Non-Alcoholic Fatty Liver Disease Overview
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Questions and Answers

What is palmar erythema associated with in chronic liver disease?

  • Elevated circulating estrogen levels (correct)
  • Reduced blood flow to the extremities
  • Increased progesterone levels
  • Low levels of liver enzymes

    • What does caput medusae indicate in a patient with cirrhosis?

  • Distended superficial paraumbilical veins (correct)
  • Increased blood pressure in the cranial veins
  • Accumulation of fluid in the abdominal cavity
  • Increased estrogen production by the liver

    • Which physical manifestation is associated with the accumulation of fluid in the abdominal cavity due to liver disease?

  • Ascites (correct)
  • Palmar erythema
  • Gynecomastia
  • Caput medusae

    • Which condition is characterized by engorged veins radiating from the umbilicus across the abdomen?

    <p>Caput medusae</p> Signup and view all the answers

    Gynecomastia in chronic liver disease is primarily due to what factor?

    <p>Elevated estrogen levels</p> Signup and view all the answers

    What histological finding is associated with Grade 1 NAFLD?

    <p>Steatosis up to 66% with occasional ballooning</p> Signup and view all the answers

    Which stage of NAFLD corresponds to the presence of cirrhosis?

    <p>Stage 4</p> Signup and view all the answers

    What does the NAFLD Activity Score (NAS) NOT include in its assessment?

    <p>Degree of portal fibrosis</p> Signup and view all the answers

    How is the histological stage of fibrosis classified as Stage 2 in NAFLD?

    <p>Zone 3 and periportal fibrosis</p> Signup and view all the answers

    What is a significant caveat regarding the use of NAS in diagnosing NASH?

    <p>It is not sufficient for definitive diagnosis of NASH</p> Signup and view all the answers

    What defines Non-Alcoholic Fatty Liver Disease (NAFLD)?

    <p>Evidence of hepatic steatosis with secondary causes excluded</p> Signup and view all the answers

    Which condition is characterized by both fat accumulation and inflammation in the liver?

    <p>Steatohepatitis</p> Signup and view all the answers

    Which demographic has the highest prevalence of Non-alcoholic Steatohepatitis (NASH) among the given groups?

    <p>Hispanics</p> Signup and view all the answers

    At what average age is NAFLD typically diagnosed?

    <p>50 years</p> Signup and view all the answers

    Which physical exam finding has the highest specificity according to the diagnostic accuracy data?

    <p>Dilated abdominal veins</p> Signup and view all the answers

    What is the positive likelihood ratio (LR+) for palmar erythema?

    <p>9.8</p> Signup and view all the answers

    What percentage of obese adults is primarily affected by NAFLD?

    <p>40%</p> Signup and view all the answers

    Which condition may accompany the development of NAFLD as part of metabolic syndrome?

    <p>Dyslipidemia/hypertriglyceridemia</p> Signup and view all the answers

    Which condition is represented by the presence of easy bleeding and gynecomastia?

    <p>Chronic liver disease</p> Signup and view all the answers

    What is the likelihood ratio for the presence of a palpable gallbladder?

    <p>0.04</p> Signup and view all the answers

    How does the prevalence of NAFLD in children compare to adults?

    <p>NAFLD affects approximately 3-10% of children</p> Signup and view all the answers

    What percentage of patients typically presents with hepatomegaly?

    <p>75%</p> Signup and view all the answers

    Which condition is indicated by signs such as edema and caput medusae?

    <p>Portal hypertension</p> Signup and view all the answers

    Which of the following manifestations is NOT typically associated with jaundice?

    <p>Fatigue</p> Signup and view all the answers

    What is the primary use of noninvasive tests in patients with NAFLD?

    <p>To reduce the need for liver biopsy</p> Signup and view all the answers

    Which noninvasive test has the highest sensitivity for diagnosing fibrosis at its specified cutoff?

    <p>Enhanced liver fibrosis panel</p> Signup and view all the answers

    Under what condition should a liver biopsy be considered according to the guidelines?

