A time bomb hidden in the belly

• The risks posed by fatty liver

BY Dr. Chamara Dalugama The liver is a vital organ in the body that carries out many life-supporting functions. It weighs around 1.5 kilogrammes (kg) in an average adult. The liver is essential in maintaining blood glucose levels. When there is a surplus of glucose, the liver stores glucose in the form of glycogen and releases glucose into the bloodstream during fasting. It also stores bile and helps with digestion. The liver synthesises proteins which are much needed for many processes happening in the body.  It produces substances that help the blood to clot in injuries. It is a storehouse which stores many important substances including iron. The liver helps fight infection by making immune factors and it removes harmful bacteria and toxins from the body. It produces some vital hormones as well. It is indispensable for the survival of humans. A healthy liver will have some fat in it, which is usually less than 5% of the weight of the liver. It becomes a problem if the fat percentage exceeds 5-10% of the liver’s weight, which is generally referred to as “fatty liver”.  How common is fatty liver?  We do see an ever-increasing number of patients carrying a diagnosis of fatty liver. According to data taken from around the world, nearly half of the global population could potentially have excess fat in the liver based on ultrasound scans, and these numbers are shown to be increasing exponentially over the years.  What are the causes for fatty liver?  The excess use of alcohol is a common cause for fatty liver (Alcoholic Fatty Liver Disease – ALFD). But we do see many patients who do not consume alcohol but are diagnosed with this condition, which is referred to as Non-Alcoholic Fatty Liver Disease (NAFLD). Interestingly, NAFLD is becoming more common than those with ALFD.  Common causes for Non-Alcoholic Fatty Liver Disease include:

1. Being overweight and obese
2. Diabetes mellitus
3. Metabolic syndrome (Collective term for those with high sugar, cholesterol, blood pressure, and are overweight)
4. Certain medications (Some heart medications and cancer medications)
5. Certain infections of the liver (hepatitis)

Are you at increased risk of developing a fatty liver? For Asians, the answer is “yes”. In addition, if an individual is overweight, particularly with a high level of belly fat, and has diabetes and high cholesterol, it increases the risk of developing a fatty liver. If you are a snorer at night, the risk of having a fatty liver is high.  What symptoms do you get if you have a fatty liver? Unfortunately, most people with a fatty liver will not know that they have it, as it is largely without any symptoms. Some might generally feel unwell and experience a lack of energy and excessive tiredness. Abdominal bloating, discomfort, and pain particularly over the right upper belly are among the other common symptoms. Some might experience a loss of appetite and nausea. Is it a serious condition?  Fatty liver could be a serious condition for some, as it can lead to cirrhosis. Some patients with fatty liver can develop persistent inflammation of the liver cells (steatohepatitis) and a subset of patients can end up in liver fibrosis leading to cirrhosis. Cirrhosis is an irreversible condition and can eventually lead to liver failure, liver cancer, and death. But the good news is that the liver has a remarkable capacity to repair and heal itself. So early diagnosis, managing risk factors, and prompt treatment could reverse the fatty liver completely.  How do doctors diagnose a fatty liver? As many patients are asymptomatic, your doctor may be the first one to detect it. Sometimes, routine blood tests might raise a red flag that you could potentially have a fatty liver. If you are overweight or obese, have diabetes or high cholesterol, you can request – or your doctor might suggest – a screening for a fatty liver. The following investigations can be arranged to look for a fatty liver:

1. Liver enzyme tests (Serum Glutamic Pyruvic Transaminase [SGPT] or alanine aminotransferase [ALT]) – Suggest that the liver is injured but does not confirm the diagnosis
2. Ultrasound scan of the liver – Might suggest excess fat in the liver and can detect complications of fatty liver such cirrhosis.
3. Fibroscan – This is a special ultrasound scan available in some hospitals in the country which can find out the amount of fat and scar tissue in the liver.
4. Liver biopsy – This is not a commonly performed test as it is invasive and the tests mentioned above gives the diagnosis in most cases, but in a very few patients with a diagnostic dilemma, a small part of the liver is taken and examined under the microscope, and this is the gold standard way to confirm a fatty liver.

How is a fatty liver treated?  The most important aspect of treating a fatty liver is to identify the risk factors and manage them. Modifications in the lifestyle and targeting a gradual weight loss are of paramount importance to reverse the fatty liver. The following lifestyle changes would help to reverse a fatty liver by achieving the desired amount of weight loss:

1. Diet –  Increase fruits, vegetables, and fibre in the diet. Avoid fatty fish and meat. Consume low or nonfat milk. Reduce oil and fat intake.  Cut down on sweets and sugary foods. 
2. Exercise – Moderate aerobic exercise for at least 30 minutes a day for five days a week.

Always talk to your doctor, get your body mass index (BMI) calculated and find your ideal body weight for your height and have a realistic target of losing weight. A nutritionist can help you to plan a suitable diet to achieve your goal. Sometimes, doctors might consider some medications to help with your weight loss. If you are very obese and committed to losing weight, your doctor might refer you to special surgeons to discuss the option of weight reduction surgery.  In addition to weight loss, controlling other risk factors such as diabetes and high cholesterol are important. Abstaining from alcohol will help the liver repair.  In most patients, the fatty liver can be fully reversed with the above mentioned lifestyle changes.  Are there any drugs that can treat fatty liver? There is no specific medication for fatty liver disease but doctors might assess you and prescribe some medications to treat fatty liver. Vitamin E is shown to have some beneficial effects on patients with fatty liver. Some diabetic medications (Pioglitazone) are shown to have some promising effects on improving a fatty liver. But these medications should never be taken over the counter without consulting your doctor.  Always remember that the liver is an organ that you cannot live without. A fatty liver is a very common, potentially dangerous condition that can damage the liver. As Asians, we are at risk and the higher the risk is if you are already overweight or diabetic. Talk to the doctor and get screened for a fatty liver and always remember that simple changes in lifestyle could add many quality years to your life.  (The author is a consultant physician at the Teaching Hospital, Peradeniya, and a Senior Lecturer at the Peradeniya University’s Medicine Department)