What is the management and treatment for fibrofatty liver (Non-Alcoholic Fatty Liver Disease (NAFLD)) diagnosed on a Computed Tomography (CT) scan?

Management of Fibrofatty Liver (NAFLD) Diagnosed on CT Scan

CT scan findings of fibrofatty liver require immediate risk stratification using FIB-4 score or other non-invasive tests to determine fibrosis stage, as CT cannot reliably assess steatohepatitis or fibrosis severity, and management depends entirely on whether advanced fibrosis is present. 1

Limitations of CT for NAFLD Assessment

• CT scan can detect moderate to severe steatosis but has poor sensitivity (53.8%) and suboptimal performance for mild steatosis. 1
• Unenhanced CT showing hepatic attenuation <48 HU has 100% specificity but only 53.8% sensitivity for moderate to severe steatosis. 1
• CT cannot reliably assess steatohepatitis or fibrosis—the critical determinants of prognosis and treatment decisions. 1
• CT raises radiation concerns and is affected by iron, copper, glycogen, or amiodarone deposition, limiting its utility for serial monitoring. 1

Immediate Next Steps: Risk Stratification for Fibrosis

Calculate FIB-4 score immediately using age, AST, ALT, and platelet count to stratify fibrosis risk. 1

FIB-4 Score Interpretation:

• FIB-4 <1.3: Low risk (NPV 92.7%)—manage in primary care with lifestyle interventions 1
• FIB-4 1.3-2.67: Indeterminate risk—proceed to elastography or refer to hepatology 1
• FIB-4 >2.67: High risk—refer to hepatology for further evaluation including possible liver biopsy 1

Alternative validated scores include NAFLD Fibrosis Score (cutoffs: <-1.455 excludes advanced fibrosis; >0.676 suggests advanced fibrosis). 1

Management Based on Risk Stratification

Low-Risk Patients (FIB-4 <1.3, No Advanced Fibrosis)

Lifestyle modification is the cornerstone—no pharmacotherapy is indicated for simple steatosis without fibrosis. 1, 2, 3

Weight Loss Targets:

• Target 7-10% total body weight reduction through hypocaloric diet (500-1000 kcal deficit). 1, 2, 3
• Weight loss of 3-5% improves steatosis; 7-10% is needed to improve inflammation and potentially fibrosis. 3
• Critical: Gradual weight loss only (<1 kg/week)—rapid weight loss can precipitate acute hepatic failure in advanced disease. 4, 3

Dietary Recommendations:

• Implement Mediterranean diet: vegetables, fruits, whole grains, legumes, olive oil as principal fat, moderate fish, minimal red meat. 1, 4
• Avoid fructose-containing beverages and foods. 3
• Restrict alcohol consumption: <30g/day for men, <20g/day for women, or consider complete abstinence. 2, 3

Exercise Prescription:

• Vigorous-intensity exercise (≥6 METs) for at least 150 minutes weekly—moderate-intensity exercise does NOT improve NASH severity or fibrosis. 1, 2, 4

Monitoring:

• Annual follow-up with repeated FIB-4 score or elastography to detect progression. 1, 2

Intermediate/High-Risk Patients (FIB-4 ≥1.3 or Indeterminate)

Refer to hepatology for vibration-controlled transient elastography (VCTE) or consider liver biopsy. 1

Elastography Interpretation:

• LSM <8.0 kPa: Low risk—manage as above with 6-month follow-up 1
• LSM 8.0-12.0 kPa: Indeterminate—consider MRE or liver biopsy 1
• LSM >12.0 kPa: High risk of advanced fibrosis—liver biopsy recommended 1
• LSM ≥20 kPa or thrombocytopenia: Cirrhosis likely—variceal screening required 1

When Liver Biopsy is Indicated:

• Biopsy-proven NASH with fibrosis is required before initiating pharmacotherapy, as patients without steatohepatitis or fibrosis have excellent prognosis. 4, 3
• Consider biopsy when non-invasive tests are discordant or when other liver diseases cannot be excluded. 1, 3

Pharmacological Treatment (Only for Biopsy-Proven NASH with Fibrosis)

Pharmacological treatment should be limited to patients with biopsy-confirmed NASH and significant fibrosis (≥F2). 4, 3

First-Line Pharmacotherapy Options:

• Vitamin E 800 IU daily: Consider in patients with biopsy-confirmed NASH without diabetes or cirrhosis. 2, 4
• Pioglitazone 30 mg daily: Consider in patients with biopsy-confirmed NASH without cirrhosis, with or without diabetes. 2, 4

Management of Metabolic Comorbidities:

• GLP-1 receptor agonists (liraglutide, semaglutide): Preferred for patients with type 2 diabetes and NASH/fibrosis. 2, 3
• Metformin: NOT recommended as specific treatment for NAFLD—has no significant effect on liver histology despite metabolic benefits. 4, 3
• Statins: Safe and should be used to treat dyslipidemia despite liver disease; may reduce HCC risk by 37%. 2, 3

Monitoring for Treated Patients:

• Follow-up every 6 months with liver function tests and non-invasive fibrosis markers. 2

Management of Cirrhosis (If Present)

LSM ≥20 kPa or clinical/laboratory evidence of cirrhosis requires immediate hepatology referral. 1

• HCC surveillance: Right upper quadrant ultrasound ± AFP every 6 months lifelong. 2, 4
• Variceal screening: Perform esophagogastroduodenoscopy (EGD) in all patients with known cirrhosis. 1, 4
• Liver transplantation evaluation: Refer when first major complication occurs or hepatic dysfunction develops. 4

Critical Pitfalls to Avoid

• Never pursue rapid weight loss in NAFLD patients—this can precipitate acute hepatic failure, especially with advanced disease. 4, 3
• Do not start pharmacotherapy without biopsy confirmation of NASH with fibrosis—no drugs are approved specifically for NAFLD, and simple steatosis has excellent prognosis. 4, 3
• Do not rely on CT alone for disease severity assessment—it cannot detect inflammation, hepatocyte injury, or fibrosis stage. 1
• Do not use moderate-intensity exercise as primary intervention—only vigorous-intensity exercise (≥6 METs) improves NASH. 1, 2, 4
• Avoid aggressive glycemic targets (A1C <7%) in advanced liver disease due to elevated hypoglycemia risk from impaired gluconeogenesis. 4

Exclude Other Liver Diseases

Before confirming NAFLD diagnosis, exclude competing etiologies: 1

• Excessive alcohol use (detailed quantification required)
• Viral hepatitis (HBV, HCV serology)
• Hemochromatosis (ferritin, transferrin saturation, consider HFE gene testing if elevated)
• Autoimmune hepatitis (ANA >1:160, ASMA >1:40 warrant further workup if very high aminotransferases or globulin)
• Wilson's disease (in younger patients)
• Hepatotoxic medications (review all medications)