    <p>When noninvasive tests yield indeterminate results</p> Signup and view all the answers

    Which statement about the AST/platelet count ratio is true?

    <p>It has a cutoff of 1 with a sensitivity of 27%.</p> Signup and view all the answers

    What is a recommended course of action for NAFLD patients identified as low risk of fibrosis?

    <p>They do not require a liver biopsy.</p> Signup and view all the answers

    What is the specificity of the FibroTest (FibroSure) at its cutoff value?

    <p>73%</p> Signup and view all the answers

    Which of the following noninvasive tests has a positive predictive value (PPV) greater than 85%?

    <p>Fibrometer</p> Signup and view all the answers

    Which test has the lowest sensitivity in diagnosing fibrosis based on the provided data?

    <p>FibroTest (FibroSure)</p> Signup and view all the answers

    Study Notes

    Non-Alcoholic Fatty Liver Disease (NAFLD)

    • An umbrella term for conditions characterized by fat accumulation (macro-vesicular steatosis) in the liver, excluding secondary causes like alcohol consumption or medications.

    Terminology

    • Steatosis: Abnormal retention of fat (lipids) 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 (scar tissue replaces liver cells).

    Progression of NAFLD

    • Simple steatosis (NAFL): Liver contains 5% or greater hepatic steatosis without hepatocellular injury or fibrosis.
    • Non-alcoholic steatohepatitis (NASH): Liver contains 5% or greater hepatic steatosis with hepatocellular injury and inflammation, with or without fibrosis.
    • NASH with hepatocellular carcinoma: Advanced stage of NASH leading to liver cancer.

    Epidemiology

    • Most common cause of liver disease in Canada.
    • NAFLD prevalence is 20-30% in Western countries.
    • Affects approximately 20% of Canadians and 37% of adult Americans.
    • NASH prevalence is 3-5%.
    • More common in obese and overweight adults but can affect non-obese individuals.
    • Average age at diagnosis is 50 years.
    • Rising childhood obesity increases prevalence in children, ranging from 3-10%.
    • Prevalence is higher in Hispanics compared to Caucasians and African Americans.
    • In Caucasians, men are more likely to have NAFLD than women, but there is no sex difference in Hispanics and African Americans.

    Risk Factors and Causes

    • Principal causes:
      • Obesity (40% of NAFLD patients).
      • Diabetes mellitus (>20% of NAFLD patients).
      • Dyslipidemia/hypertriglyceridemia (>20% of NAFLD patients).
    • Associated with insulin resistance and metabolic syndrome.

    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

    • Diagnostic Accuracy of Physical Exam Findings:
      • Midclavicular liver span ≥ 10 cm on percussion: sensitivity 61-92%, specificity 30-43%.
      • Palpable liver edge: sensitivity 39-71%, specificity 56-85%, LR+ 1.9, LR- 0.6.

    Diagnosing Hepatocellular Disease in Patients with Jaundice

    • Diagnostic Accuracy of Physical Exam Findings:
      • Spider angiomas: sensitivity 35-47%, specificity 88-97%, LR+ 4.7, LR- 0.6.
      • Palmar erythema: sensitivity 49%, specificity 95%, LR+ 9.8, LR- 0.5.
      • Dilated abdominal veins: sensitivity 42%, specificity 98%, LR+ 17.5, LR- 0.6.
      • Ascites: sensitivity 44%, specificity 90%, LR+ 4.4, LR- 0.6.
      • Palpable spleen: sensitivity 29-47%, specificity 83-90%, LR+ 2.9, LR- 0.7.
      • Palpable gallbladder: sensitivity 0%, specificity 69%, LR+ 0.04, LR- 1.4.
      • Palpable liver: sensitivity 71-83%, specificity 15-17%.
      • Liver tenderness: sensitivity 37-38%, specificity 70-78%.

