of compensated cirrhosis, there are those who suggest that obesity surgery leads to higher risk of complications while others indicate that it is actually beneficial for the patients, there is not enough information to justify the surgery only in these advanced stages of the disease. Those in which surgery is definitely contraindicated is in those who already suffer from decompensated non-alcoholic liver cirrhosis because mortality is very high.
Other non-surgical measures are: adequate nutrition concerning quality and quantity as well as regular exercise, proper control of diabetes and cholesterol, avoiding the intake of alcohol and hepatotoxic medicines.
The treatment will also depend on the degree of affection of the liver because it is not the same to treat a fatty liver disease than cirrhosis in an advanced or decompensated state.
Do you suffer from mild, moderate or severe obesity? If you want to know what we can do to determine if you have the disease and how bariatric surgery can reverse the situation don’t hesitate to contact us, we can gladly guide you.