Symptoms of Fatty Liver Disease
Fatty liver disease is most commonly asymptomatic, with the majority of patients having no symptoms at all, even when hepatomegaly is present. 1, 2
Typical Clinical Presentation
Most Common Scenario
- NAFLD is usually discovered incidentally through abnormal liver enzyme tests (particularly elevated ALT) or when hepatic steatosis is noted on imaging studies performed for other reasons 1, 2
- Up to 50% of patients with simple steatosis have completely normal liver biochemistries, making the condition even more difficult to detect clinically 1, 3
When Symptoms Do Occur
Non-specific symptoms are the hallmark when fatty liver disease becomes symptomatic:
- Fatigue is the most commonly reported symptom when present 1, 2
- Right upper quadrant discomfort or epigastric fullness may occur, likely due to distension of the liver capsule 1, 2, 3
- These symptoms are typically mild and vague, making them easy to overlook or attribute to other conditions 1
Physical Examination Findings
- Hepatomegaly may be the only physical finding in the absence of advanced disease 1
- The liver edge, when palpable, may be smooth and tender 1
- The physical examination is often completely unremarkable in most patients 3
Signs of Advanced Disease
When cirrhosis develops, more specific signs may appear:
- Splenomegaly 1
- Spider angiomata 1
- Palmar erythema 1
- Ascites 1
- Signs of portal hypertension appear only in later stages 1
Laboratory Abnormalities
- Mildly elevated AST and/or ALT with an AST:ALT ratio typically <1 is the most common laboratory finding 1
- Alkaline phosphatase and/or gamma-glutamyltransferase may be mildly elevated, but bilirubin typically remains normal unless advanced disease is present 1
- Up to 80% of patients with NASH may be identified based on elevated transaminases, though this still means 20% have normal enzymes 1
Critical Clinical Pearls
Severe symptoms are atypical for uncomplicated NAFLD and should prompt evaluation for alternative diagnoses such as:
- Acute fatty liver of pregnancy (in pregnant/postpartum women) 4
- Drug-induced liver injury 4
- Autoimmune hepatitis 4
- Gallstone disease (more common in NASH patients with metabolic syndrome) 4
Normal ALT does not exclude significant liver disease—approximately 50% of patients with NAFLD and up to 10% with advanced fibrosis may have normal ALT using conventional thresholds 1, 5