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Fatty liver usually doesn’t produce any symptoms. Commonly, it is suspected in the following cases where:
• Deranged liver enzyme (AST and ALT) levels are found during the LFT test or,
• In people who have metabolic syndrome or risk factors for metabolic syndrome such as obesity, diabetes, etc, which are enumerated above.
Many times, it is identified with an imaging test (USG, CT, or MRI) performed for some other health issue or during health check-ups.
In cases of high suspicion or the presence of fatty liver, the doctor takes history to identify the cause for Fatty liver Diagnosis.
Firstly, the doctor would ask for a history of alcohol intake. In cases of alcohol intake, the doctor would further enquire about the quantity of alcohol intake to know if it could be significant to cause fatty liver.
Cases of the fatty liver where alcohol intake is found to be significant are considered to be caused by alcohol and are labeled as alcoholic fatty liver disease (AFLD).
People with no or insignificant alcohol intake are asked to undergo further tests to evaluate the other causes for fatty liver.
Lab tests for Fatty liver Diagnosis:
1. Liver function test: ALT and AST (If not done prior). In simple fatty liver, ALT level tends to be higher than AST.
Viral hepatitis B: if HBsAg is positive, then anti-HBc and anti-HBs are done for chronic hepatitis.
Viral hepatitis C: Anti-HCV, if positive HCV-RNA is done.
3. Autoimmune hepatitis: More common in women and should be done especially if there are associated complaints of rashes or presence of arthritis, thyroiditis, vasculitis.
Test done: Antinuclear antibodies and anti-smooth muscle antibodies. Sometimes, the anti-LKM-1 antibody is also done.
4. Iron overload: Serum ferritin and transferrin levels are done. If found elevated then test for genetic hemochromatosis is done.
5. Wilson disease: a genetic disease where excessive copper gets deposited in the liver and brain. Total serum copper and ceruloplasmin levels are done which are found reduced in Wilsons. The urine test for copper shows increased excretion.
If any of the above tests done comes out to be positive for the specific condition, the condition is treated accordingly.
If the above tests are found to be negative, the person is said to be having NAFLD.
These cases are then further evaluated for the presence of fibrosis or liver cell damage by the following tests:
1. Fibrosis predictive serum biomarkers (blood test):
• LFT: ALT, AST including alkaline phosphatase, albumin, and γ-glutamyl transferase done for children. In advanced fibrosis, AST to ALT ratio is more than 1.
• Coagulation tests: PT/INR
• CBC with platelet count
2. Fasting blood glucose or hemoglobin A1C
3. Lipid profile: Serum total cholesterol, HDL-C, and triglyceride levels
The above blood tests for glucose and lipid profile are done to evaluate the risk factors for metabolic syndrome.
Results of Fatty liver Diagnosis:
Negative: If the biomarker test for fibrosis is negative, then no other test is performed and the person is asked for regular follow up to check for the development of any fibrosis.
Positive: If the biomarker tests suggest fibrosis then an elastography test is done to check for the degree of fibrosis.
If both elastography and biomarker results are in line with each other, then no other test is needed to be done.
If the above tests don’t correlate or the cause of NAFLD can’t be identified, then a biopsy can be advised which is considered the gold standard to:
Confirm diagnosis of NAFLD or NASH
Confirm the presence of fibrosis and the degree of fibrosis.
The imaging tests play a central role in the fatty liver diagnosis and management of the fatty liver and its complication.
These tests can help in diagnosing the condition as well as grade it in severity. Few of the tests can even help to grade the degree of fibrosis in the liver. These tests also help in assessing the complication of the fatty liver like cirrhosis and portal hypertension.
1. Ultrasound(USG): it is the first imaging test that is used to assess the fatty liver. It can diagnose fatty liver and grade the degree of fat accumulation in the liver. It is especially considered a good imaging test to diagnose a moderate to severe degree of fatty liver. It is less specific to diagnose mild fat accumulation, particularly in children.
The ultrasound grades the fatty liver diagnosis into 3 categories namely mild, moderate, and severe.
2. CT scan: it is usually not done to assess fatty liver as such but, to evaluate its complications such as cirrhosis, portal hypertension, or HCC (cancer).It uses X-rays to make images.
3. MRI: is highly sensitive in detecting fat accumulation. It doesn’t use radiation (X-rays). Like CT it can be used in liver fat estimation.
4. Elastography: it is a test that can assess the degree of fibrosis present in the liver. It helps by assessing the degree of stiffness. It helps in directing further workup by suggesting the presence or absence of fibrosis and many times helps in avoiding the need for biopsy. This can be done in two ways: ultrasound elastography or MRI elastography.
Liver biopsy allows the doctors to observe the structure of the liver cells closely under the microscope. This allows them to check for any abnormality developing in the liver cells, such as fat accumulation, inflammation, fibrosis, or even tumor cells.
It is considered a gold standard test to confirm the diagnosis of NAFLD, NASH, and to grade the degree of fibrosis. However, due to its invasive nature, it is particularly used in cases where imaging findings don’t match with clinical findings or where there is a diagnostic dilemma.
The procedure is done without general anesthesia. A special needle is used to take a small sample of liver tissue which is usually inserted through the skin of your abdomen. This is generally done with the help of ultrasound which guides the needle to the right direction avoiding blood vessels. The removed sample of the tissue is seen under the microscope to check for any abnormality.
Read more about: Causes, Complications and Risk Factors of Fatty Liver
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