WHS PR Symposium - Non-Alcoholic Fatty Liver Disease
WHS PR Symposium - Non-Alcoholic Fatty Liver Disease
WHS PR Symposium - Non-Alcoholic Fatty Liver Disease
BarrettsEsophagus
Esophagus
Federico Rodrguez-Prez
Gastroenterologist and Hepatologist
Objectives
To understand the epidemiology and
natural history of NAFLD
Recognize the clinical presentation of
NAFLD
Understand the strategies for the
diagnosis and treatment of NAFLD
Non-Alcoholic
Non-AlcoholicFatty
FattyLiver
LiverDisease
Disease(NAFLD)
(NAFLD)
What is it?
Why care?
Whom to treat?
NAFLD
What is it?
Evidence of hepatic steatosis either by
imaging or histology
No other causes for secondary hepatic fat
accumulation
Significant alcohol consumption
NAFLD
NAFLD is the most common cause of
CLD
Strongly associated with metabolic
risk factors: obesity, diabetes
mellitus, and dyslipidemia
Histologically categorized into
steatosis and steatohepatitis
In US, 30 million
adults may have
NAFLD
8.6 million may have
NASH !!
Prevalence of
NAFLD in the US
is 20 -51%
58.3
58.3
44.1%
44.1%
Fatty liver
M
35.1%
35.1%
24%
24%
Hispanics
Whites
Blacks
NAFLD
NAFL
Steatosis
(Macrovesicular)
NASH
Steatosis
Inflammation
Ballooning
Cirrhosis
Fibrosis
Inflammation
Non-Alcoholic
Non-AlcoholicFatty
FattyLiver
LiverDisease
Disease(NAFLD)
(NAFLD)
What is it?
Why care?
Who to treat?
Non-Alcoholic
Non-AlcoholicFatty
FattyLiver
LiverDisease
DiseaseClinical
ClinicalImplications
Implications
Non-Alcoholic
Non-AlcoholicFatty
FattyLiver
LiverDisease
DiseaseClinical
ClinicalImplications
Implications
dead
dead
Non-Alcoholic
Non-AlcoholicFatty
FattyLiver
LiverDisease
DiseaseClinical
ClinicalImplications
Implications
Morbidity / mortality
significant
liver-related
co-morbidities
NAFLD
Steatosis
Cirrhosis
Cirrhosis
Hepatocellular
carcinoma
Diagnostic
DiagnosticGoal
Goal#1
#1Determine
DetermineEtiology
EtiologyisisFLD
FLD
High prevalence in
patients with
Cryptogenic
cirrhosis
Strong predictor
for NASH
** MAY IDENTIFY
PATIENTS WITH
ABNORMAL LIVER
TESTS WHO WILL
BENEFIT FROM A
LIVER BIOPSY**
30
20
10
0
Not DM or HTN
HTN
DM
DM + HTN
Age
Gender
Hispanic
HTN
Obesity
Diabetes
ALT and AST level
AST/ALT
Insulin level
Initial Evaluation
Negative viral / autoimmune / genetic markers
Patients with NAFLD can present with mild elevation of
ferritin.
But patients with persistent increased ferritin level and
increase iron saturation in the context of homozygous or
heterozygous C282Y HFE mutations liver biopsy.
Diagnostic Tools
Non-Invasive Markers of
Fibrosis
NAFLD Fibrosis Score
(http:nafldscore.com)
Age, BMI, hyperglycemia, platelet count,
albumin, AST/ALT ratio
< -1.455 had 90% sensitivity and 60%
specificity to exclude advanced
fibrosis
> 0.676 had 67% sensitivity and 97%
specificity to identify the presence of
advanced fibrosis
Imaging Techniques
US, CT, and MRI can
identify steatosis
Insensitive and not
specific
Can suggest the
presence of cirrhosis
when manifestations
of portal
hypertension are
evident
Transient Elastography
Liver stiffness is proportional to shear
wave velocity
Formula (Youngs Modulus): E=pv22
V=velocity
P=density of tissue
Stiffness is measured in kilopascals
Conclusions
Ask yourself what it is that you want to know
If NASH vs not NASH
Consider liver biopsy
The more the risk factors, the greater the likelihood the
Management of NAFLD
Lifestyle Modifications
Lifestyle Modifications
Exercise
Metabolic benefit vs weight loss
Gym
Trainer
Dancing
Walking: 3 times to 5 times per week
Bariatric Surgery
Foregut bariatric surgery can be
effective in improving hepatic
histology in selected patients
(severely obese) without liver failure
or portal HTN
Not contraindicated in obese
patients with NAFLD w/o cirrhosis
but type, safety, and efficacy not
established in cirrhotics
Mummadi et al. 2008, 2012 AASLD guideline
Management of NASH
PIVENS Study
Further analysis showed that best
results were seen in patients who
took Vitamin E and also achieved
weight loss
Vitamin E may increase
cardiovascular risk and prostate
cancer
Avoid alcohol
Avoid Fructose diets
Use of Probiotics (lactobacillus)
Use of Prebiotics (lactulose)
Symbiotics: Probiotics + Prebiotics