Non-Alcoholic Fatty Liver Disease (NAFLD) - Diagnosis Algorithm
Low Suspicion:
≤ 1 feature of MetS, No family history of cirrhosis
AND
FIB < 1.3 or NFS < -1.455, AST<20
Intermediate to High Suspicion:
≥ 2 of the following: obesity (BMI > 30 kg/m2, > 25 kg/m2 in Asians), age > family history of cirrhosis
OR
Any of the following: ≥ features of MetS, persistent AST > 20, FIB4 ≥ 1.3 or NFS ≥ -1.455
#NonAlcoholic #Fatty #Liver #Disease #NAFLD #Diagnosis #Algorithm #hepatology
Non-alcoholic fatty liver disease algorithm.
For those patients with NAFLD or liver disease of unknown aetiology, the next step is to determine the likelihood of liver fibrosis. Initial assessment includes calculation of a FIB4 or NAFLD fibrosis score with values <1.3 and ≤1.455, respectively, signifying a low risk of advanced fibrosis. Higher cut-off points, <2.0 and <0.12, should be used for patients aged over 65 years. Second-line tests that should be considered include serum markers such as ELF and imaging modalities such as ARFI elastography/FibroScan. For children, the text should be consulted for modification of recommendation. Cut-off points for ARFI vary according to manufacturer and thus should be tailored to the device used. ARFI, acoustic radiation force impulse; ELF, enhanced liver fibrosis; FIB-4, fibrosis-4; HCC, hepatocellular carcinoma; NAFLD, non-alcoholic fatty liver disease; NFS, NAFLD Fibrosis Score.
#NonAlcoholic #FattyLiver #Disease #NAFLD #algorithm #Referral #Management #Hepatology
NAFLD Diagnosis Algorithm
Two-step diagnostic strategy for NAFLD
1st step:
- Clinical biomarkers, scoring systems- FIB4, NAFLD fibrosis score, NAFIC, etc.
- Selection of patients who require further inspection of liver fibrosis.
2nd step:
- Ultrasound-based elastography, MR elastography
#NonAlcoholic #Fatty #Liver #Disease #NAFLD #Diagnosis #Algorithm #hepatology #NASH
Abnormal liver function tests algorithm.
This figure details the initial response to abnormal liver blood tests. Boxes in yellow indicate the initial evaluation of the clinical presentation. Patients with marked derangement of liver blood tests, synthetic failure and/or suspicious clinical symptoms/signs should be considered for urgent referral to secondary care (red box). For the remainder, a clinical history alongside evaluation of the pattern of liver blood test derangement will determine choice of pathway and is shown in the grey boxes. A grey box indicates all the tests that should be requested at that stage rather than a hierarchy within it. The presence of metabolic syndrome criteria should be sought to support a diagnosis of NAFLD. For children, the text should be consulted for modification of recommendation. Areas of diagnostic uncertainty are indicated in orange boxes and the decision for repeat testing or referral to secondary care will be influenced by the magnitude of enzyme elevation and clinical context. Green boxes indicate final/definitive outcomes for users of the pathway. *Abnormal USS may well include extrahepatic biliary obstruction due to malignancy, which should result in urgent referral. ALP, alkaline phosphatase; ALT, alanine aminotransferase; ARLD, alcohol-related liver disease; AST, aspartate aminotransferase; BMI, body mass index; FBC, full blood count; GGT, γ-glutamyltransferase; INR, international normalised ratio; LDH, lactate dehydrogenase; NAFLD, non-alcoholic fatty liver disease; T2DM, type 2 diabetes mellitus; USS, ultrasound scan.
#LFTs #Abnormal #Algorithm #Hepatology #Liver #Enzymes #Differential #Diagnosis
Hepatic Encephalopathy - Diagnosis and Management Summary
Definition:
• Alteration in brain function manifested by neuropsychiatric symptoms
• Caused by liver insufficiency and/or portosystemic shunting
• * Diagnosis of exclusion: always rule out other causes of neurologic/cognitive impairment
Prevalence: At cirrhosis diagnosis: 10-14%. If decompensated: 16-21%
Incidence: Occurs in 30-40% over course of disease
Recurrence: Up to 40% over a 30-day period
Precipitants: Infection, GI bleeding, Diuretic overdose, Electrolyte imbalances, Constipation, Alcohol binge, Malnutrition, TIPS
West Haven Criteria:
• Grade 1: Trivial lack of awareness, Altered sleep, Shortened attention span, Impaired addition
• Grade 2: Lethargy, apathy, Personality change, Asterixis, Inappropriate behavior, Disorientation to time, place
• Grade 3: Somnolence (but responsive), Confusion, Gross disorientation
• Grade 4: Coma (unresponsive to verbal or noxious stimuli)
TREATMENT
Initiate empiric treatment while identifying and addressing any precipitating factors
Lactulose: non-absorbable disaccharide that is metabolized to lactic acid by colonic bacteria, acidifying the lumen and promoting NH3 -> NH4+ (which is trapped in lumen and excreted)
• Titrate to maintain 2-3 bowel movements per day
• Beware of dehydration, electrolyte abnormalities
• Polyethylene glycol can be used in cases of lactulose intolerance
Rifaximin: non-absorbable antibiotic, thought to reduce ammonia-producing colonic bacteria
• Guidelines recommend using as add-on to lactulose to prevent recurrence
Other therapies to consider: Zinc supplementation, IV L-ornithine L-aspartate (LOLA), oral branched chain amino acids *Supporting data is limited
Diet: protein restriction is detrimental!
• Skeletal muscle metabolizes ammonia important to avoid malnutrition and promote building muscle mass
- Lizzie Aby, MD @LizzieAbyMD
#Hepatic #Encephalopathy #Grading #Classification #Diagnosis #Management #treatment #hepatology
