 I am Dr. Harish Babu Reddy, Consultant Gastroenterologist at Manipal Hospital, Malishparam and Jainagar, Bangalore. Today in this Facebook Live program, I will be talking about fatty liver in the next 15 to 20 minutes. I decided this topic of fatty liver as we are very commonly seen in the OPD day-to-day practice. One of the main patients come to us with the reports of fatty liver. So, we will be understanding about this fatty liver in the next 15 to 20 minutes under 4 or 5 subreddings, like as to know what is a fatty liver, what are the causes of fatty liver, who are the population at risk for developing this fatty liver and how this fatty liver progresses over a period of time to become what we call as cirrhosis and how does they present to us, like what are the problems which patients face from day-to-day with this fatty liver problems and what are the tests and what are the treatment options which were available. And more importantly, in the end, I will be discussing what are the preventive measures we can take in preventing this fatty liver and also progression of this fatty liver from stage 2 to stage 3 to become a cirrhosis. So, now coming to the first question, like what is fatty liver? As like it is there in the name, fatty liver means there is excess fat in the liver. It sets that according to our research, it is inside that more than 5% of hepatocytes filled, the hepatocytes are the liver cells filled with fat is called as, we call it as a fatty liver or even more than 5% of the dry weight of the liver whenever it is more than 5% fat content, we call it as a fatty liver. Coming to the types of fatty liver, the most commonly we have alcoholic related fatty liver and the second one broadly we classify as a non-alcoholic fatty liver disease. Alcoholic fatty liver is completely altogether a different topic which we will discuss in next sessions but today our discussion will limit it to the non-alcoholic fatty liver disease which is very, very common including even in children of late we are seeing this patients. Coming to this fatty liver, who are these people who come with fatty liver to us? These are the patients who are usually obese, who have diabetes, who have cholesterol issues, what we call as dysplopidemia and who are usually have this sedentary lifestyle. These are the patients, these are the people when they go for a routine ultrasound checkup or ultrasound is done for some other health issue, then they get this fatty liver report and then they usually come and see a gastroenterologist. So, this fatty liver over a period of time because of this global rise in epidemic of the obesity that is reflecting in the fatty liver also. This is the kind of a reflection of the obesity towards diabetes or towards hypertension it is same gastro component what we call as a fatty liver. And over a period of time especially in the European and American countries it has become a most common reason for chronic liver disease what we call as cirrhosis. Even in India also we can see that there is lot of increase in this fatty liver cases in the middle age group people and also we are seeing very commonly even in the children also because of this lifestyle and food habit changes. And over a period of time it can be a very big epidemic turning into you know progression into chronic liver disease. So, it is better that we understand it in the very early stages and try to prevent it from the progression or even revert it back to normal with all our lifestyle and food habit changes. So, if you see in the general population it is said that like 25% of the people out of 125 people are known to have fatty liver. And if you see in a patients who are obese and diabetic it can be as high as 45 to 50% of the people can have this fatty liver in one of the stages whatever the stages of the fatty liver it is. So, now coming to the stages of the fatty liver and how this fatty liver kind of progresses over a period of time. So, this fatty liver whatever we call the broadly word we use as N-A-F-L-D that is called non-alcoholic fatty liver disease. This non-alcoholic fatty liver disease basically has three stages. One of the first stage is fatty liver that is just there is a fat deposition in the liver but there is no any swelling of the liver or there is no any damage to liver cells or what we call as hepatocytes. But over a period of time because of this excess fat getting into the liver and deposition the liver will starts getting swollen. And along with that this fat will also keep on damaging the liver cells that we call as hepatocytes damage. So, along with this hepatocytes damage and the swollen liver what we call it as the N-A-F-L-D that is MASH. So, it means that non-alcoholic steatohepatitis. Steatohepatitis means because of the fat there is a damage to the liver cells leading to the inflammation within the liver. But one thing we should all know is liver is one beautiful organ where it has a lot of regeneration ability. So, whenever there is a damage by whatever mechanism it can be because of the fat or it can be because of alcohol or it can be because of the viruses still the liver always tries to kind of come back to its normal this normal capacity. But when this process becomes repetitive and chronic always then what happens will be repeated damage to the liver again and again so that leads to scarring. Once the scarring comes into the liver the liver will start becoming stiff the liver will start sunken in size and it might become even a nodules on the surface that's when we use that word as a cirrhosis. Once it goes to cirrhosis that is where it is difficult for a liver to come back. But whenever it is in the fatty liver stage or a non-alcoholic steatohepatitis phase it can usually come