This page was last reviewed 17-05-20
Non-alcoholic fatty liver disease (NAFLD) is the commonest chronic liver disorder in the UK and is increasing in prevalence. NAFLD refers to the liver disorder associated with the metabolic syndrome and comprises simple fatty liver (steatosis), non-alcoholic steatohepatitis (NASH) and NAFLD cirrhosis. This disorder is very similar to alcoholic liver disease in its pathology and natural history.
It is usually identified in patients with mildly abnormal LFTs or an ultrasound suggestive of a fatty liver. The commonest LFT abnormalities are modestly elevated ALT and GGT, although some patients will have normal LFTs and in those with cirrhosis sometimes only the GGT is elevated. An ultrasound examination is usually reported as showing a bright or fatty liver. In those with cirrhosis a heterogeneous or coarse echotexture, a nodular outline or splenomegaly may be found, but patients with cirrhosis may have a normal ultrasound.
Most patients will have a BMI over 30 and/or type 2 diabetes mellitus but this is not invariable. A liver screen will be negative and alcohol intake within recommended limits. The combination of alcoholic liver disease and NAFLD is common and it is sometime difficult to assign the major component.
These guidelines should be used in conjunction with the RefHelp guidelines on the management of asymptomatic abnormal LFTs. Not all patients with NAFLD require to be referred and most can be managed in primary care with lifestyle advice.
The reasons to refer to secondary care are:
1. Diagnostic uncertainty (remember overweight or diabetic patients can develop other liver diseases)
2. Suspected more advanced disease than simple steatosis, as indicated by the presence of hepatic fibrosis which should be suspected in patients with an AST:ALT ratio > 1.0, a reduced platelet count or an US scan suggesting cirrhosis.
Who to refer:
Patients with NAFLD and suspected advanced hepatic fibrosis or diagnostic uncertainty.
Patients referred to hepatology may be allocated a clinic appointment or may have further fibrosis assessment arranged e.g. a Fibroscan or serum hyaluronic acid.
Who not to refer:
Patients with NAFLD without hepatic fibrosis
Patients with NAFLD without significant fibrosis will be managed in primary care.
The role of Fibroscan, other imaging such as ARFI, hyaluronic acid, other serum biomarkers such as ELF, the AST:ALT ratio and other indirect ratios such as Fibrosis 4 score and NAFLD fibrosis score are being actively evaluated.
Most patients with NAFLD will have simple steatosis and can be managed in the community with lifestyle advice about exercise, diet and weight reduction, along with active management of diabetes, hypertension and hyperlipidaemia Metformin is the oral hypoglycaemic agent of choice, ACE inhibitors or ARBs are the preferred antihypertensive agents for their antifbrotic properties, and statins can be safely used on NAFLD.
There is increasing evidence that coffee has therapeutic benefit in chronic liver disease.
The NAFLD should be re-staged, but at what interval and by what method is unclear; at present, we advise repeating LFTs and FBC every 2-3 years, and consider referring patients developing hepatic fibrosis as indicated by an AST:ALT ratio >1.0 or a low platelet count
Patient Website – https://patient.info/health/non-alcoholic-fatty-liver-disease
British Liver Trust – https://www.britishlivertrust.org.uk/liver-information/liver-conditions/non-alcohol-related-fatty-liver-disease/
American College of Gastroenterology Patient Education & Resources – http://patients.gi.org/topics/fatty-liver-disease-nafld/
NHS Choices – http://www.nhs.uk/conditions/fatty-liver-disease/Pages/Introduction.aspx
