Fatty Liver (Steatosis Hepatis)

Fatty liver (steatosis hepatis) is the most common chronic liver disease. As a result, fat accumulates in the liver. Although a fatty liver initially causes hardly any symptoms, it can have serious consequences. Learn about the symptoms of fatty liver, life expectancy with fatty liver disease, how to treat it, and how to reduce your risk of developing fatty liver.

ICD codes for this disease: K76 | K70

Quick overview

  • Symptoms: initially hardly any symptoms, as the disease progresses and additional liver inflammation, a feeling of pressure/ fullness in the right upper abdomen, pain in the liver area, nausea/vomiting, sometimes fever.
  • Treatment: Mainly change in eating and exercise habits.
  • Causes and risk factors: Non-alcoholic fatty liver is mainly associated with obesity, insulin resistance or diabetes mellitus; medication is rarely the cause.
  • Diagnostics: A doctor’s consultation, blood value analyses, ultrasound of the liver, tissue sample from the liver shows how far the disease has progressed.
  • Course of the disease and prognosis: If left untreated, fatty liver often develops into inflammation of the liver (hepatitis) and eventually even cirrhosis of the liver, with the threat of serious complications up to and including liver failure. If a fatty liver is treated in time, complete healing is possible.
  • Life expectancy with fatty liver disease: Most people live a long life with nonalcoholic fatty liver disease (NAFLD). However, NAFLD may reduce life expectancy by about 4.2 to 4.4 years.

What is fatty liver?

In a fatty liver (hepatic steatosis), liver cells store more fat (especially triglycerides). The fat content of the liver is normally less than five percent of the liver cells. Depending on the extent of obesity, different degrees of severity of fatty liver can be distinguished:

  • Mild fatty liver: Less than a third of the liver cells are excessively fatty.
  • Moderate fatty liver: Less than two-thirds but more than one-third of the liver cells are excessively fatty.
  • Severe fatty liver: More than two-thirds of the liver cells are excessively fatty.

The exact extent of liver cell fatty degeneration can be determined by a histological (histopathological) examination of a tissue sample from the liver (liver biopsy).

Accompanying symptoms and consequences of fatty liver

A fatty liver in itself is initially not dangerous. A suitable fatty liver diet can reduce excessive fatty degeneration in the liver cells. However, if fatty liver remains undetected and untreated for a long time, the liver structure changes, which leads to inflammation. Such inflammation of the liver is also called hepatitis. If there is also increased connective tissue between the liver cells and this tissue becomes scarred, this is referred to as cirrhosis of the liver. With such scarring of the liver, fatty liver therapy no longer helps.

Almost all fatty liver patients are overweight. About every second person also suffers from diabetes (diabetes mellitus) or has elevated blood lipid levels. In addition, fatty liver is often a side effect of the metabolic syndrome.

Last but not least, fatty liver is an important risk factor for liver cell cancer (hepatocellular carcinoma).

Frequency and classification of fatty liver

Fatty liver (steatosis hepatis) is a very common liver disease. Most of those affected become ill between the ages of 40 and 60. Men are slightly more likely to be diagnosed with fatty liver disease than women. But children and adolescents are also increasingly developing fatty liver.

As the name suggests, alcohol is the trigger of alcoholic fatty liver disease (AFL) – more specifically, chronic alcohol abuse. If alcoholic fatty liver leads to liver inflammation, this is referred to as alcoholic steatohepatitis (ASH).

Fatty liver disease not caused by alcohol abuse is referred to as non-alcoholic fatty liver disease (NAFLD). These include “simple” non-alcoholic fatty liver disease (NAFL) and the resulting inflammation of the liver, called non-alcoholic steatohepatitis (NASH).

Non-alcoholic fatty liver disease is considered a “disease of affluence”. In industrialized countries, for example, they are becoming increasingly common in children and adolescents because they are becoming increasingly overweight, which is a central trigger of NAFLD. Non-alcoholic fatty liver disease (NAFL) is significantly more common in overweight boys than in overweight girls.

