BHUBANESWAR: Rabinarayan Mishra, 50, did not pay much attention to his diet, led a sedentary lifestyle, and neither did he undergo regular check-ups or exercise. As a pure vegetarian, who took food without onion and garlic, and did not even drink alcohol, he thought that he would never end up with any liver ailment.
One fine morning, he complained of indigestion and when it did not subside, despite medication, doctors advised him sonography, which detected fatty liver. He was also diagnosed with diabetes and hypertension. Since he was obese, elastography (fibroscan) was conducted to ascertain the extent of scarring in the liver. Further diagnosis confirmed that Mishra had developed chronic liver disease. Months later, as the accumulation of fluid in his abdomen was frequent, and with no other options, he underwent liver transplantation. Now his condition is better but with a lot of restrictions.
“Mishra was suffering from non-alcoholic fatty liver disease (NAFLD), which led to cirrhosis before he could even get a hint of it. He might not be consuming non-veg food or alcohol, but calorie-rich food and diabetes damaged his liver. Had he done regular health check-ups and controlled his diet along with regular exercise, he could have prevented it,” said his physician, senior gastroenterologist and advanced therapeutic endoscopist Dr Manoj Sahu.
Unfortunately, most liver diseases, including fatty liver, are asymptomatic till the time the liver is sufficiently damaged. Fatty liver disease has emerged as a silent epidemic in India. The prevalence of NAFLD, which is a multifactorial metabolic disorder, varies from 9-53% in the general population.
A recent study published in The Lancet Regional – South East Asia indicated that the overall prevalence of NAFLD is around 26.9%, with high heterogeneity and the risk of the disease is as high as 54% among people with metabolic disorders.
The prevalence was 22.6% in rural and 32.9% in urban population.“The prevalence of NAFLD varies from region to region. Overall, one in every three people has fatty liver. A study conducted in Chandigarh found 53% of 1,000 blood donors with fatty liver. A meta-analysis of 50 studies conducted across the country involving around 24,000 adults found that 38.6% of them had fatty liver. The prevalence among adolescents is around 35%,” said Dr Ajay Duseja, head of the hepatology department at PGIMER, Chandigarh.
Causes and symptoms
Fatty liver disease is a condition caused by extra fat in the liver. Fat is generally stored in the fat cells of the human body. When more and more fat accumulates due to high-calorie food and a sedentary lifestyle, the hormones that store fat in the cells become less functional, resulting in the fat from the cells moving to the liver. When the fat in the liver goes up from the usual 5-10% of the liver’s weight, it becomes fatty.
Noted gastroenterologist Dr SP Singh said all fatty livers are not the same. “In most cases, fatty liver disease doesn’t cause any serious problems or prevent the liver from functioning normally. Some can have mild disease and some can have serious disease. The disease gets worse over time in 7-30% of people with the condition,” he said.
Age is an important factor as younger people will have mild disease and the severity of the disease increases with age. Gender also plays a role. In general, women in their reproductive age are protected from fatty liver because of estrogen in their bodies. Once they attain menopause, the level of estrogen goes down and the risk of fatty liver increases.
The primary causes of NAFLD are obesity, type II diabetes, hypertension, lipid abnormalities (dyslipidemia) and insulin resistance.
“The five factors are responsible for the accumulation of fat (steatosis) in the liver. Steatosis leads to inflammation of hepatic cells and fibrosis. When inflammation is acute, the liver gets damaged leading to nonalcoholic steatohepatitis (NASH). If left untreated, it develops into liver cirrhosis,” said Prof Duseja.
In case of disease severity, patients may develop symptoms like dyspepsia, abdominal pain or a feeling of fullness in the upper right side of the abdomen, nausea, loss of appetite or weight loss, itchy skin, yellowish skin and jaundice, swollen abdomen, ankles and legs (oedema), extreme tiredness or mental confusion and weakness.
Diagnosis
People are usually detected with fatty liver during tests and ultrasounds carried out for some other symptoms. As fatty liver has hardly any symptoms, doctors usually spot it from elevated liver enzymes that turn up in a blood test conducted for other conditions. Elevated liver enzymes are a sign that the liver is hurt. A blood test followed by an ultrasound confirms a fatty liver.
“Once a person is detected with fatty liver with or without symptoms, some basic investigations like fibroscan, liver biopsy and x-ray, CT scan or MRI are done to see how severe the liver disease is. Fibroscan is conducted instead of a liver biopsy to find out the amount of fat and scar tissue in the liver,” said VGM Hospital (Coimbatore) chairman Dr VG Mohan Prasad.
Management and treatment
Since fatty liver is a lifestyle disease, controlling weight, diabetes, hypertension and dyslipidemia along with daily exercise will help prevent or reverse it. There is no medication currently that can treat NAFLD, but various drugs can be useful in managing the problems associated with the condition. Sans specific medications, doctors help patients manage factors that contribute to the condition.
“There is no drug for those who have mild disease. The only drug for them is physical exercise and a healthy diet. Drugs are required for those who have more scarring, inflammation and fibrosis in the liver to bring the conditions down. There are specific treatment protocols for liver cirrhosis and liver cancer,” Dr Singh said.
In the case of non-cirrhotic fatty liver disease, there are specific drugs and procedures available for those who fail to control their weight. Certain endoscopic procedures are also performed in the stomach to ensure that the appetite goes down and hormones improve. However, it is impossible to reverse the condition, if a patient develops severe liver cirrhosis.
“There are two stages of liver cirrhosis – compensated and decompensated. In the compensated stage, the liver functions nearly normally. We prescribe certain drugs and advise patients to go for weight control and manage other components like diabetes and hypertension to get it reversed. If a patient with cirrhosis goes into decompensation, an acute deterioration in liver function, leading to deposition of fluid in the abdomen and hepatic encephalopathy, then a change of liver (liver transplantation) is the only option left other than medication,” Dr Duseja observed.
Prevention
The liver has the ability to repair itself. It is possible to reduce liver fat and inflammation and reverse early liver damage by adopting a healthy lifestyle. Obese people can adopt a balanced diet to lose weight slowly, but steadily. Rapid weight loss can actually make fatty liver disease worse. Doctors often recommend a healthy diet, which is high in vegetables, fruits and good fats.
Regular physical exercise also helps improve insulin sensitivity, which controls fatty liver, body weight, diabetes, blood pressure and lipids. In addition, people need to maintain a balanced and healthy diet and shun fat, trans fat, junk food, high calorie and fried food. Sweetened carbonated drinks must be avoided as they are rich in fructose that gets converted into fat in the liver.
“Fatty liver can be a silent killer because the progression of the disease is very gradual. Awareness and early intervention will always be beneficial. A first-of-its-kind pan-India study has been planned to ascertain the exact prevalence rate among children. The initiative - ROCCO (INASL-Rotary combating childhood obesity and fatty liver) will be piloted in Tamil Nadu and Kerala in collaboration with Rotary International before getting implemented in other states of the country,” added Dr Mohan Prasad,
chairman of the consortium.