NAFLD: symptoms & diagnosis
What are the symptoms of NAFLD?
Most people with mild NAFLD are unlikely to notice any symptoms. Some may experience discomfort n the liver area and tiredness.
For those who go on to develop NASH, Fibrosis and Cirrhosis it may be many years before symptoms develop. The following symptoms may indicate a serious development in your liver condition. Patients with a liver condition who develop any of the following symptoms should see urgent medical attention:
- yellowness of the eyes and skin (jaundice)
- bruising easily
- dark urine
- swelling of the lower tummy area (ascites)
- vomiting blood (haematemesis)
- dark black tarry faeces (melena)
- periods of confusion or poor memory (encephalopathy)
- itching skin (pruritus)
If your skin and the whites of your eyes turn yellow you may have jaundice.
Two things can cause jaundice:
- a blockage (obstruction) in the bile duct
- damage to your liver or some defect affecting the liver so that it cannot deal with bilirubin, a by-product of the breakdown of old red blood cells.
If either of these occurs, bilirubin – which is yellow – flows back into the blood and shows up in the skin and the eyes.
Swelling in your abdomen is known as ascites. The swelling is caused by fluid building up in the lining around your abdomen. This can happen slowly over weeks or months and can be painful, especially if the fluid becomes infected and requires urgent attention.
You may also get swelling in your legs, ankles or feet, known as peripheral oedema.
People with cirrhosis are prone to infections, which can make their liver condition worse. As a result, they should seek medical attention if they develop a temperature..
Internal bleeding due to liver damage is often first noticed in very dark or black tarry faeces (maelena) and the vomiting of blood (haematemesis). Having either of these symptoms will need urgent medical attention.
If your liver is badly scarred from extensive fibrosis or cirrhosis, blood will be unable to flow through it easily. As a result, pressure builds up in the vein that carries blood to the liver from the gut – the portal vein.
Having high blood pressure in the portal vein is known as portal hypertension. As the pressure mounts, blood begins to back up. It finds another way of reaching the heart by using extra veins
lining your oesophagus and stomach known as varices. Varices have fragile walls, which cannot easily handle the increased blood flow and often burst, leading to internal bleeding.
This blood loss may just be a gentle ooze, resulting in symptoms of anaemia that include tiredness and shortness of breath, but sometimes there can be major bleeding, with a haemorrhage and vomiting of blood. Haemorrhaging varices are a serious and life-threatening complication of cirrhosis and need emergency medical treatment.
How is NAFLD diagnosed?
In most cases people only find out they have a fatty liver when a routine blood sample (usually liver function tests) shows there may be a problem. If this happens you may be asked a lot of questions about your lifestyle, such as, any drugs you are taking (including over-the-counter medication and nutritional supplements), your diet, the amount of exercise you do and the amount of alcohol you drink.
Further tests may be needed to confirm the diagnosis such as an Ultrasound, FibroScan, CT or CAT Scan or MRI scan. In some cases a liver biopsy may be needed.
Treatment for NAFLD
There is no specific treatment for NAFLD that all doctors agree on.
However, if your NAFLD is linked to being overweight then you will be advised to make various lifestyle changes including losing weight gradually and taking sensible exercise. There is good evidence that gradual weight loss coupled with increased exercise can reduce the amount of fat in your liver.
In mild cases of NAFLD doctors may concentrate on treating associated conditions, such as obesity and diabetes, which can cause fat to build up. They will also treat disorders such as high blood pressure and high cholesterol as these are often associated with NAFLD.
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Making lifestyle changes and cutting alcohol out of your diet may help delay progression.
Many causes of liver disease can now be treated much more successfully than before to stop or at least slow down any decline in the condition of your liver.
This includes treating infections such as hepatitis B or C with new anti-viral medications and autoimmune diseases such as Autoimmune Hepatitis (AIH) with steroid-based drugs. Genetic
Haemochromatosis (GH), an inherited liver disease, can be managed successfully with phlebotomy or venesection, a procedure similar to blood donation in which a quantity of blood is
regularly taken from a vein in your arm.
Until recently, it was thought that a liver with cirrhosis could not be healed. This is usually the case because most diseases that cause scarring of your liver (fibrosis) are long-term and difficult to ‘cure’.However, recent research has shown that it may be possible to heal scarring and even cirrhosis where the liver disease causing this damage is able to be successfully treated.
The treatment of Hepatitis B and C, as already mentioned, gives hope for the development of new drugs to combat scarring of the liver. More research, however, needs to be done before any
new treatments become widely available.
Another aspect of treatment is to deal with the complications of cirrhosis as early as possible. For this reason your doctor may suggest you have regular tests to identify problems even before you notice any symptoms. You may also be given other drugs to reduce blood pressure, to prevent and treat infections and to help support your body’s functions.
Medicines including beta blockers such as propranolol can reduce the risk of bleeding and reduce the severity of any bleed, should it occur. If there is a serious bleed, initial treatment is to replace the fluid and then to identify and correct the cause of bleeding. There are several techniques aimed at stemming the bleeding which involve endoscopy.
