Simple steatosis: Fat accumulation without liver inflammation/damage
NASH: Fat accumulation causing inflammation and fibrosis → may progress to cirrhosis
Note: NAFLD is now considered a part of the metabolic syndrome spectrum

Causes

Overweight, insulin resistance
Higher risk of NASH in patients with metabolic syndrome → requires further investigation for cirrhosis (e.g., referral to gastro for biopsy)
Consider NAFLD scoring tools and ultrasound elastography for assessment
OSA has been associated with an increased risk of NASH due to intermittent hypoxia

Presentation

Usually asymptomatic
Sometimes fatigue, abdominal discomfort
Clinical Pearl: Hepatomegaly may be found incidentally during an abdominal examination

Diagnosis

LFT Pattern:
- Elevated ALT/AST ratio <1.5
- Raised GGT; sometimes elevated ALP
Diagnosis of exclusion:
- Exclude:
  - Alcohol consumption
  - Other causes of hepatic steatosis (e.g., methotrexate, amiodarone, pregnancy)
  - Other causes of elevated transaminases (e.g., hepatitis, autoimmune hepatitis, haemochromatosis)
Simplified Approach: Perform a full liver screen as part of LFT investigations
Note: Use the FIB-4 score (age, ALT, AST, platelets) for non-invasive fibrosis assessment

Management

If No Cirrhosis/Portal Hypertension:

If Advanced Disease or Suspected Cirrhosis:

Refer for further evaluation (e.g., transient elastography, liver biopsy if required)

Complications

NASH: → Increased risk of HCC and liver cirrhosis
Additional Complications: NAFLD is associated with a higher risk of cardiovascular disease (CVD), which remains the leading cause of mortality

Monitoring:

Repeat LFTs and weight assessment every 6–12 months for patients with NAFLD without fibrosis
Patients with cirrhosis require 6-monthly surveillance for HCC using ultrasound ± AFP

NAFLD (Non-Alcoholic Fatty Liver Disease)

Types

Simple Steatosis: Fat accumulation in hepatocytes without significant inflammation or fibrosis.
NASH (Non-Alcoholic Steatohepatitis): Fat deposition with inflammation and varying degrees of fibrosis; can progress to cirrhosis.
NAFLD is often part of metabolic syndrome (obesity, hyperglycaemia/insulin resistance, dyslipidaemia, hypertension).

Causes / Risk Factors

Overweight, Insulin Resistance (central obesity, type 2 diabetes).
Higher risk of NASH in patients with metabolic syndrome → warrants vigilance for advanced fibrosis (referral to gastroenterology if suspicion).
OSA (obstructive sleep apnoea) is associated with an increased risk of NASH (intermittent hypoxia).
Certain medications (e.g. methotrexate, amiodarone) can also cause hepatic steatosis but are not classified under NAFLD.

Presentation

Diagnosis

LFT Pattern

Mildly elevated ALT and AST (ratio <1.5)
Elevated GGT, sometimes raised ALP
Diagnosis of Exclusion: Rule out other causes (excess alcohol, viral hepatitis, autoimmune hepatitis, haemochromatosis, Wilson’s disease, etc.).

Further Tools

FIB-4 Score: (Age, ALT, AST, platelets) → non-invasive estimation of fibrosis
Ultrasound or Transient Elastography: Assess fat infiltration and liver stiffness.
If advanced disease suspected, consider referral for possible liver biopsy to confirm NASH and staging.

Management

If No Cirrhosis/Portal Hypertension

Lifestyle Modification (cornerstone therapy):
- Weight Reduction (aim for 5–10% loss if overweight/obese)
- Diet: Mediterranean diet approach; reduce refined carbs, saturated fats
- Exercise: ≥150 min/week moderate-intensity (brisk walking, cycling)
- No Smoking, minimise/avoid alcohol
Address Comorbidities:
- Diabetes control (target normal glycaemic range)
- Dyslipidaemia: Consider statins, safe in NAFLD
- Hypertension: Follow standard guidelines
Referral:
- Dietitian for personalised meal planning
- Endocrinologist if complex metabolic issues
- Bariatric Surgery if severe obesity or failed lifestyle interventions
Monitoring: If LFTs remain elevated or no improvement after ~6 months, specialist referral indicated (hepatologist/gastroenterologist).

If Advanced Disease or Suspected Cirrhosis

Refer to specialist for further evaluation (elastography, potential biopsy).
Surveillance for varices, HCC if cirrhosis is present.

Complications

NASH increases risk of HCC (hepatocellular carcinoma) and progressive cirrhosis.
Cardiovascular Disease is the leading cause of death in NAFLD → emphasise overall risk factor reduction.

Monitoring

NAFLD Without Fibrosis: Repeat LFTs & weight checks every 6–12 months.
Cirrhosis: 6-monthly ultrasound ± AFP for HCC screening, assess portal hypertension complications, screen varices.

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