How does a fatty liver manifest itself?

The occurrence of fatty liver correlates with obesity and an unhealthy diet. In particular, greasy foods and high-sugar foods and drinks play a role here. However, sometimes a very low-protein diet or extremely rapid weight loss also leads to the development of fatty liver.

Read more about fatty liver diet

Blood pressure and blood lipid levels are usually elevated long before fatty liver symptoms appear. If the waist circumference is also larger and there is insulin resistance, as in the case of diabetes (diabetes mellitus), more attention should be paid to fatty liver symptoms.

This is often difficult without a visit to the doctor, as people with mild fatty liver usually have no symptoms at first and only develop symptoms as the disease progresses. Sometimes those affected feel a slight feeling of pressure or fullness in the upper right abdomen. These symptoms occur when the liver becomes significantly enlarged as part of fatty liver disease (hepatomegaly) and puts pressure on the surrounding organs and the abdominal wall.

Fatty liver symptoms with alcoholic causes

Fatty Liver (Steatosis Hepatis)

Even if increased alcohol consumption is the cause of fatty liver disease, there are initially no specific fatty liver symptoms. One indicator is usually alcohol consumption: for women, the critical limit for regular alcohol consumption is 20 g alcohol per day (corresponds to about 0.5 l beer), and for men it is 40 g per day.

Symptoms of chronic alcohol use are often easier to spot than fatty liver symptoms. The air breathed by those affected smells of alcohol. If the alcohol addiction is more advanced, the patients often neglect personal hygiene or no longer eat enough. A resulting vitamin deficiency can damage the nerves, for example.

Fatty liver symptoms in secondary diseases

The non-alcoholic fatty liver disease leads to liver inflammation (hepatitis) in about one in four people affected, and the alcoholic form in almost one in three. The symptoms of non-alcoholic fatty hepatitis (NASH) and alcoholic fatty hepatitis (ASH) do not differ.

If the cause of the fatty liver is not remedied, cirrhosis of the liver sometimes develops after a few years due to the fatty liver. Liver cirrhosis is the most serious complication of fatty liver because it is an irreversible, life-threatening disease and liver cirrhosis greatly increases the risk of liver cancer. It should be noted, however, that there are other possible causes for both hepatitis and liver cirrhosis.

Hepatitis symptoms

In the case of fatty liver inflammation (steatohepatitis), there is a pronounced inflammatory reaction in the liver. A typical symptom of this inflammatory reaction is severe pain in the liver area, i.e. under the right costal arch. On the other hand, functional disorders of the liver occur due to the inflammation. For example, the blood breakdown product bilirubin is no longer sufficiently metabolized by the liver.

The increased bilirubin level in the blood is also visible externally when the bilirubin is deposited in the tissue and the skin and eyes appear yellowish as a result. This is therefore also known as ” jaundice “. People with fatty liver hepatitis also often suffer from poor appetite, nausea, vomiting and occasionally fever.

Fatty liver symptoms in cirrhosis

If the disease progresses unchecked, the fatty liver may develop into liver cirrhosis, in which the connective tissue of the liver changes. Possible symptoms include:

  • Pressure and fullness in the upper abdomen.
  • Nausea and vomiting.
  • Weight loss due to lack of appetite.
  • Yellowing of the skin and eyes (jaundice) due to increased levels of bilirubin in the blood.
  • Itching caused by bilirubin or bile acids that have not been broken down in the skin.
  • Spider web-like changes in the skin (spider naevi).
  • Red palms (palmar erythema).
  • Strikingly reddened, shiny lips (“lacquer lips”).
  • Water retention in the legs (leg edema) and abdomen (ascites).
  • Visible blood vessels around the navel (caput medusae).
  • Male Breast Augmentation (Gynecomastia).
  • Decreased hairiness in the abdominal area in men (“abdominal baldness”).
  • Blood clotting disorder; usually recognizable by increased nosebleeds and bruises.