One of these is called banding, where a single vein (called an oesophageal varix) is sucked into a ring at the end of the endoscope. A small band is then placed around the base of the varix which will control the bleeding.
Injection sclerotherapy is also used and involves injecting a substance into the veins of the gullet to induce clotting and scar tissue that will help stop the veins from bleeding.
If bleeding can not be stopped by endoscopy, a Sengstaken tube is passed down the throat into the stomach. This device has two balloons which once inflated, put pressure on the varices and help control the bleeding. People are heavily sedated for this procedure.
If bleeding still cannot be controlled a procedure to lower pressure in the portal vein called a transjugular intrahepatic portosystemic stent shunt (TIPSS) may be needed. In this procedure a metal tube (stent) is passed across your liver to join two large veins (the portal vein and hepatic vein). This creates a bypass (shunt) so the blood flows straight into the hepatic vein relieving the pressure which causes the varices.
Ascites (fluid building in your abdominal cavity, appearing like a bulge across your tummy area) and peripheral oedema (swelling in your ankles and legs) are very common in people with advanced cirrhosis. Ascites can be uncomfortable and make it hard for people to breathe and eat normally. In addition, there is a risk of infection in the fl uid, called spontaneous bacterial peritonitis (SBP), which can be life threatening and is treated with antibiotics.
The main treatments for ascites and oedema are sodium restriction (low salt diet and diuretics, such as spironolactone and Furosemide). It can be helpful to see a dietitian about how to manage on such a strict diet. Some patients benefit from having the fluid drained off the abdomen with a needle and tube. This usually needs to be repeated every few weeks. Patients considered at higher risk of infection may be offered prophylactic (preventative) antibiotics to take every day.
Many people with cirrhosis experience episodes of hepatic encephalopathy, most at a level where it is not very noticeable. In overt stages (where it is noticeable), it can show up as sleep disturbance, mild confusion, subtle personality changes and slightly poorer performances in tests such as drawing a star and connecting dots. It can also feature problems in movement (called ataxia) and speech, slurring of words, tremor and a particular symptom of fl apping hands when you extend your arms (called asterixis). In some people the sleepiness can progress to a loss of consciousness and even to a coma, where it can be life-threatening.
The main treatment for encephalopathy is lactulose (a sweet syrupy medicine). This not only acts as a laxative but also helps the body remove the toxins that build up in the body when the liver is failing. People are given enough lactulose so that they have one or two loose bowel movements each day. They may also be given other laxatives and/ or an enema. Most periods of encephalopathy are triggered by problems such as an infection, constipation, dehydration, a medicine or a bleed. It is important that patients seek medical advice so the cause of an episode can be identified and treated.
The liver makes products to help blood clot (including clotting factors and platelets) and when the liver stops working effectively, patients can be at risk of severe bleeding. Treatments include administering vitamin K and plasma in medical emergencies. People should seek specialist advice before having medical procedures, including any dental work, and ensure that they treat any cuts that bleed with pressure and bandages and seek medical help.
People with decompensated cirrhosis who are already very ill with problems such as encephalopathy, jaundice and bleeding problems, are at risk of a serious complication called hepatorenal syndrome, which is kidney failure in liver disease. For most patients, a liver transplant is needed, for some urgently.
Some people with cirrhosis develop liver cancer, most commonly hepatocellular carcinoma (HCC). The aim is to detect and treat liver cancer as early as possible.
Treatment can involve cutting out the part of the liver affected by cancer. There are a variety of other treatments aimed at controlling the cancer, including injections of chemotherapy, radio frequency ablation and oral medicines. A liver transplant may be an option for some patients.
If your liver is very badly damaged, a liver transplant may be needed. This is a procedure where a diseased liver is removed during a lengthy operation and replaced with a healthy donor liver.
A liver transplant is usually only recommended if other treatments are no longer helpful and your life is threatened by end stage liver disease. It is a major operation and you will need to plan it carefully with your medical team, family and friends.
Liver transplantation is usually very successful although in some cases it is possible for liver diseases to return and affect your new liver.
Discuss any worries you have about your suitability for treatment with your specialist nurse or doctor and those nearest to you
Maintaining a healthy weight through eating a well-balanced diet and taking regular exercise is the best way to prevent NAFLD. The health risks from being overweight or obese can impact on your physical, social and emotional well being. People with NAFLD who go on to develop Cirrhosis are at a higher risk of liver failure.
Although it is not always possible to avoid NAFLD, as some factors such as genetics cannot be prevented, you can significantly reduce your risk by exercising as much as you are able to, and eating healthily to control your weight (see our diet and liver disease information).
Better control of existing medical conditions, such as glucose levels in diabetes, can also help prevent the development of NAFLD and NASH.
NICE have published a new quality standard Obesity in adults: prevention and lifestyle weight management programmes. Click here to view.
NICE have also issued a new guideline on how to identify the adults, young people and children with non-alcohol related fatty liver disease (NAFLD) who have advanced liver fibrosis and are most at risk of further complications. It outlines the lifestyle changes and treatments that can manage NAFLD and advanced liver fibrosis.
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