back to normal by the changes in the lifestyle and diet which I will be discussing with you in the later discussion. But once it becomes cirrhosis that is when there is a permanent scarring that means the liver has become stiff the liver has become decreased in size it cannot come back to its normal. So we should all take these preventive steps to prevent progression of fatty liver to the cirrhosis. Once it becomes cirrhosis it can be cirrhosis it will behave like the same way as alcoholic patients or it can be some viral related problem. So once cirrhosis happens it can progress to become what we call like we can have a decompensation of this by terms of blood omitting or jaundice or there will be fluid accumulation or what we call asitis in the abdomen and then further it can even lead to very rarely to even epitocellular carcinoma the liver cancer also to some place. So this we have to always target these patients very early and we need to understand this in the terms of fatty liver and NASH and try to prevent it from further progression to the further disease. So this is how the fatty liver progresses but it progresses over a long period of time. It takes around like 10 to 15 years if there are no further insults like further insult means if this patient starts taking alcohol then this progression can occur very fast. If this patient gets some viral infection this progression can happen in 5 to 10 years also but only fatty liver will take around 15 to 20 years. So as of now whenever we see a fatty liver patient who has progressed into cirrhosis they are usually in the older age like say 50 or in the 60s but because this fatty liver is now coming in the very early age group like the children and in the first to second decade itself these patients by the age of 40 to 50 when they are really economically and you know socially they are working they are really productive in that age group in that age group they start developing cirrhosis that's when it's going to have a big impact personally and also an economic impact towards on a larger scale towards the country also. So this is how the fatty liver kind of progresses. Now who are these people whom we should be worried about and like who are these patients we should be very careful to screen and like identify these high risk patients what we call and try to intervene as early as possible. So the first group of people is the obesity and obesity as you guys already know it is rising epidemic in this every part of the world and even in India also. So whenever we have like what we call as a body mass index for Saudi stations it is said that the ratio if it is more than 43.5 we call it as a obesity in those patients who are at high risk and the second group of patients are those who already have a type 2 diabetes that is a second component. Third patients are those who are already having cholesterol issues in terms of high total cholesterol or high triglyceride levels these are all the people who can have this at risk for developing high risk for developing the fatty liver. Next even some viral infections like our hepatitis C that can also kind of predispose to fat accumulation and one important thing is all of the people should watch on for what medicines you are taking and you should always discuss with your doctor or with whomever healthcare practitioner you are seeing what are its effects on the liver. Because liver is kind of it will face the brunt of all the medicines what we use in a day to day practice either it can be steroids it can be any other counter like when we take the over the counter medicine or alternative medicines even to some extent excess between A that also can cause like fat accumulation in the liver. So these are some of the risk groups but there are some even genetic predispositions also but these are the factors where we can identify this subgroup of people and educate them about this fatty liver and try to prevent it to further progression into the liver disease. Now coming to the clinical manifestations how do these patients usually get present to the OPD or how do they come to know that either they are having a fatty liver or not. Most of the times it is just asymptomatic. They don't have any issues because of the fat accumulation liver because it is such an ability for a liver to kind of carry on its functions with normalcy. So but once in a while we get to see people like have some mild discomfort below the right rib cage that is like the liver area or usually the patient will have either fatigue or some kind of lethargy. They don't know but they are not able to cope up with the normal work they get tired easily this is some of the presentations usually what we see. But once the fatty liver progresses to cirrhosis that what we call chronic liver disease or cirrhosis of the liver that will be same manifestations irrespective of whatever is the problem either it is because of alcohol or it is because of this non-alcoholic fatty liver disease or the virus infection doesn't matter if they develop have a jaundice they can have accumulation of fluid in the abdomen what we call as ascites they can have the blood omitting and they can have decreased concentration, altered sensorium and all these things. So these are the complete clinical manifestations wherein we kind of identify these patients and kind of intervene them very heavily. Why I am stressing on this NFLD too much is this has a lot of associated problems in the same patient like they can have diabetes they can have cholesterol issues they can have a heart problem or they can have a stroke problem or any of these problems they all are kind of associated in the same family. So this is the non-alcoholic fatty liver disease or fatty liver what I am talking