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Questions and Answers
Which risk factor is NOT associated with the development of NAFLD?
What is a common laboratory abnormality in patients with NAFLD?
Which of the following is a suggested alternative name for NAFLD?
Which imaging study is commonly used to evaluate steatosis in NAFLD?
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What is a potential severe complication of advanced NAFLD?
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Which condition is characterized by fat accumulation in the liver without hepatocellular injury or fibrosis?
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What is a significant risk factor for the development of NAFLD?
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In terms of demographics, which group has the highest prevalence of NAFLD?
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Which of the following terms refers to permanent liver damage characterized by scar tissue replacing liver cells?
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What percentage of the adult population in Canada is affected by NAFLD?
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What is a significant risk factor for the progression of NAFLD to cirrhosis?
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Which statement about the histopathology of NAFLD is true?
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What is the annual risk percentage of developing hepatocellular carcinoma in patients with NAFLD?
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Which of the following is NOT a complication of NAFLD?
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What is the strongest predictor of progression of NAFLD according to histological findings?
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Which factor is associated with mortality risk in patients with end-stage liver cirrhosis and hepatocellular carcinoma?
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Which condition can NAFLD coexist with?
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What percentage of patients may develop end-stage liver disease and liver failure over 10 years if they have NAFLD?
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Which of the following predicts cardiovascular events and chronic kidney disease in conjunction with NAFLD?
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Which of the following best describes the early stages of NAFLD?
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Study Notes
NAFLD Overview
- An umbrella term for a spectrum of conditions characterized by excessive fat accumulation in the liver, excluding secondary causes.
- Most common cause of liver disease in Canada, affecting ~20% of Canadians and ~37% of adult Americans.
Key Concepts
- Steatosis: Abnormal retention of fat within an organ.
- Hepatic Steatosis: Fat accumulation in the liver.
- Hepatitis: Inflammation of the liver.
- Steatohepatitis: Fat accumulation and inflammation of the liver.
- Fibrosis: Scarring.
- Cirrhosis: Permanent liver damage where scar tissue replaces liver cells.
NAFLD Progression
- Simple Steatosis (or Non-alcoholic fatty liver (NAFL)): 5% or greater hepatic steatosis without hepatocellular injury or fibrosis.
- Non-alcoholic steatohepatitis (NASH): 5% or greater hepatic steatosis with hepatocellular injury and inflammation, with or without fibrosis.
- NASH with hepatocellular carcinoma: Can progress from NASH.
Epidemiology
- Prevalence: 20-30% in western countries.
- NASH Prevalence: 3-5%.
- More common in obese/overweight adults, but can affect non-obese individuals.
- Average age at diagnosis: 50 years.
- Increasing prevalence in children due to rising childhood obesity: 3-10% in children.
- Ethnic disparities: Hispanics > Caucasians > African Americans.
- Sex disparities in Caucasians: Men > Women; No sex differences observed in Hispanics and African-Americans.
Risk Factors and Causes
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Principal Causes:
- Obesity (40% of patients with NAFLD)
- Diabetes mellitus (>20% of patients with NAFLD)
- Dyslipidemia/hypertriglyceridemia (>20% of patients with NAFLD)
- Association with: Insulin resistance and metabolic syndrome.
Metabolic Syndrome
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Important questions to ask patients during history taking:
- Family history of obesity or diabetes.
- Lifestyle habits, including diet, exercise, and alcohol consumption.
- Medications used.
- Presence of any existing conditions like high blood pressure, high cholesterol, and cardiovascular disease.
NAFLD Timing and Clinical Course
- Slowly progressive disease: Silent liver disease when there is only steatosis.
- Early Stages (simple steatosis or NAFL) are reversible.
- Progression: NAFL → 20% develop NASH → 20% progress to cirrhosis → possible liver failure and liver cancer.
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Risk Factors for Advanced Hepatic Fibrosis and Cirrhosis:
- Advanced age
- Obesity
- Diabetes mellitus
- Strongest predictor of progression: The degree of inflammation on the first liver biopsy.
NAFLD Complications
- Cardiovascular Disease
- Hepatocellular carcinoma: Annual risk 1-2%.
- End-stage liver disease and liver failure: Develops over 10 years in 45% of patients.
- Coexistence with other chronic liver conditions
- Cardiovascular risk factors contribute to mortality in those with end-stage liver cirrhosis and hepatocellular carcinoma.
Other Predicted Risks of NAFLD
- Cardiovascular events
- Chronic kidney disease
- Colorectal cancers
- Type 2 diabetes mellitus
NAFLD Signs and Symptoms
- Most patients are asymptomatic.
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Possible Presentations in early stages:
- Fatigue
- Malaise
- Mild abdominal discomfort (right upper quadrant)
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Possible Presentations in advanced stages:
- Nausea
- Vomiting
- Jaundice
- Pruritis
- Memory impairment
- Easy bleeding
- Loss of appetite
- Hepatomegaly (in 75% of patients)
- Spider angiomas
- Signs of portal hypertension: edema, ascites, caput medusae
- Palmar erythema
- Gynecomastia - Dupuytren contracture - Petechiae
Detecting Hepatomegaly
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Physical exam findings:
- Midclavicular liver span on percussion ≥ 10 cm: Sensitivity: 61-92%, Specificity: 30-43%
- Palpable liver edge: Sensitivity: 39-71%, Specificity: 56-85%
Diagnosing Hepatocellular Disease in Patients with Jaundice
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Physical exam findings:
- Spider angiomas: Sensitivity: 35-47%, Specificity: 88-97%
- Palmar erythema: Sensitivity: 49%, Specificity: 95%
- Dilated abdominal veins: Sensitivity: 42%, Specificity: 98%
- Ascites: Sensitivity: 44%, Specificity: 90%
- Palpable spleen: Sensitivity: 29-47%, Specificity: 83-90%
- Palpable gallbladder: Sensitivity: 0%, Specificity: 69%
- Palpable liver: Sensitivity: 71-83%, Specificity: 15-17%
- Liver tenderness: Sensitivity: 37-38%, Specificity: 70-78%
Diagnosing Cirrhosis in Patients with Chronic Liver Disease
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Physical exam findings:
- Spider angiomas: Sensitivity: 33-84%, Specificity: 48-98%
- Palmar erythema: Sensitivity: 12-70%, Specificity: 49-98%
- Gynecomastia: Sensitivity: 18-58%, Specificity: 92-97%
- Reduction of body or pubic hair: Sensitivity: 24-51%, Specificity: 94-97%
- Jaundice: Sensitivity: 16-44%, Specificity: 83-99%
- Dilated abdominal wall veins: Sensitivity: 9-51%, Specificity: 79-100%
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Description
Test your knowledge on non-alcoholic fatty liver disease (NAFLD) and its various components. This quiz will cover key concepts like steatosis, hepatitis, and the progression from simple steatosis to cirrhosis. Understand the implications and prevalence of this condition, particularly in North America.
