NAFLD

Question 1

Definition of NAFLD

Answer 1

> 5% of hepatocytes steatotic - fatty infiltration of liver in absence of secondary cause
Liver manifestation obesity and metabolic syndrome

Question 1

Staging of NAFLD

Answer 1

Hepatic steatosis only
Steatohepatitis +/- fibrosis - NASH
Cirrhosis

Question 2

What is NASH

Answer 2

Steatohepatitis +/- fibrosis
Fat and hepatocellular injury and inflammation
can still regress from fibrosis

Question 3

Prognosis of cirrhosis

Answer 3

• 45% risk of decompensation in 10 years
• 2% risk HCC/year
• 20% mortality - 10 years

Question 4

Pathogenesis of NAFLD

Answer 4

• Visceral obesity → insulin resistnace
• Increase lipolysis in peripheral tissues → more free fatty acids in blood in the liver
• Lipogenesis - more fat produced in liver, also decreased export
• Gut microbiota, oxidative stress and genetics, age, geneder, ethnicity → inflammation

Question 5

Factors affecting NAFLD progression

Answer 5

T2DM
Weight gain
Poor DM contol
Metabolic syndrome
Inacitivity
Diet - high fat, sugar, fructose
Increasing age
Genetics - PNPLA3, TM5F6
Sleep apnoea

Question 6

Factors slowing NASH progression

Answer 6

Weight loss
Exercise
Mediterranean diet
DM control
Coffee

Question 7

WHo suspect NAFLD in

Answer 7

• All overwieght/obese individuals
• Older sedentary
• T2DM/metabolic syndrome

Question 8

How is NAFLD identified

Answer 8

Raised liver enxymes but ofetn normal
Imaging of steatosis
Imagine evidence of cirrhosis or liver cancer

Question 9

What is criteria for NAFLD diagnosis

Answer 9

Raised ALT+/or GGT + steartosis on imaging
OR evidence of insuline resistance/central obesity/metabolic facotrs

Question 10

How to rule out other differentials in NAFLD

Answer 10

No hisotry of alcogol excess
Pre-exisitng liver disease
Hepatotoxic drugs
Negative liver screen for other diseases eg virus
Liver biopsy if uncertain diagnosis

Question 11

What does a raised ALT fall with

Answer 11

Advancing fibroris
Age

Question 12

What is most common LFT abnormality in NAFLD

Answer 12

Raised GGT
Next - ALT, IgA, ferritin w normal TS

Question 13

What aminotransferase increases with fibrosis

Answer 13

AST

Question 14

Imaging for NAFLD

Answer 14

US
MRI - PDFF
MR spectrocsopy

Question 15

What is CAP

Answer 15

Controlled attenuation parameter
Bedside measure of steatosis

Question 16

Staging of fribrosis

Answer 16

F0-1
F2-3
F4

Question 17

Managment of FO-1 fibrosis

Answer 17

Lifestyle advice, treat metabolic syndrome
Reassess FIB4/TE 3 years

Question 18

F2-3 manamgenet

Answer 18

Lifestyle + metabolic treat
NAFLD direct therapy

Question 19

F4 fibrosis managmenet

Answer 19

NAFLD direct therapy
HCC and varices screen
lifestyle + treat metabolic

Question 20

Tests for fibrosis

Answer 20

Scores -
FIB-4
NAFLD fibrosis score
ELF test
Fibrotest
ProC3

Question 21

What level means fibrosis on a transient elastograhy and suggests liver biopsy

Answer 21

> 8kPa

Question 22

Imaging for fibroris

Answer 22

Transient elastography
Acoustic force radiation imaging - ARFI
Mr ELASTOGRAPHY

Question 23

Clinical scores for fibroriss

Answer 23

AST:ALT ratio >0.8 = advanced fibroris
FIB-4 score

Question 24

What FIB-4 scores suggest transient elastography

Answer 24

>1.3 if under 65 >2 if over 65

Question 25

What is conisidered in FIB4

Answer 25

- Age - AST - ALT - Platelet count - 0.3 = no fibrosis

Question 26

What FIB4 diagnoses fibrosis level

Answer 26

>2.67 if under 65 >3.25 if over 65

Question 27

Treatment for NAFLD

Answer 27

Weight loss - 10% goal Exercise Manage CVS risk

Question 28

Weight loss help in NAFLD

Answer 28

Orlistat Clinic visits Support schemes/programmes, diets etc Bariatric surgery if BMI >40 or >35 + comorbidity (caution in cirrhosis)

Question 29

What medications are good for NAFLD that treat diabetes

Answer 29

Metformin - reduce HCC Pioglitazone, liraglutide - reduce steatosis + slows fibrosis progression

Question 30

Pioglitazone side effects

Answer 30

weight gain, increased risk bladder cancer, reduced bone density

Question 31

Maangement of metabolic syndrome in NAFLD

Answer 31

Treat DM - metformin, pioglizine, liraglutide HPTN - ARBs/ACEis (antifibrotic) Dyslipidemia - statins Sleep apnoea Smoking cessation

Question 32

Treatment for F3 NASH non diabetic vs diabetic

Answer 32

Vit E if non diabetic Assess ALT response after 6 monhts - should decline Diabetic - GLP-1, piaglitzone or empaglaflozin

Question 33

What blood test can test for advanced fibrosis

Answer 33

Enhanced liver fibrosis - ELF blood test

Question 34

What does ELF blood test test

Answer 34

hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1.

Question 35

What investigations used together to for diagnosis of NAFLD

Answer 35

FIB-4 or NAFLD fibrosis + fibroscan (transient elastography)