Non Alcoholic Fatty Liver

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Non Alcoholic Fatty Liver

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  • Case Presentation 34 yrs old maleSecurity officerFrom Manikhinna

  • Presenting complaintsFatigue, malaiseEpigastric fullness, 8 monthsdyspeptic symptomsDarkening of skin 4 month

  • History of presenting complaints8 month ago developed fever vomiting &abdominal pain, admitted to hospital,diagnosed as viral hepatitisSymptoms gradually improvedBut continue to feel fatigue, malaiseFeel tired on exertionHad never became jaundice, developed on/off episodes of itching

  • History cont..Abdominal pain & discomfortepigastric pain with dyspeptic symptoms, aggravate with meal , no particular radiation or other aggravating /relieving factorsProgressive darkening of skinfor the last 4-5 months he has noted increased pigmentation of skin , generalized, not in skin creases or scarsNo H/O jaundice, skin rashes , arthritis or fever

  • History cont..No recurrent diarrhea or bleeding PR or altered bowel habitsNo dry mouth, eye or sicca syndromeNo H/O wheezing attacks, haemoptysisNo history of, orthopnoea, exertional chest pain or dyspnoeaNo legs or body swelling

  • Past medical history/ DrugsNo DM , inflammatory bowel disease, Rheumatoid arthritis , Movement disorders or psychiatric illnessNot on drugs, Aurvedic Rx No exposure to Organo-phosphates or organic compoundsHad T. Toxoid 1 1/2 yrs agoNo H/O blood transfusion

  • Family / Social historyNo cirrhosis , Psychiatric illness , Movement disorders or haematological diseaseNo sexual promiscuityUnmarried security officer, 6000/=Non alcoholic, non smoker

  • General examinationNot pale, not icteric, not emaciatedgeneralized pigmentation, not in skin creases or scarsNo chronic liver stigmata's or scratch marksNo tendon or palmar xanthomasHas considerable amount of acneNo finger clubbing, lymhpadinpathy, oral or genital ulcers

  • System examinationABDOMAN1cm smooth , non tender hepatomegaly. No splenomegaly or free fluid or massCVSBP- 130/80mmHg, Clinically normalAll other systems clinically normal

  • summery34 yrs old male, presented with 8month H/O malaise, fatigue,epigastric pain & dyspeptic symptoms,progressive darkening of skin with preceding H/O hepatitisNot pale or icteric, no evidence of liver stigmata's1cm hepatomegaly,no splenomegaly, free fluid or massOther systems clinically normal

  • Causes for chronically elevated AST/ALTHepaticAlcohol abuseChronic Heb B/ C----HepBsAg/ C AbNAFLD( NASH )Autoimmunne hepatitis-- young ,female----- S. Electroph: --^ polyclonal emmunoglobulin-- 80%Haemochromatosis-- TS >45%Wilsons -- (
  • Cont..NON HEPATICCeliac sprue-- Anti endomyosial Ab, AntigliadinMuscle disorders -- CPK / AldolaseStrenuous Exercise

  • Inv.SGOT-- >60 U/L -------------- 82SGPT ---> 60 U/L --------------- 170S. bilirubin 10umol/l ----------
  • Inv cont..S. Fe 116umol/l ( N )TIBC 320umol/l ( N )S. Ferritin 322ng/ml ( N )ANF ----------------------- negAnti-smooth muscles Ab -- negS electrophoresis --- normalS. Ceruloplasmin 25ng dl ( N )KF rings -- negLipids-- TG 189 ( 157 )Liver Bxperiportal fibrosis with septa formation & mononeuclear cell infiltration. Extensive fatty changers & focal necrosis of parenchymal cells Bile duct proliferation not seen

  • Non Alcoholic Fatty Liver DiseaseIncreasingly recognized condition may progresses to end stage liver diseaseDiabetic hepatitis, NASH, Fatty liver hepatitisSteatosis==> Steatohepatitis ==> Cirrhosis10 -24 % general populationThe most common cause of abnormal LFT in adultCryptogenic cirrhosis share many clinical, demographical features of NAFLD

  • Risk FactorsObesity ( truncal ) 10 - 100%DM type 210 - 75 %Hyperlidemia ( TG ) 20 -92 %Family H/O NAFLD or cryptigenic cirrhosisMiddle age women , some says male

  • PathogenesisPoorly understood, hypotheticalNet retention of lipids in hepatocytes prerequisite for NAFLDsynthesis*DegradationSecretionInsulin resistance is the most reproducible factorEnzyme deficiency of beta oxidation & Acytyl-coenzyme A important cause of microvesicular steatosisi

  • Clinical PresentationMostly asymptomatic at diagnosisFatigue, malaise, fullness of abdomenSymptoms & signs of advance liver diseaseOnly physical finding may hepatomegaly, acanthosis nigricance

  • DiagnosisSuspect== increased AST/ALT, Radiological fatty liver & persistent hepatomegalyShould exclude alcohol abuse, secondary causesHistologicaly--- Liver Bxsteatosis,monocytes, neutrophils, ballooning necrosis, Mallorys bodiesportal tracts relatively sparedin some cirrhotic, steatosis & necro-inflammation may be not seen

  • Laboratory investigationAST to ALT --
  • Investigation Cont..USSincreased diffused echogenasity similar to cirrhosissensitivity - 89% specificity - 93%CTlow density hepatic paranchymafatty sparingfocal fatty infiltration -- mimic focal mass

  • Natural historyNot well defined28% progressive liver damage in 3- 11yrs58 % no change13 % improves or completely resolved

  • ManagementGood control of DM , HyperlipaedemiaReduction of WtDrugsNo placesmall pilot studies-- gemfibrozil, Vit E, Metformin, Ursodiol improves LFTLiver transplant--- in end stage liver disease, but may recur

  • Bad prognosisAge-- > 45 yrsObeseDM- type 2AST/ ALT ratio > 1 -- indicate advance fibrosisIncreased TGLiver Bx == Steotohepatitis or advance fibrosis