What is the management plan for a patient with hepatomegaly (enlarged liver) and steatosis (fatty liver disease) on a computed tomography (CT) scan of the abdomen and pelvis?

Management of Hepatomegaly with Steatosis

Lifestyle modifications with a target of 7-10% weight loss through dietary changes and exercise should be the first-line treatment approach for patients with hepatomegaly and steatosis identified on CT scan of the abdomen and pelvis. 1

Initial Assessment and Risk Stratification

• Evaluate for cardiometabolic risk factors (type 2 diabetes, obesity, dyslipidemia, hypertension)
• Perform non-invasive fibrosis assessment:
  • Start with blood-based scores (FIB-4)
  • Follow with imaging techniques (transient elastography) to rule out/in advanced fibrosis 2
• Check liver enzymes (ALT, AST)
• Screen for harmful alcohol intake to differentiate between MASLD and alcohol-related liver disease

Treatment Algorithm

Step 1: Lifestyle Modifications

• Weight Loss Goals:

  • Initial target: >5% weight loss to reduce liver fat
  • Optimal target: 7-10% weight loss to improve liver inflammation
  • Advanced target: >10% weight loss to improve fibrosis 1
  • Aim for gradual weight reduction (<1 kg/week) to avoid worsening inflammation

• Dietary Recommendations:

  • Mediterranean dietary pattern with focus on whole, unprocessed foods
  • Hypocaloric diet with 500-1000 kcal daily deficit
  • Limit sugar-sweetened beverages and refined carbohydrates
  • Increase fiber consumption through vegetables, fruits, and whole grains 1

• Exercise Recommendations:

  • At least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous-intensity physical activity
  • Combine aerobic exercise and resistance training for optimal results 1

Step 2: Management of Comorbidities

• For Patients with Type 2 Diabetes:

  • Consider GLP-1 receptor agonists (e.g., semaglutide, tirzepatide) which have beneficial effects on both diabetes and hepatic steatosis 2
  • SGLT2 inhibitors may improve cardiometabolic profile 1

• For Dyslipidemia:

  • Statins are safe and recommended for MASLD patients 1

• For Patients with Obesity:

  • Consider incretin-based therapies if indicated 2
  • Bariatric surgery may be considered for patients with obesity and hepatic steatosis 2, 1

Step 3: MASH-Targeted Pharmacotherapy

• For non-cirrhotic MASH with significant liver fibrosis (stage ≥2):
  • Consider resmetirom if locally approved 2
  • Note: No MASH-targeted pharmacotherapy is currently recommended for cirrhotic stage 2

Monitoring and Follow-up

• Monitor liver enzymes every 3-6 months
• Repeat non-invasive fibrosis assessment (FIB-4, transient elastography) every 1-2 years
• Regular monitoring of metabolic parameters (glucose, lipids, blood pressure) 1
• For patients with cirrhosis: surveillance for portal hypertension and HCC 2

Special Considerations

• Alcohol consumption: Discourage alcohol consumption as it can worsen steatosis 2
• Medication safety: Prior to initiating therapy with medications like pioglitazone, evaluate liver enzymes as these drugs should not be started if ALT exceeds 2.5 times the upper limit of normal 3
• Rare causes: Consider other etiologies of hepatic steatosis in appropriate clinical contexts (e.g., celiac disease has been reported as a rare cause of massive hepatic steatosis) 4, 5

Pitfalls and Caveats

• Avoid rapid weight loss (>1 kg/week) as it may worsen liver inflammation
• Do not assume all hepatic steatosis is MASLD; rule out secondary causes including alcohol, medications, and other conditions
• Recognize that normal BMI does not exclude significant steatosis; patients with normal BMI can still have moderate/severe steatosis with metabolic syndrome 6
• Understand that hepatomegaly with steatosis represents a spectrum of disease that can progress to fibrosis, cirrhosis, and HCC if not properly managed 2