“Ask Dr. HKSH” – Non-alcoholic fatty liver disease (NAFLD)

Dr. HSU Shing Jih, Axel

Specialist in Gastroenterology & Hepatology

Q1. What is fatty liver disease? I am not overweight, why do I have fatty liver?

Fatty liver is common in urban populations. People who have central obesity or belly fat, or drink heavily are more likely to store excess fat in the liver. Beer, in particular, can more readily contribute to fat accumulation and cause fatty liver. Additionally, overconsumption of various types of alcohols, including red wine and white wine, can also result in excess fat build-up.

In Hong Kong, several local studies have shown that approximately 25% to 30% of the population may have fatty liver disease, whether obese or not. Nearly 70% of patients with diabetes are affected by fatty liver, which tends to be more severe. They are also more likely to develop conditions associated with fatty liver, including fibrosis, cirrhosis, etc.

Q2. How is fatty liver disease diagnosed?

Doctor will take a medical history to diagnose the causes of fatty liver, for example, by asking if the patient drinks too much beer or alcoholic beverages. With alcohol-related causes being ruled out, fatty liver disease is often attributed to metabolic issues, namely the "three highs": high blood pressure, high blood sugar, as well as high cholesterol and blood lipids. Excess body fat can also accumulate in the liver and cause fatty liver. After consultation, doctor will perform a simple physical examination, which may include blood tests and a liver ultrasound to confirm excess fat accumulation in the liver.

Q3. What are the symptoms of non-alcoholic fatty liver disease (NAFLD)?

Non-alcoholic fatty liver disease (NAFLD) usually causes no specific symptoms. When the liver becomes inflamed due to excessive fat accumulation, patients may experience fatigue, tiredness, and a dull ache or discomfort in the liver area, which is located in the upper right abdomen near the ribcage. As liver inflammation worsens, patients may feel weaker and have dark urine. The degree of inflammation caused by fatty liver is classified as mild, moderate, or severe by doctors based on blood test results. Severe cases are usually presented with more symptoms, and abnormalities in the liver's structure and shape may be detected during ultrasound examinations.

Severe liver inflammation may lead to liver fibrosis, which needs further investigations to assess the extent of the condition. If cirrhosis has developed, the liver may shrink with irregular surface. Specialist follow-up is required if severe fibrosis or cirrhosis occurs.

Q4. Can NAFLD be reversed? How can fatty liver be improved?

Early-stage NAFLD can surely be reversed, especially if it involves mild accumulation of excess fat accumulation or is associated with the "three highs" (high blood sugar, high blood pressure, as well as high cholesterol and blood lipids). Improvements can be achieved by burning excess calories with lifestyle changes, a healthy diet, regular exercise, and dietary restrictions. Also improve lifestyle and dietary habits, based on the guidance from your doctor or dietitian.

For patients already with fibrosis or cirrhosis, specialist follow-up is essential. Ongoing monitoring with regular blood tests, FibroScan, and other liver assessments can help doctors determine if cirrhosis may occur in future. Effective control of "three highs" — blood glucose, blood pressure, as well as cholesterol and blood lipids is of utmost importance. It helps prevent further deterioration if both fibrosis and fatty liver are detected early and receive treatment.

Q5. Can NAFLD be left untreated if asymptomatic? When should it be treated?

Patients diagnosed with NAFLD are often asymptomatic. They are often unsure if the condition will deteriorate. Therefore it is crucial to have a doctor conduct an assessment, review medical history, arrange blood tests and ultrasound examinations, and possibly perform FibroScan to confirm liver fibrosis. Fibrosis and significant inflammation may increase the risk of serious liver conditions and can even affect life expectancy. Therefore, management decisions should be based on blood test results, as well as doctor's clinical assessment and diagnosis. This will determine whether patient needs regular follow-ups and investigations in the future.

Q6. How is a liver fibrosis scan performed?

FibroScan is performed to confirm the presence of excess liver fat and measure liver fibrosis. As a simple, quick, and non-invasive procedure, a probe is placed on the skin over the liver area, i.e. the upper abdomen, by medical personnel to measure the amount of excess liver fat and liver stiffness. Unlike a standard ultrasound, a FibroScan can both assess the liver structure and help estimate the risk of future liver-related diseases. In case of a high liver fibrosis score or cirrhosis, close monitoring and regular follow-ups are required to prevent worsening of cirrhosis.