Fatty Liver (Hepatic Steatosis)

• Aetiology: Non-Alcoholic Fatty Liver Disease (NAFLD): Associated with metabolic syndrome (obesity, insulin resistance, dyslipidemia, hypertension). Alcoholic Fatty Liver Disease (AFLD): Due to chronic excessive alcohol consumption.

• Pathophysiology: Insulin resistance leads to increased free fatty acid delivery to the liver and de novo lipogenesis. Oxidative stress, inflammation, and lipotoxicity drive progression to steatohepatitis (NASH or ASH) and fibrosis.

• Common symptoms: Often asymptomatic; nonspecific symptoms may include fatigue, right upper quadrant discomfort.
• Signs: Hepatomegaly (may be palpable).
• Red-flag symptoms: Jaundice, ascites, or signs of chronic liver disease (e.g., spider angiomas, palmar erythema) suggest advanced disease or cirrhosis.

• Clinical assessment: History (alcohol use, metabolic risk factors), physical exam.
• Laboratory tests: Elevated liver enzymes (ALT, AST); AST:ALT ratio >1 suggests AFLD or advanced fibrosis. Exclusion of other liver diseases (viral hepatitis, autoimmune, etc.).
  Non-invasive fibrosis markers (e.g., FIB-4, ELF test).
• Imaging: Ultrasound (first-line): Increased echogenicity (“bright liver”).
  Transient elastography (e.g., FibroScan) for fibrosis staging.
• Liver biopsy: Gold standard for diagnosing steatohepatitis and fibrosis staging.

• Non-pharmacological: Weight loss (7–10% total body weight for NAFLD). Dietary modifications (reduce saturated fats, sugars; Mediterranean diet). Exercise regimen. Alcohol abstinence (for AFLD or mixed aetiology).
• Pharmacological: Vitamin E (for non-diabetic NASH with fibrosis).
  Pioglitazone (select cases of NASH). GLP-1 receptor agonists (e.g., semaglutide) for weight loss and metabolic benefits.
• Management of comorbidities: Optimise control of diabetes, dyslipidemia, and hypertension.

• Progression to steatohepatitis (NASH/ASH), fibrosis, cirrhosis.**
• Hepatocellular carcinoma (HCC).**
• Liver failure.**
• Cardiovascular disease (leading cause of mortality in NAFLD).**

Prevention:**

• Healthy lifestyle: balanced diet, regular exercise, moderation/abstinence from alcohol.
• Early intervention in metabolic syndrome.

Follow-up:**

• Monitor liver enzymes and metabolic parameters annually.
• Regular fibrosis assessment (e.g., biennial elastography in high-risk cases).
• Surveillance for HCC in cirrhotic patients (ultrasound ± AFP every 6 months).