Fatty Liver Disease: Stages, Diagnosis, and Treatment

Fatty liver is the accumulation of fat within the liver, such that fat comprises more than 5%–6% of your normal liver tissue. (1)

In the absence of proper treatment, this fat buildup inside the liver can trigger inflammation, cell necrosis, scar tissue formation, and eventually end-stage liver disease (i.e., cirrhosis).

Nonalcoholic fatty liver disease (NAFLD) is diagnosed in patients who do not have significant alcohol consumption.

What Are the Different Stages of Fatty Liver Disease?

The different stages of fatty liver start from a benign nonalcoholic fatty liver and progress to nonalcoholic steatohepatitis (NASH). (2) NASH can lead to cirrhosis.

A FibroScan is a useful device that can be used in an office visit to ascertain the stage of fatty liver. It gives an estimate of the amount of fat and degree of scarring in the liver.

The Controlled Attenuation Parameter (CAP) Score on the FibroScan determines the amount of fat in the liver. A normal score is <230 decibels/meter. (3) The score ranges from F0, where there is no damage, to F4, which is a shrunken, scarred liver consistent with cirrhosis.

An MRI of the liver can sometimes be helpful in the quantitative estimation of fat.

NAFLD develops in four main stages:

1. Simple fatty liver (steatosis) is mostly a benign stage characterized by the accumulation of fat inside the liver cells, which is usually accidentally caught on other routine blood or imaging tests. (4)
2. Nonalcoholic steatohepatitis (NASH) is a relatively serious stage wherein your fatty liver starts to become inflamed. (4) This inflammation is usually accompanied by death of healthy liver cells and scarring. (5)
3. Fibrosis occurs after a few years of NASH, especially if untreated. The persistent inflammation leads to more scar tissue formation around the liver as well as inside the surrounding blood vessels, which limits blood flow inside the liver. But even with this damage, the liver manages to function normally. (4)(5)
4. Cirrhosis is the most advanced and severe stage that develops after many years of liver inflammation. The prolonged inflammation makes the liver shrink and shrivel up while also developing scars and lumps. At this stage, the liver damage is irreversible, which greatly hampers the organ’s ability to function properly. In fact, your liver may even shut down or turn cancerous. (4)

What Is the Best Treatment Plan for Fatty Liver Disease?

Patients with fatty liver should abstain completely from alcohol consumption, especially heavy drinking, which is defined as >14 drinks a week or >4 drinks a day for men and > 7 drinks a week or >3 drinks a day for women. (6) Patients with fatty liver can benefit from immunization against hepatitis A and B.

Initial management is aimed at improving diet, exercising, and losing weight. Those with diabetes should optimize glycemic control. Those with a high cholesterol level may benefit from medications such as statins. Weight loss can result in the lowering of liver enzymes and serum insulin levels. (7)

A change in diet and exercise regimen should be implemented for at least 6 months. Some patients may benefit from speaking with a nutritionist. Diet modifications include reducing meal portions; eating fruits and vegetables; consuming baked, boiled, and steamed foods, increasing protein intake, and reducing carbohydrate intake.

Go for lean meats such as chicken and fish and avoid red meat. Sugary, fatty, and fried foods should be eliminated. Two to three cups of coffee daily has been proven to be beneficial for liver health.

Thirty minutes of daily exercise five times a week is recommended. A goal of loss of 7%–10% body weight in 6 months is recommended. (8) After six months, if the above lifestyle modifications have not proven to be useful, bariatric surgery can be considered. Medications can be prescribed for those that have NASH and greater than fibrosis stage.

Vitamin E 800 IU daily can be used in those without diabetes. It should not be used if there is a strong personal or family history of prostate cancer. In diabetic patients, metformin is often used. However, this does not improve the long-term disease course of fatty liver. In such patients, pioglitazone and semaglutide can be used.

If you have fatty liver, make sure to get your liver enzyme levels checked every 3–6 months. The results should be correlated to the change in diet and weight loss. If the liver enzymes have not been improving and the patient has lost weight, other reasons for liver disease should be sought.

Diagnosing Fatty Liver Disease

Fatty liver does not cause any symptoms until it has progressed to an advanced stage. So, it can be hard to catch it early, unless you go for regular health checkups. In most cases, it is diagnosed by way of routine blood tests to check your liver function.

The doctor will conduct additional tests to confirm the diagnosis. These include imaging tests such as a special ultrasound and MRI scans to spot fat deposits or scar tissue in the liver. (9) If these tests corroborate the initial diagnosis, the doctor will conduct a biopsy of the liver tissue to make sure it is indeed fatty liver disease.

Here’s how the diagnosis is made after examining the liver tissue under a microscope:  

• If it has fat deposits without any inflammation or liver damage, the diagnosis is NAFLD. (10)
• If it has fat deposits along with inflammation and tissue damage, the diagnosis is NASH. (11)
• If there are signs of scar tissue in your liver sample, it is called fibrosis and is an early sign of cirrhosis. (9)

What Is the Difference Between Nonalcoholic and Alcoholic Fatty Liver Disease?

A standard alcoholic drink is any kind of alcohol that contains about 14 g of pure alcohol. (12) This corresponds to 12 oz of regular beer containing 5% alcohol, 5 oz of wine containing 12% alcohol, and 1.5 oz of distilled spirits containing 40% alcohol.

Excessive alcohol intake is defined as an average intake of more than 21 normal-sized drinks every week in men or less than 14 average-sized drinks every week in women.

If you have had this drinking pattern for at least 2 years and show signs of fat deposits or tissue damage inside the liver, it is generally referred to as alcoholic fatty liver disease.

However, if your ultrasound shows signs of fatty liver without high alcohol consumption and other potential causes of liver disease, it is referred to as NAFLD. (2)

Who Are Prone to Fatty Liver Disease?

Patients with obesity, high blood pressure, high cholesterol, and diabetes are at a higher risk of developing fatty liver disease.

Important Points Regarding Fatty Liver Disease

• Untreated or poorly treated fatty liver can progress to end-stage liver disease.
• Fatty liver generally sets in without presenting any symptoms.  
• The diagnosis of nonalcoholic fatty liver disease is made when significant alcohol consumption and other causes of liver disease are excluded and there is evidence of fatty liver on ultrasound.
• Initial management is aimed at improving diet, exercising, and losing weight.
• Patients with fatty liver should abstain completely from alcohol consumption.