Fatty liver symptoms in liver failure

Many patients don’t even know that their liver is fatty if they don’t have any fatty liver symptoms. However, if the liver is already damaged, substances such as alcohol or certain medications can more easily lead to acute liver failure.

Unlike an initial fatty liver, liver failure results in symptoms that are unmistakable. The skin and whites of the eyes are discolored yellowish. Blood coagulation is disturbed because the liver no longer produces any coagulation factors. Even small bumps can result in bruises. If the bleeding is larger, those affected may vomit blood or pass black-colored stools.

Consciousness is impaired in patients with liver failure. They often speak slowly, have a bad memory or are no longer able to speak properly. In addition to the general fatty liver symptoms, there are often fluctuating blood sugar levels and altered mineral levels in the blood. In the case of liver failure, the same blood values are greatly increased as in a symptom-free fatty liver.

Fatty liver diseases are often only noticed when secondary diseases have already occurred. In order to prevent these consequences, non-specific fatty liver symptoms must also be taken seriously, diagnosed and treated quickly.

How is fatty liver treated?

Currently, all potentially helpful active ingredients are still in the testing phase. There is no scientific evidence for alternative healing methods such as Schuessler salts. There is no evidence that potentially helpful home remedies such as liver wraps have a positive effect on fatty liver. Efficacy has not yet been proven for food supplements either.

A specific medicinal fatty liver therapy or the one effective home remedy that makes the fatty liver disappear does not exist so far. Rather, therapy is about eliminating or treating the triggering causes.

A fatty liver can be reduced with a targeted lifestyle change. Existing excess weight should be sustainably reduced with a low-fat, low-sugar and calorie-reduced diet and regular exercise.

If fatty liver is diagnosed early enough and treated appropriately, the liver can make a full recovery. However, it is not about losing weight as quickly as possible. Because even if it sounds contradictory: losing weight too quickly promotes fatty liver. Therefore, a change in diet aimed at long-term success should take place.

Fatty liver patients who are not overweight should also eat a diet low in fat and sugar. All patients with fatty liver should also avoid alcohol altogether.

If patients who are very overweight (obese, BMI ≧35) do not lose weight despite diet and exercise program, there is the possibility of weight-reducing surgery in which the stomach is reduced (bariatric surgery).

If you have a fatty liver, it is also important to have your doctor adjust your blood sugar, blood pressure and blood lipid levels correctly. If the fatty liver is caused by medication, an alternative preparation may be found.

Fatty liver treatment includes regular check-ups (such as measuring liver values and ultrasound) in order to detect the progression of the disease to liver inflammation or possible liver cirrhosis at an early stage.

If the disease is already more advanced and has led to connective tissue remodeling of the liver (liver cirrhosis), the therapy consists primarily of treating any complications that may arise. Since a fatty liver is one of the greatest risk factors for liver cancer, the liver should also be examined regularly in order to detect liver cancer at an early stage.

If the liver tissue is completely destroyed, there is no chance of healing the fatty liver. Liver transplantation is then the last treatment option. If a suitable donor is found, the liver of another person is used to take over the failed liver function.

Causes and risk factors

How fatty liver develops has not yet been explained in detail.

What is clear is that there is a mismatch between calorie intake and calorie consumption. As a result, there are too many neutral fats (triglycerides) in the liver cells. These fats are made by the liver itself from fatty acids that are transported from the food in the intestines to the liver via the blood. A certain proportion of the fatty acids is burned immediately and made available to the body as energy. However, if too much fat reaches the liver, fatty liver develops.

There are various explanations for how this imbalance develops. One theory is that certain transporter proteins in the liver transport too many fats into the organ. In the case of a vitamin B deficiency, on the other hand, the fat contained in the liver, for example, is not processed properly and accumulates.

Alcohol as a cause

There is a clear connection between alcohol consumption and fatty liver. Alcohol is high in energy and is broken down in the liver. Among other things, this produces fatty acids, which are stored in the liver. If people drink alcohol constantly, this is a common reason for fatty liver. A maximum of 10g of alcohol per day is recommended for women and 20g per day for men. 10 g alcohol corresponds to about 250 ml beer or 100 ml wine.

