Case 4: Summary

Diagnosis:  Non-Alcoholic Fatty Liver Disease (NAFLD)

Case Summary:

This case describes a middle-aged man with multiple metabolic risk factors referred for an incidental finding of fatty liver on abdominal ultrasound. His transaminases are mildly elevated and he has no signs of advanced liver disease. This is a typical case encountered in an outpatient hepatology practice. The most likely underlying diagnosis is NAFLD but serologic workup should be done to rule out other causes of chronic liver disease.

Clinical decision aids such as the NAFLD fibrosis score and FIB-4 index can be used to identify those at high risk for advanced fibrosis. Vibration controlled transient elastography (VCTE) is also useful to non-invasively assess fibrosis and will report stages of fibrosis from F0 (no fibrosis) to F4 (cirrhosis). Liver biopsy can be considered in patients suspected of having NAFLD in whom a coexisting diagnosis cannot be ruled out without a biopsy or in patients at increased risk of steatohepatitis and/or advanced fibrosis.

Lifestyle measures are the key component of management with a goal of weight loss of 7-10% body weight through dietary modification and exercise. Pharmacological treatments aimed primarily at improving liver disease should generally be limited to those with biopsy-proven NASH and fibrosis. Pioglitazone improves liver histology in patients with and without diabetes with biopsy-proven NASH and can be considered. Vitamin E improves liver histology in nondiabetic patients with biopsy-proven NASH and may be considered for this patient population. Bariatric surgery can be considered in otherwise eligible obese patients. Patients with NAFLD are at high risk for cardiovascular morbidity and mortality, and aggressive modification of CVD risk factors should be considered in all patients.

Case authored by: Jonathan Nahas MD and Kamron Pourmand MD

References

1. Chalasani N., Younossi Z., Lavine J.E., Diehl A.M., Brunt E.M., Cusi K., Charlton M., Sanyal AJ. The diagnosis and management of non-alcoholic fatty liver disease: Practice Guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Hepatology. 2012;55:2005–2023. 

2. Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017;65:310–335. 

3. de Franchis R; Baveno V Faculty. Expanding consensus in portal hypertension. Report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 2015;63:743-752.

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Case 4 Index:
Introduction
Physical Exam

Diagnostic Testing
Management