    Further Testing

    • Grading and Staging of NAFLD Histological Lesions:
      • Grade:
        • Grade 1 (mild): Steatosis up to 66%, occasional ballooning in zone 3, scattered polymorphs with or without lymphocytes, mild or no portal inflammation.
        • Grade 2 (moderate): Any degree of steatosis, obvious ballooning predominantly in zone 3, intralobular inflammation with polymorphs and chronic inflammation, and mild to moderate portal inflammation.
        • Grade 3 (severe): Panacinar steatosis, ballooning and obvious disarray predominantly in zone 3, intralobular inflammation with scattered polymorphs with or without mild chronic and mild to moderate portal inflammation.
      • Stage:
        • Stage 0: No fibrosis.
        • Stage 1: Zone 3 perisinusoidal fibrosis only.
        • Stage 2: Zone 3 perisinusoidal and periportal fibrosis.
        • Stage 3: Bridging fibrosis.
        • Stage 4: Cirrhosis.

    NAFLD Activity Score (NAS)

    • Used in NAFLD patients who have had a liver biopsy.
    • Score based on histology results:
      • Steatosis grade.
      • Lobular inflammation.
      • Liver cell injury (ballooning).
    • Score correlates with steatohepatitis diagnosis but should not be used to definitively diagnose NASH.
    • Online calculator available via MDCalc.

    Noninvasive Tests for Liver Fibrosis

    • Noninvasive tests and scoring systems predict risk of fibrosis.
    • May reduce the need for liver biopsy in patients with NAFLD.
    • Noninvasive tests:
      • AST/ALT ratio (AAR).
      • AST/platelet count ratio index (APRI).
      • BARD score.
      • Enhanced liver fibrosis (ELF) panel.
      • Fibrosis-4 (FIB-4) index.
      • FibroTest (FibroSure).
      • Fibrometer.
      • Magnetic resonance elastography.
      • Nonalcoholic fatty liver disease fibrosis score (NFS).
      • Ultrasound elastography.
      • Liver biopsy should be offered to patients at high risk of NASH and advanced fibrosis based on noninvasive testing.
      • Liver biopsy should be ordered if noninvasive tests produce an indeterminate result.

    Diagnostic Accuracy of Noninvasive Tests for Liver Fibrosis

    • Test:
      • AST/ALT ratio: cutoff 0.8, sensitivity 74%, specificity 78%, PPV 59%, NPV 88%, LR+ 1.4, LR- 0.1.
      • AST/platelet count ratio: cutoff 1, sensitivity 27%, specificity 89%, PPV 51%, NPV 49%, LR+ 1.1, LR- 0.4.
      • BARD score: cutoff 2, sensitivity 89%, specificity 44%, PPV 41%, NPV 90%, LR+ 0.7, LR- 0.1.
      • Enhanced liver fibrosis panel: cutoff 10.5, sensitivity 100%, specificity 98%, PPV 96%, NPV 100%, LR+ 21, LR- 0-∞
      • FIB-4 index: cutoff 1.3, sensitivity 85%, specificity 65%, PPV 51%, NPV 91%, LR+ 1.0, LR- 0.1.
      • FibroTest (FibroSure): cutoff 0.7, sensitivity 15%, specificity 98%, PPV 76%, NPV 73%, LR+ 3.2, LR- 0.3.
      • Fibrometer: cutoff 0.8, sensitivity 79%, specificity 96%, PPV 89%, NPV 91%, LR+ 8.5, LR- 0.09.
      • Magnetic resonance elastography: cutoff 2.74 kPa, sensitivity 94%, specificity 73%, PPV 60%, NPV 97%, LR+ 1.5, LR- 0.04.
      • NAFLD fibrosis score (NFS): cutoff -1.5, sensitivity 78%, specificity 58%, PPV 44%, NPV 86%, LR+ 0.8, LR- 0.2.
      • NAFLD patients with low risk of fibrosis based on noninvasive testing do not require a liver biopsy.

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    Fatty Liver Disease CMS200 PDF

    Description

    Explore the key concepts surrounding Non-Alcoholic Fatty Liver Disease (NAFLD), including terminology like steatosis and fibrosis. Understand the progression from simple steatosis to advanced stages like non-alcoholic steatohepatitis and its complications. Enhance your knowledge on liver health and disease.

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