Non-alcoholic fatty liver disease (NAFLD and NASH)

Non-alcoholic fatty liver disease is a disease where fat builds up in the liver. There are two types of non-alcoholic fatty liver disease:

• Non-alcoholic fatty liver disease, also known as NAFLD (non-alcoholic fatty liver): In patients with NAFLD, there is fat accumulation in the liver but the liver is not inflamed.
• Non-alcoholic steatohepatitis (NASH) or non-alcoholic liver inflammation: In patients with NASH, there is a build-up of fat in the liver and the liver is inflamed. NASH can lead to liver cirrhosis and liver cancer.

Approximately 20 to 30% of people with non-alcoholic fatty liver disease (NAFLD) develop NASH.

NASH is a liver infection that is not the result of excessive alcohol consumption. Patients with NASH usually drink little or no alcohol, but they get the same symptoms as patients who get liver inflammation from drinking too much alcohol.

Most patients with NAFLD and NASH have little to no symptoms.

Liver diseases usually only cause symptoms at a late stage. This is because the healthy part of the liver can perform the various functions well enough. When symptoms occur, the disease is usually already at an advanced stage.

Patients with NASH are often referred to a liver doctor via their GP because of impaired blood liver tests.

If there are symptoms of NASH, it is often the following:

• Fatigue
• Weight loss
• Muscle weakness

The disease is often already advanced and, in most cases, has already occurred. cirrhosis of the liver developed.

NALFD and NASH are common in Western countries, specifically in the following patient groups:

• Overweight (obese) people
• People who have diabetes mellitus, more specifically type 2 diabetes mellitus.
• People with metabolic syndrome.

The metabolic syndrome is a combination of 5 factors that can disrupt the metabolism:

• Waist circumference
  • in men: >102 cm;
  • in women: > 88 cm
• Increased blood pressureIncreased blood fat levels (triglycerides)
• Low HDL cholesterol
• Increased blood sugar levels

Non-alcoholic fatty liver disease is the result of impaired fat metabolism and/or sugar metabolism in the liver, which will cause fat to accumulate in the liver cells. Fatty liver disease is a reversible process. This means that the fat accumulation disappears when the cause is removed.

Blood tests

The liver doctor will do various blood tests to rule out other underlying causes of liver disease. You will therefore usually be tested for the following conditions: hepatitis C, hepatitis B, etc.

FIB 4 score

The FIB 4 score is a score calculated based on some blood values (AST, ALT, platelets) and your age. In this way, we can divide patients into groups that are more at risk of the evolution of NAFLD into fibrosis and cirrhosis.

A blood test involves taking a tube of blood from a vein on the inside of the arm, usually in the crease of the elbow. In order to see and feel this vein properly, a thrust band is pulled tightly around the upper arm. The vein is pricked with a needle so that the blood is drawn into the tube. The needle is used only once and then destroyed.

Radiological examination

Images will be taken of the liver. This can be done via an ultrasound, a CT scan or an MRI scan. Through these studies, we get a good idea of the state of the liver and the degree of fatty liver disease and/or inflammation.

Fibroscan

NAFLD and NASH cause scar tissue on the liver. The fibroscan is an examination that measures the stiffness of the liver. The more scar tissue, the stiffer the liver.
A fibroscan is an examination in which a type of ultrasound head is placed between the ribs on the right side of the body (where the liver is located). Tiny shock waves are sent to the liver. The examination takes about 10 minutes and does not hurt.

Liver biopsy

A liver biopsy is the only test that can tell with certainty whether you have fatty liver disease and whether it causes you to have liver inflammation. If the doctor is unsure whether you have fatty liver disease, wants to know if you have any other liver disease or if they want to know if there is inflammation in the liver, a liver biopsy will be chosen. A liver biopsy can clarify the severity of liver inflammation and the stage of the disease.
There are two types of liver biopsy:

• Percutaneous liver biopsy: In this biopsy, the doctor pierces the skin, between the ribs, to remove a piece of liver. (link to folder)
• Transjugular liver biopsy: When there is too much risk of bleeding (e.g. When the patient takes a blood thinner that cannot be stopped, if the patient has a clotting disorder, etc.), a transjugular liver biopsy is chosen. This means that a small piece of liver tissue is removed via your blood vessels.

After both biopsies, the pieces of tissue go to the lab to be further examined. You will receive the results at the next consultation, which will be scheduled shortly afterwards.

Fatty liver disease is a reversible process. This means that the fat accumulation disappears when the cause is eliminated. The condition of the liver can therefore improve if other issues that often go hand in hand with NASH are treated.

Changing lifestyle

By reducing the intake of calories and increasing physical activity, weight loss can occur. A weight loss of 5 to 10% already leads to a reduction in fatty liver disease.

Making these life adjustments not only helps improve the condition of the liver and thus also fatty liver disease, but also reduces the risk of a heart attack, for example. This is important because patients with NASH often also have an increased risk of a heart attack.

Treating elevated blood sugar levels

Patients who also have diabetes mellitus in addition to fatty liver disease are usually also seen by a doctor who specializes in this (endocrinologist). They therefore often start medication for this purpose.

Vitamin E

If you have a severe form of NASH and you don't have diabetes or heart disease, vitamin E can be started. Vitamin E would somewhat reduce the liver damage caused by NASH, according to some scientific studies.

Preventing further liver damage

If you have fatty liver disease, it is important to avoid other factors that also cause damage to the liver. For example: do not overuse alcohol, do not take medication that is harmful to the liver, get vaccinated against hepatitis B, etc.

Operation

Sometimes bariatric surgery is recommended for patients who have difficulty losing 5 to 10% of body weight. Bariatric surgery is a collective name for all surgeries that aim to lose weight. Examples of such operations include a “gastric sleeve” and a “gastric bypass”.

Future

Currently, pharmaceutical companies are doing a lot of research into new medications to prevent fat accumulation in the liver. This medication is currently being tested in advanced phases of research. The medication has therefore already proven its effectiveness and safety, but now it still needs to be tested on larger groups of patients. In AZ Delta, we are also participating in such studies that test a type of this medication. If you are a patient suffering from NAFLD or NASH can, and you are interested in these studies, you can always reach the Gastrointestinal and Liver Diseases Study Team:

• Line Decaesteker: 051/23 75 12
• Elien De Cock: 051/23 75 34
• Ann D'Hondt: 051/23 75 33

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Learn more about fatty liver disease here [uptodate.com]

Read more about fatty liver disease here [mlds.nl]