In this episode of PodMD, experienced Gastroenterologist and Hepatologist Dr Matt Kitson will be discussing the topic of fatty liver, including what fatty liver is, the risks of the condition, the red flags GPs should look out for, when a GP should refer and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Matt Kitson
Dr Matt Kitson is an experienced Gastroenterologist and Hepatologist whose private practice is based in Glen Iris, Melbourne. He completed Gastroenterology training in 2011 and was awarded a PhD by Monash University in 2015. Dr Kitson is a consultant at the Alfred Hospital and Senior Lecturer at Monash University. He also provides specialist medical services to Gippsland in regional Victoria and is involved in providing endoscopy and Gastroenterology training for Pacific Island doctors.
Today, we’ll be discussing the topic of fatty liver.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Matt, thanks for talking with us on Pod MD today.
Matt: Thank you for having me.
The topics of today’s discussion is Fatty Liver. Matt, can you describe for our listeners what Fatty Liver is?
Matt: Yeah, so fatty liver otherwise known as non alcoholic fatty liver disease is the most common cause of liver disease in Australia and actually in Western countries. And it’s where more than 5% of the liver is fat and you get this accumulation of fat in the liver. It affects about 20 to 30% of people. So it’s incredibly common. The main causes of fatty liver really are related to metabolic factors, so people with an elevated body mass index or the presence of type 2 diabetes. Excess alcohol use is also a really important cofactor on top of these other things. And there’s also some other medications that can actually cause.
Fat accumulation in the liver.
How is it diagnosed and what are symptoms patients are typically reporting?
Matt: The most common manifestation of fatty liver is the presence of abnormal liver function tests and the most common pattern that we see is mild elevation of the ALT or Gamma GT. Quite often what happens then is that a patient is referred for a liver ultrasound, and on the ultrasound. We can see fat in the liver. It can also be diagnosed as an incidental finding on either ultrasound or CT. If those scans are being performed for another reason, it’s really important in patients with abnormal liver function tests to assess whether hepatitis B or C is present. Quite different patients are asymptomatic. Although some patients might get a very vague right upper quadrant discomfort. About 70% of diabetics have fatty liver, so it’s a really common finding in a lot of your diabetic patients. And the reason for this is that insulin resistance is a common factor that leads to both diabetes and the accumulation of fat in the liver.
What are the risks of this condition?
Matt: The good news with fatty liver is that this condition is low risk in the majority of people, but the presence of fatty liver indicates to the patient that a change in lifestyle is necessary. There’s also an association of fatty liver with a higher risk of cardiovascular mortality, and so it’s really important to take a holistic view of these. Patients only a small proportion of patients are at a higher risk of progression to liver fibrosis and cirrhosis, and in my experience the high-risk patients or those with diabetes and those with the body mass index more than 35. The other important cofactors that can lead to a high risk of cirrhosis, excess alcohol use, presence of hepatitis B&C, infection, the presence of hereditary, hemochromatosis, and also patients who are on methotrexate for other reasons.
I find a family history is really helpful in identifying patients that are a higher risk. There are genetic factors that contribute to the development of fatty liver, and there’s also genetic factors that contribute to the development of cirrhosis. So identifying that family history of cirrhosis or hepatocellular carcinoma is important. Fibroscan is a key non-invasive tool in stratifying risk in each individual patient, and it’s fairly widely available in most capital cities. It measures the stiffness of the liver using ultrasound technology and the stiffness of the liver correlates with any scarring of the liver, it’s an easy 10 to 15 minutes scan that is very valuable in helping us identify which patients are at higher risk.
What management options are available for this condition?
Matt: When patients are diagnosed with fatty liver, they often want to know how can I get rid of this and the cornerstone of management is sustainable life lifestyle modification, so I tend to tell patients that their liver is just another place in our body where fat can be stored and that if they can achieve weight loss than that will reduce the amount of fat in their liver. It’s important to assess alcohol intake as well in patients, both because this can cause an accumulation of fat and delivered as well, but also it’s important in dietary and lifestyle changes that patients need to achieve to manage this condition. These dietary and lifestyle changes really need to be sustainable and it’s really important that they limit intake of processed carbohydrates as these tend to be calories that our body is very adept at turning into fat.
