Dr. Roach: Fatty liver disease can be present without alcohol use
Dear Dr. Roach: I am a normal-weight female, age 71, who is very active. I take no medications and have never had an alcoholic drink in my life. My liver tests were abnormal (AST 58, ALT 71), and my doctor found moderate strands of fat in my liver, but no fibrosis on a FibroScan.
What is the difference between high liver enzymes and fatty liver disease? Has my liver been damaged beyond healing with these conditions, or will it heal? I am prediabetic.
Dear C.D.: AST and ALT are enzymes made by the liver. There is supposed to be a small amount in the blood, but high levels of these liver enzymes indicate there’s been damage to the liver cells. There are many, many causes, but an increasing one is “fatty liver” — a catch-all term for excess fat in the liver. Non-alcoholic fatty liver disease would be the name used for a person who, like you, does not have excess alcohol consumption and has no other known causes for fat in the liver.
A thorough work-up should be performed looking for these other causes, among them autoimmune hepatitis, Wilson’s disease (abnormal copper metabolism) and hemochromatosis (abnormal iron metabolism).
If there is evidence of inflammation in the liver, then the correct term is NASH, non-alcoholic steatohepatitis. “Steato” is Greek for “fat”; “hepar” is both the Latin and Greek root for “liver.” It’s important to know all these, because there is often a progression from fatty liver to steatohepatitis and then to fibrosis. Cirrhosis develops in people with fibrosis, and fatty liver is set to become the most common cause of cirrhosis in North America. Fortunately, your FibroScan (an ultrasound-like noninvasive test for fibrosis) result shows no fibrosis.
A FibroScan is helpful but not perfect. The definitive test for NASH remains a liver biopsy, but many experts feel that a biopsy is not necessary if a person meets certain specific criteria. You have several good criteria in your favor: Your weight is normal, you don’t use alcohol, and you don’t have diabetes — yet. Further, although your AST and ALT are elevated, they are not beyond the limit of twice the normal value, which is again a good finding.
As long as the damage is not extensive (advanced fibrosis or cirrhosis), the liver has a remarkable ability to heal itself. There is some general advice for anyone with fatty liver. Abstaining from alcohol and managing weight if overweight are both of the highest importance. A diet low in saturated fat is prudent, and both aerobic and weightlifting exercises have been proven to reduce fat in the liver. Do whichever is easiest for you.
Medications are not a big part of treatment for fatty liver. Vitamin E has been used in some situations in people without diabetes. Other treatments, such as aspirin, statins and omega-3 fatty acids, have shown promise but no definitive benefit.
I make sure all patients with any kind of liver disease are vaccinated for hepatitis A and B, since these diseases can be deadly in people with any chronic liver problem.
Readers may email questions to ToYourGoodHealth@med.cornell.edu.