Adult-Gerontology Acute Care Practice Guidelines
Definition
A.Medical condition characterized by fatty infiltration in the liver without a history of alcohol use.
B.Two types exist based on presence of inflammation.
1.Nonalcoholic fatty liver disease (NAFLD)—benign condition without inflammation.
2.Nonalcoholic steatohepatitis (NASH)—Inflammation is present which leads to scarring. May progress to cirrhosis in 20% of the population.
Incidence
A.Most common liver disease in Western industrialized countries.
B.In the United States, the prevalence of NAFLD is estimated at 10% to 46%.
C.Incidence as high as 50% to 75% in obese patients.
Pathogenesis
A.Cause is not fully understood but thought to be linked to insulin resistance and oxidative stress in an individual with risk factors.
Predisposing Factors
A.Male sex.
B.Higher prevalence in Hispanics.
C.Commonly diagnosed at age 40 to 50.
D.Metabolic syndrome is present with one or more of the following.
1.Obesity.
2.Diabetes.
3.Hypertension (HTN).
4.Dyslipidemia.
E.Other disorders that may be associated: Polycystic ovarian syndrome (PCOS), sleep apnea, hypothyroidism.
Subjective Data
A.Common complaints/symptoms.
1.Most patients are usually asymptomatic.
2.May have fatigue, malaise, or right upper quadrant (RUQ) discomfort.
B.Common/typical scenario.
1.Incidental findings of elevated alanine aminotransferase (ALT) on lab testing or imaging suggestive of fatty infiltration.
C.Family and social history.
1.Take a detailed history of alcohol intake to rule out alcohol-related liver disease.
2.Diet and weight history.
D.Review of systems.
1.There are very few symptoms.
2.In advanced liver disease, they may have evidence of synthetic dysfunction.
Physical Examination
A.Most patients are obese.
B.Hepatomegaly.
C.In cirrhosis, may have stigmata of chronic liver disease.
Diagnostic Tests
A.Diagnosis made after exclusion of other causes and positive findings of fatty infiltration on imaging or biopsy.
B.Labs: Complete blood count (CBC), comprehensive metabolic panel (CMP), cholesterol, iron studies, ferritin, thyroid-stimulating hormone (TSH), celiac antibody.
C.Hepatitis A, B,and C serologies.
D.Autoimmune markers antinuclear antibody (ANA), AMA, ASMA.
E.Ceruloplasmin, Alpha 1 antitrypsin, HFE gene for hemochromatosis.
F.Imaging: Ultrasound or MRI.
G.Liver biopsy.
Differential Diagnosis
A.Viral hepatitis.
B.Autoimmune disease.
C.Wilson’s disease.
D.Alpha 1 antitrypsin deficiency.
E.Hemochromatosis.
F.Alcohol-related hepatitis.
G.Celiac disease.
H.Thyroid disease.
I.Medication induced: Amiodarone, methotrexate, tamoxifen, steroids, antiretrovirals.
Evaluation and Management
A.General plan.
1.If no biopsy performed, consider noninvasive testing to assess degree of fibrosis, that is, Fibroscan.
2.Lifestyle modifications—weight loss, diet, and exercise.
3.Control of sugars.
4.Treatment of hyperlipidemia and HTN.
5.Monitor liver tests every 3 months.
6.Bariatric surgery may be considered if appropriate.
B.Patient/family teaching points.
1.In general, control of risk factors contributing to metabolic syndrome.
2.Weight loss of 7% to 10% of current weight to improve fibrosis.
3.Avoid alcohol.
4.Good glucose control.
5.Vitamin E is not recommended if patient has heart disease or diabetes.
6.Reassure the patient that NAFLD is a chronic condition. Most people will not develop advanced liver disease.
C.Pharmacotherapy.
1.Vitamin E: Improves liver histology. 800 IU per day is recommended.
2.Statin therapy.
3.Clinical trials: Obeticholic acid (OCA) shows promise for future therapy.
D.Discharge instructions.
1.Follow-up with gastrointestinal (GI)/hepatologist, pneumocystis pneumonia (PCP), and/or endocrinologist.
2.Lifestyle modifications of diet and exercise.
3.Avoid alcohol.
4.Do not take any new medications/supplements without consulting your doctor.
Follow-Up
A.As noted in the discharge instructions, follow-up with PCP, GI/hepatology, and/or endocrinology.
B.Patients with NASH cirrhosis will need hepatocellular carcinoma (HCC) screening and esophageal varices screening under the supervision of a hepatologist.
Consultation/Referral
A.Dietician.
B.Endocrinologist.
C.Bariatric surgeon.
D.Cardiologist.
Special/Geriatric Considerations
A.Another cause of hepatic steatosis is acute fatty liver of pregnancy.
B.This is a rare condition and typically occurs in the third trimester to mothers with multiple gestation pregnancies.
C.Early diagnosis and prompt delivery is primary treatment.
Bibliography
Chalasani, N., Younossi, Z., Lavine, J. E., Charlton, M., Cusi, K., Rinella, M., … Sanyal, A. J. (2018). The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. Hepatology, 67(2), 328–357. doi:10.1002/hep.29367
Chopra, S., & Lai, M. (2018, December 10). Management of nonalcoholic fatty liver disease in adults. In K. M. Robson (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/management-of-nonalcoholic-fatty-liver-disease-in-adults
Sheth, S. G., & Chopra, S. (2018, April 3). Epidemiology, clinical features, and diagnosis of nonalcoholic fatty liver disease in adults. In K. M. Robson (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/epidemiology-clinical-features-and-diagnosis-of-nonalcoholic-fatty-liver-disease-in-adults
Tendler, D. A. (2018, September 14). Pathogenesis of nonalcoholic fatty liver disease. In K. M. Robson (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/pathogenesis-of-nonalcoholic-fatty-liver-disease