From the Guidelines
The evaluation and management of suspected fatty liver disease should begin with a comprehensive assessment, including medical history, physical examination, laboratory tests, and imaging studies, with a focus on lifestyle modifications and management of comorbidities, as recommended by the most recent guidelines 1. The initial laboratory evaluation should include liver function tests (ALT, AST, alkaline phosphatase, bilirubin), complete blood count, lipid profile, fasting glucose, and HbA1c. Imaging typically starts with an abdominal ultrasound, which can detect steatosis when fat comprises more than 20-30% of the liver. In cases where diagnosis remains uncertain, FibroScan (transient elastography) or MRI may be used to assess steatosis and fibrosis. Some key points to consider in the evaluation and management of fatty liver disease include:
- Lifestyle modification, including weight loss, dietary changes, and physical exercise, is beneficial for all patients with nonalcoholic fatty liver disease (NAFLD) 1.
- Weight loss of 7-10% of body weight can lead to nonalcoholic steatohepatitis resolution and fibrosis regression or stability 1.
- A hypocaloric diet targeting 1200–1500 kcal/d or a reduction of 500–1000 kcal/d from baseline, and regular physical activity, such as 150–300 minutes of moderate-intensity aerobic exercise per week, are recommended 1.
- Management of comorbidities, such as diabetes, hyperlipidemia, and hypertension, is essential, and medications like pioglitazone, GLP-1 agonists, or SGLT2 inhibitors may have hepatic benefits 1.
- Alcohol cessation is crucial for those with alcoholic fatty liver disease.
- Regular monitoring with repeat liver function tests every 3-6 months and follow-up imaging annually is recommended to assess disease progression or improvement. It is also important to note that resmetirom, a MASH-targeted treatment, may be considered for adults with non-cirrhotic MASH and significant liver fibrosis (stage ≥2), as it has demonstrated histological effectiveness on steatohepatitis and fibrosis with an acceptable safety and tolerability profile 1.
From the Research
Evaluation Approach
The evaluation and management approach for a patient with suspected fatty liver disease involves several steps:
- Diagnosis: Liver biopsy remains the gold standard for definitive diagnosis, but noninvasive methods such as imaging and biomarkers can also be used 2, 3.
- Assessment of liver fat: Quantification of liver fat is crucial in evaluating the severity of the disease and monitoring therapy 2.
- Evaluation of cardio-metabolic risk factors: Patients with fatty liver disease are at increased risk of cardiovascular disease, diabetes, and liver-related complications, and therefore, evaluation of these risk factors is essential 4, 5, 6.
Management Approach
The management approach for fatty liver disease includes:
- Lifestyle modifications: Lifestyle modifications such as weight loss, diet, and exercise are the mainstay of treatment for patients with fatty liver disease 4, 6, 3.
- Pharmacotherapy: Pharmacotherapy such as vitamin E and pioglitazone may be used in patients with nonalcoholic steatohepatitis (NASH) and advanced fibrosis 4, 5.
- Treatment of underlying conditions: Treatment of underlying conditions such as obesity, type 2 diabetes mellitus, and dyslipidemia is also essential in managing fatty liver disease 4, 5, 3.
Monitoring and Follow-up
Regular monitoring and follow-up are crucial in managing fatty liver disease:
- Monitoring of liver fat: Regular monitoring of liver fat is essential in evaluating the response to therapy and monitoring disease progression 2.
- Monitoring of cardio-metabolic risk factors: Regular monitoring of cardio-metabolic risk factors such as blood pressure, lipid profile, and glucose levels is also essential in managing fatty liver disease 4, 5, 6.