Other potential dietary options for patients to look at a a Mediterranean diet that’s high in fibre and in unsaturated fats and other options that can be looked at to achieve weight loss. Things like intermittent fasting or the well publicised 5/2 diet or another manifestation of that is time restricted eating where patients are fast for 16 hours a day and only have caloric intake for 8 hours a day, so there’s many different potential management options, and all of these things are safe in the long term. Another fairly popular option is a keto diet or a very low carb diet, but really this is only a short-term option for up to three months and that can help patients achieve fairly rapid weight loss, but it’s not a sustainable or healthy diet to be on in the long term. I find that it’s important to take a multi disciplinary approach in patients and quite often all involve a dietitian in their management as well.
Have there been any developments in treatment in recent years or are there any in trials or development now?
Matt: It’s been an incredible amount of research into fatty liver in the last 10 or 15 years. Vitamin E was something that was looked at about 10 years ago and it showed some benefit in the management of fatty liver, but it’s associated with an increased risk of cardiovascular events, so it’s not routinely used. Another medication that’s been shown to be a benefit is a diabetic drug called pioglitazone, but unfortunately this results in weight gain, so it’s not really an ideal long term option. There’s been some really encouraging data on a new diabetic medication called semaglutide, which you may know as it’s Brand name as Ozempic, so this is a once a week injection and it’s shown very promising data in the treatment of fatty liver and is now PBS listed in Australia for the treatment of Type 2 diabetes. For patients who are really struggle to achieve weight loss, another potential option is bariatric surgery and this has been shown to result in the regression of liver fibrosis, but it’s contraindicated if cirrhosis is present.
What are the red flags that GPs should look out for?
Matt: The two things that I really want to know about in patients with fatty liver is one, is there another cause of liver disease present in addition to fatty liver and two is advanced liver disease present such as advanced fibrosis or cirrhosis. Hepatitis B&C serology needs to be checked in all patients as a minimum if abnormal liver function tests are present and the red flags that really need to be looked out for the features of either cirrhosis or portal hypertension on CT or ultrasound imaging.
Patients who consistently have an ALT above 100 needs to be further investigated as this degree of abnormal liver function tests is unusual in fatty liver and patients who have an elevated bilirubin or an alkaline phosphatase more than two times the upper limit of normal may also have another cause of liver disease. And another important marker of the presence of cirrhosis and portal hypertension is a low platelet count, so these are really the things that you need to be on the lookout for.
When should a GP refer?
Matt: I think when any of those red flags are present, so features of cirrhosis or portal hypertension, unusually high liver function tests or a low platelet count, a gastroenterologist needs to be involved in the assessment and management of the patient and the other thing to really be mindful of is if things don’t quite seem right, such as when a patient with a normal body mass index has features of fatty liver on imaging.
What role does the GP play in the treatment of Fatty Liver?
Matt: A GPs role in the management of fatty liver is incredibly important as we need to take a holistic view in the management of these patients. Often other medical comorbidities, such as diabetes or cardiovascular disease, are present, and it’s important to manage these conditions well. Encouraging patients in achieving and maintaining sustainable, healthy lifestyle changes is important as well, and a good relationship with their GP is a cornerstone in the management of these patients.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on Fatty Liver.
Matt: So the first take home message is that fatty liver follows a benign course in the vast majority of patients and really, it’s important to identify those who are at higher risk of the development of advanced liver disease and in my experience, Fibroscan is a key non-invasive tool in helping to identify these patients.
The second key take home point is it’s important to be on the lookout for indicators of other causes of liver disease, such as unusually high liver function tests or fatty liver in the patient with a normal body mass index and the 3rd.
and final take home message I think that’s important is that sustainable lifestyle modification is the corner of management and we should have a low threshold for involving a dietitian in a patient management.
Thanks for your time and the insights you’ve provided.
Matt: Thank you for having me