However, these are only approximate guide values. It is also crucial how long the constant alcohol consumption has existed and whether additional metabolic diseases such as diabetes mellitus or obesity (obesity), rare congenital metabolic disorders or a hormonal imbalance (polycystic ovarian syndrome, PCOS) are present.

In addition, the liver is often damaged by the toxic effects of alcohol and its breakdown products. These substances sometimes lead to the liver being remodeled and cirrhosis of the liver developing. In addition, the liver becomes inflamed more easily with constant alcohol consumption, which in the worst case means that even a single excess of alcohol triggers acute liver failure.

However, not all people who drink alcohol develop fatty liver. This is due to individual sensitivity, gender and individual equipment with enzymes that break down alcohol.

Diet, obesity and diabetes as risk factors

Many people with fatty liver are confronted with the misconception that they drink too much alcohol. In fact, alcohol does play a role in some cases. However, non-alcoholic fatty liver diseases are much more common than the so-called alcoholic fatty liver disease. They have many possible causes and also occur in people who don’t drink alcohol at all.

Non-alcoholic fatty liver disease is often associated with increased calorie intake and an increased body mass index (BMI) as a measure of obesity. Heavy fat deposits on the abdomen (visceral obesity) are particularly dangerous.

Another important risk factor for non-alcoholic fatty liver disease is insulin resistance or type 2 diabetes. One speaks of insulin resistance when the body cells only react insufficiently or not at all to the blood sugar-lowering hormone insulin – i.e. absorb little or no blood sugar for energy production. Eventually, manifest type 2 diabetes develops from insulin resistance.

The insufficient absorption of blood sugar in the body cells causes the cells to suffer from a lack of energy. To compensate, the body increasingly breaks down stored fat, which now provides energy instead of sugar. More free fatty acids get into the blood and the liver cells absorb them more. This promotes fatty liver.

When the body has developed a certain resistance to insulin, more iron is also deposited in the liver. This creates harmful substances (oxide radicals) that cause an inflammatory reaction more quickly. People with type 2 diabetes are therefore also at a higher risk of liver inflammation.

Type 2 diabetes is a very important trigger of non-alcoholic fatty liver disease. There is also a correlation in the opposite direction: patients with non-alcoholic fatty liver are more likely to develop type 2 diabetes than people without fatty liver.

Other risk factors

Non-alcoholic fatty liver disease is associated with older age. Genetic predisposition also plays a role. Regardless of nutritional factors, lack of exercise is a risk factor for non-alcoholic fatty liver disease.

Rare causes of fatty liver

However, fatty foods or diabetes are not always to blame for non-alcoholic fatty liver. Other possible triggers of fatty liver are prolonged starvation periods, pronounced weight loss, long-term sugar infusions (e.g. in the case of pancreatic defects) and artificial nutrition.

In some cases, certain medications are also the reason why the liver becomes fatty. These include, for example, the breast cancer drug tamoxifen, synthetic estrogens and other steroids. The so-called glucocorticosteroids are used, for example, in rheumatism, asthma or chronic inflammatory bowel diseases.

There are also operations on the small intestine, liver and pancreas, after which there is increased accumulation of fat in the liver.

In addition, inflammatory bowel disease (such as Crohn’s disease) is a rare but possible cause of fatty liver.

Acute fatty liver of pregnancy develops in about one in a million pregnancies. In late pregnancy (usually after the 30th week of pregnancy) there is a sudden fatty degeneration of the liver. This very rare disease is very dangerous and leads to death in 30 to 70 percent of cases. How acute pregnancy fatty liver develops is unclear. A genetic enzyme defect may be responsible for this.

investigations and diagnosis

Anyone who suspects that they are suffering from fatty liver should contact their family doctor or an internist.

