From the Guidelines
For a patient with fatty liver on ultrasound, elevated liver enzymes, and a FIB-4 score of 2.07, I recommend a comprehensive evaluation for non-alcoholic fatty liver disease (NAFLD) and potential non-alcoholic steatohepatitis (NASH) using a stepwise approach with non-invasive tests, as suggested by the most recent guidelines 1. This approach should include a complete metabolic panel, HbA1c, lipid profile, and hepatitis serologies to rule out viral causes. The FIB-4 score of 2.07 falls in an indeterminate range, suggesting possible but not definitive liver fibrosis. Therefore, a non-invasive assessment of fibrosis such as a FibroScan (transient elastography) or magnetic resonance elastography (MRE) would be appropriate next steps, as recommended by recent studies 1. Some key points to consider in the evaluation and management of this patient include:
- Lifestyle modifications are the cornerstone of treatment, including gradual weight loss of 7-10% of body weight through a balanced diet and regular exercise, as well as optimal management of comorbidities, such as type 2 diabetes or obesity, with medications like incretin-based therapies (e.g., semaglutide, tirzepatide) if indicated 1.
- Management of associated conditions like diabetes, hypertension, and dyslipidemia is essential, and the patient should avoid alcohol completely and hepatotoxic medications.
- If these tests suggest significant fibrosis, referral to a hepatologist for possible liver biopsy should be considered, as liver biopsy provides helpful information for assessing disease activity and excluding coexistent liver diseases 1.
- Recent guidelines also suggest considering a MASH-targeted treatment with resmetirom for adults with non-cirrhotic MASH and significant liver fibrosis (stage ≥2), if locally approved and dependent on the label 1. This approach is recommended because NAFLD is the most common cause of fatty liver and elevated enzymes, and early intervention can prevent progression to cirrhosis and liver failure, ultimately improving morbidity, mortality, and quality of life.
From the Research
Evaluation of Fatty Liver
The recommended evaluation of a liver showing fatty liver on ultrasound, elevated liver enzymes, and a FIB-4 calculation of 2.07 involves several considerations:
- The FIB-4 index is a non-invasive tool used to assess liver fibrosis, with a cut-off point of 1.45 showing 87% sensitivity and 3.25 showing 87% specificity for advanced fibrosis 2.
- However, the accuracy of FIB-4 may be limited in patients with diabetes, with a c-statistic of 0.68 compared to 0.85 in patients without diabetes 3.
- Ultrasound imaging is a valuable tool for assessing fatty liver disease, with a standardized approach taking into account the limitations of the method being essential 4.
- Increased liver echogenicity on ultrasound reflects the degree of steatosis but not fibrosis in asymptomatic patients with mild/moderate abnormalities of liver transaminases 5.
- Elastography, a non-invasive method, has enabled reliable assessment of liver fibrosis, with results comparable to those of liver biopsy 6.
Diagnostic Approach
The diagnostic approach for a patient with a FIB-4 calculation of 2.07 may involve:
- Further evaluation using elastography or other non-invasive methods to assess liver fibrosis 6.
- Consideration of the patient's medical history, including the presence of diabetes or other conditions that may affect the accuracy of FIB-4 3.
- Ultrasound imaging to assess fatty liver disease and other liver pathologies 4.
- Potential referral for liver biopsy, the gold standard method for evaluating liver fibrosis, if non-invasive tests are inconclusive or if there is a high suspicion of advanced fibrosis 2.