What investigations should be done next for a patient with mild hepatic (liver) steatosis noted on ultrasonography (u/s)?

From the Guidelines

For a patient with mild hepatic steatosis noted on ultrasonography, the next investigations should include assessing for metabolic risk factors and alternate causes for hepatic steatosis, as well as comprehensive blood tests to assess liver function and identify potential causes. These investigations are crucial in determining the underlying cause of steatosis, whether it's non-alcoholic fatty liver disease (NAFLD), alcohol-related, medication-induced, or due to other conditions 1. The assessment should include evaluating for metabolic risk factors such as obesity, glucose intolerance, and dyslipidemia, as well as alternate causes like significant alcohol consumption or medications 1. Comprehensive blood tests should comprise liver function tests (ALT, AST, GGT, alkaline phosphatase, bilirubin), complete blood count, fasting lipid profile, fasting glucose, and HbA1c to screen for metabolic syndrome and diabetes. Additional tests may include hepatitis B and C serology, iron studies (ferritin, transferrin saturation), and autoimmune markers if clinically indicated. A FibroScan (transient elastography) may be useful to assess the degree of fibrosis non-invasively, especially since it can quantify the degree of fat deposition in the liver parenchyma by measuring ultrasound attenuation, with a recent study suggesting its effectiveness in diagnosing moderate to severe steatosis 1. Patients should also be evaluated for alcohol consumption, medication history, and family history of liver disease. It is essential to note that for patients with asymptomatic and normal liver biochemistries, a liver biopsy is not recommended 1. Early identification of the cause allows for appropriate management strategies, which typically focus on lifestyle modifications including weight loss, dietary changes, exercise, and addressing any underlying conditions like diabetes or dyslipidemia. More severe cases or those with evidence of progressive disease may require specialist hepatology referral. Key points to consider in the management of mild hepatic steatosis include:

• Assessing for metabolic risk factors and alternate causes
• Comprehensive blood tests for liver function and potential causes
• Evaluation for alcohol consumption, medication history, and family history of liver disease
• Consideration of non-invasive tests like FibroScan for fibrosis assessment
• Lifestyle modifications as the primary management strategy
• Potential referral to specialist hepatology for severe or progressive cases.

From the Research

Next Steps for Patients with Mild Hepatic Steatosis

For patients with mild hepatic steatosis noted on ultrasonography, the following investigations should be considered:

• Liver function tests, including biochemical parameters such as AST, ALT, GGT, and alkaline phosphatase, as well as bilirubin and albumin levels, and coagulation tests like prothrombin activity 2
• Evaluation of the patient's metabolic profile, including assessment of factors associated with metabolic syndrome, such as adiponectin and HDL levels, as patients with steatosis are at higher cardiovascular and metabolic risk 3
• Transient elastography (Fibroscan®) and bioelectrical impedance analysis (BIA) to assess liver stiffness and fat mass, respectively 3
• Consideration of novel ultrasound technologies, such as normalized local variance (NLV) and its standard deviation, to quantify hepatic steatosis and monitor disease progression 4
• Abdominal ultrasound to evaluate the biliary system and rule out other causes of liver disease, such as biliary obstruction or intrahepatic cholestasis 2

Diagnostic Considerations

When interpreting ultrasound results, it is essential to consider the following:

• Ultrasound is a valid method for detecting the presence or absence of hepatic steatosis, with high sensitivity and specificity compared to magnetic resonance spectroscopy (MRS) 5
• Conventional ultrasound parameters, such as B-mode criteria and Doppler features, can be used to diagnose hepatic steatosis, but may have limitations in grading and assessing the severity of steatosis 6
• The use of scoring systems and novel ultrasound technologies can add additional accuracy in assessing the severity of steatosis and monitoring disease progression 6, 4