Patients who come to the emergency department with abdominal pain often get an ultrasound as part of their diagnostic workup – especially if the pain is localized to the right upper abdomen. This is done to evaluate for emergency causes of the pain, particularly if the source is related to the liver or gall bladder.
With increasing frequency over the years, I’ve seen ultrasound results demonstrating “fatty liver” in patients. In the absence of chronic alcohol abuse, non-alcoholic fatty liver disease (NAFLD) affects between 80 and 100 million Americans. That adds up to about one-third of adults. And despite its name, one-third of those diagnosed with fatty liver disease are not obese.
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Where do those fatty deposits come from?
NAFLD is actually a spectrum of liver disease that includes fatty liver, which occurs when there is an excess of fat deposits in the liver. When fatty liver is accompanied by progressive inflammation and fibrosis, this is referred to as non-alcoholic steatohepatitis (NASH). If NASH is allowed to progress, it could result in cirrhosis, a permanent scarring that leads to liver failure.
So where do the fatty deposits in our liver come from in the first place? Chronic alcohol consumption or a diet high in “bad” saturated/trans fats and excess simple dietary sugar all contribute to fatty acid deposits in the liver. Although an exact cause remains elusive, in non-alcoholics, NAFLD is the result of a complex interplay of multiple metabolic diseases including:
- Diabetes
- Hypothyroidism
- High triglycerides
- High blood pressure
- obesity
It’s no wonder then that fatty liver is an independent risk factor for heart disease. This was a major contributing factor for the American Heart Association to recently write a position paper on NAFLD.
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Fatty Liver: Silent But Dangerous
Most patients with NAFLD will likely have no symptoms. Those with fatty liver might have non-specific symptoms such as intermittent or constant pain to the right upper abdomen (where the liver is located) and chronic fatigue or tiredness.
Patients with more advanced disease such as NASH or cirrhosis might have swelling of the hands or legs, increased abdominal girth or yellowing of the skin or eyes known as jaundice.
Diagnosing fatty liver
Most patients find out they have fatty liver incidentally after a workup for abdominal pain or through their primary care physician. I hesitate to say “diagnosed with fatty liver” because as mentioned above, fatty liver is part of a collection of liver diseases whose cause is multi-factorial. And the treatment, as I will discuss below, involves addressing the multiple metabolic dysfunctions contributing to the fatty deposits.
In the emergency department, a patient’s abdominal ultrasound will indicate “fatty liver.” Liver function tests might be elevated and indicate some level of inflammation.
Fatty liver treatment: Tackling the multiple causes
Our liver is a vital organ that performs a variety of crucial tasks including metabolizing food into energy and detoxifying our body. Fortunately, fatty liver is reversible and treatable with a combination of non-pharmacological interventions.
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First and foremost, weight loss is a key component of a treatment plan for fatty liver. Remember that both strength training and cardio can reduce fat. Aim for at least 30 minutes a day of exercise most days of the week. However, rapid weight loss is dangerous and could worsen NAFLD. If you are obese, aim to lose 7-10% of your body weight over the course of one year. A simple rule of thumb is a target ideal body weight – which is your height in centimeters minus 100 kilograms. So for example if your height is 182cm (6 feet), your ideal body weight to shoot for would be 82kg (181lbs).
In general, note that no specific dieting style is superior when it comes to reducing fatty liver disease. The focus should be low-carb. Interestingly, treatment focuses on replacing simple sugars like table sugar sucrose and fructose with low glycemic fruits just as much as replacing “bad” saturated/trans fats with unsaturated fats. This is because simple sugars are a key culprit in many of the metabolic dysfunctions mentioned above that contribute to fatty deposits.
Additional guidelines to follow in developing your fatty acid diet plan:
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However, if fatty liver progresses to more advanced inflammation or fibrosis, a consult with your primary care doctor and referral to a gastrointestinal specialist is warranted. There are currently no FDA-approved medications to treat NAFLD.
Michael Daignault, MD, is a board-certified ER doctor in Los Angeles. He studied Global Health at Georgetown University and has a Medical Degree from Ben-Gurion University. He completed his residency training in emergency medicine at Lincoln Medical Center in the South Bronx. He is also a former United States Peace Corps Volunteer. Find him on Instagram @dr.daignault