History and physical examination

In order to diagnose fatty liver, the doctor first asks about symptoms and existing diseases (anamnesis). Possible questions for this conversation are:

  • Do you drink alcohol and if so how much?
  • What is your nutrition like?
  • What medications do you take?
  • Do you suffer from an increased feeling of fullness or a feeling of pressure in the upper abdomen?
  • Do you have diabetes (diabetes mellitus)?
  • What’s your weight?

After the interview, there is a physical examination. Among other things, the doctor feels the liver through the abdominal wall. If it is enlarged (hepatomegaly), this indicates a fatty liver. However, there are many other causes of liver enlargement and this one is not specific to fatty liver.

As part of the physical examination, weight and height are measured in order to calculate the body mass index from the values. The doctor also measures abdominal circumference and blood pressure.

During a physical exam, the doctor is sometimes able to palpate the enlarged liver. The changed liver structure then becomes visible at the latest during the abdominal ultrasound.

Further investigations

Blood tests are also helpful in clarifying a possible fatty liver. If certain values are permanently elevated in the blood test, this is an indication of fatty liver.

These so-called liver values are a series of substances that are released from the liver cells into the blood when the liver is damaged. These include, for example, the enzymes GOT (also called AST) and GPT (also called ALT), as well as the bilirubin value and the enzyme gamma-GT (GGT). The iron storage value ferritin, the protein albumin and blood coagulation often also provide valuable information.

However, increased liver values are not specific fatty liver symptoms, but only a general indication of liver damage, regardless of the cause. An increase in lactate dehydrogenase (LDH) also indicates acute hepatitis, i.e. liver inflammation.

However, the most important examination when a fatty liver is suspected is an ultrasound examination (sonography) of the upper abdomen. Typically, a fatty liver is conspicuously bright in the ultrasound image because fatty liver tissue is denser and therefore reflects the sound more strongly.

A liver biopsy may be performed to determine the exact extent of the fatty liver and, if necessary, to obtain indications of the cause . The doctor takes a small tissue sample from the liver with a thin hollow needle under local anesthesia. This is then examined for histological (histopathological) examination under the microscope.

Sometimes further investigation is indicated. If, for example, the fatty liver has led to pronounced scarring in the liver tissue (liver fibrosis) or even to liver cirrhosis, early detection examinations with regard to liver cell cancer are useful.

Fatty liver: finding the cause

Once the diagnosis of fatty liver has been made, it is important to determine the cause. This sometimes requires further investigation. For example, determining blood sugar levels (fasting blood sugar, long-term blood sugar HbA1c) helps to find indications of insulin resistance or previously undetected diabetes.

It is also important for the patient to be as truthful as possible about alcohol consumption in order to find out whether an alcoholic fatty liver is present.

Life expectancy with fatty liver disease

Most people live a long life with nonalcoholic fatty liver disease (NAFLD). However:

  • 30% of people develop an inflamed liver or nonalcoholic steatohepatitis (NASH) and scarring.
  • 20% of people with scarring and NASH can develop end-stage cirrhosis, leading to liver failure and cancer.

According to statistics, NAFLD may reduce life expectancy by about 4.2 years for women (95% confidence interval 1.1-7.5) and about 4.4 years for men.

For some people, the fatty liver may reverse, whereas for others, the fatty liver may progress to inflammation and ultimately liver cell damage.

Course of the disease and prognosis

In the case of fatty liver (steatosis hepatis), the prognosis depends on how early the disease is discovered and treated. On the other hand, it plays a role whether it is fatty liver caused by alcohol consumption or not. If alcohol is the cause, the prognosis is slightly worse. Nevertheless, it is initially a benign disease.

If those affected quickly do something about the causes of their fatty liver, there is a good chance that the disease will heal completely, since the liver is one of the most regenerative organs.

However, if liver cirrhosis develops from the fatty liver, there is a risk of serious complications up to and including liver failure. The liver never recovers from cirrhosis. Because the liver cells are destroyed and replaced by functionless scar tissue. To prevent this from happening, fatty liver should be treated as soon as possible.

Dr. Ashwani Kumar is highly skilled and experienced in treating major and minor general medicine diseases.