today it is a component of that syndrome that we call as a metabolic syndrome it is a gastro manifestation of whatever the metabolic syndrome we call. So once we take care of fatty liver or once we take care of diabetes or cholesterol levels it is indirectly we are taking care of the complete body so it will help us to lead a better quality of life and at the end of the day we can try to decrease the doses of medicines required for your associated conditions. So now next coming to what are the impacts like how does this fatty liver is going to affect the people or the public in a day to day practice because once the liver becomes cirrhosis as I told you that can have its own complications which I already discussed but they are also at risk for cardiovascular complications what we call like a coronary artery disease or what we call heart attack or that kind of problems are more in this fatty liver patients. Actually the fatty liver patients most of the time they have a problem more of this coronary disease or heart disease rather than the fatty liver itself and these are the patients who are also at risk for like some of the malignancies. See once the liver becomes cirrhosis that carries itself the risk of carrying a developing a cancer at the rate of 1 to 4% over the decade for every patient but that we have a screening but also it can have increasing the risk of you know large intestine adenomas what we call polyps it can be more and even it can raise the incidence of large intestine cancer also sometimes and in females it has been linked with sometimes they can even also develop the breast carcinoma also in these patients so we should be very careful with respect to the management of obesity because that is going to affect the body from every like organ aspect and these patients have told you their increased risk for liver cancer their increased risk for coronary artery disease or what we call as heart attacks and also they can have increased risk for developing the brain stroke also. So after understanding how they present the clinical manifestations of these processes and address patients also now let us kind of learn about how to diagnose this fatty liver, how to diagnose and how to assess the severity also then we will discuss later after that the management. So coming to the diagnosis it is always as I told you this non-alcoholic fatty liver disease is in those patients who are taking alcohol less than 20 grams per day for less than 5 days a week. If these patients are consuming more alcohol then there can be both the components there can be component of the alcohol also and there can be component of the non-alcohol also otherwise it will be only the non-alcohol component along with that we always whenever the fatty liver patient comes we check for their thyroid, their diabetes their cholesterol issue and their deep blood pressure depending on the parameters we might even ask for a ECG and echo also to know the cardiac status but whenever we get this fatty liver patient we do the routine blood test what we call complete hemogram and more importantly what we are interested in the liver function test if the liver function test if the SGOT and SGPD what we call liver enzymes if that values are absolutely normal then means the liver the fatty liver is still in the stage one it has not started affecting the fatty liver so that is a very ideal time for people to learn about it and try to prevent it from further progress but if the liver enzyme starts rising what we call SGOT and SGPD if there are more than whatever the cutoff levels or whatever like less than 39 or more than 40 from the lab values and in some times females we consider lesser value also if that is there then it means that the fat has started affecting the liver so that means it has gone into the second stage that is non-alcoholic state of hepatitis once the patient goes into non-alcoholic state of hepatitis and this liver values have kind of started rising then we always check in all these patients for a viral marker that is we look for hepatitis B and hepatitis C test and depending upon the age group like and also for a female patient we always try to rule out the autoimmune hepatitis by doing some of the blood test and in some patients we also consider doing of the Wilson disease also but in Indian setting we should be aware that most of our people either from villages rural side or even from the urban also have an error like very much the liver the liver problem itself tell them to take kind of go on take some alternative medicines or over the counter medicines most of the time these medicines are always at risk of damaging the liver it should be very very careful when we are trying to take any medicine which is outside the description of a doctor and even with your doctor please always discuss what are its impacts on liver for any other medicine also so we always roll out viral markers we roll out autoimmune conditions in females and anger male patients also and we roll out this Wilson disease also and always all we ask for your any of the medicine whatever you are taking whatever the preparations you are taking you may not think you may think it is not a medicine but always tell your doctor that I am taking this and this supplement because whereas it is easier to identify and to further give to you know kind of either stop it or whether to is there any treatment we can give it on it will be easier job next coming to the imaging modalities imaging modalities we tell always about like ultrasound ultrasound is the easiest investigation because it is available across the country at even rural settings everywhere the ultrasound is present and it is a very simple investigation and very sensitive so it will diagnose fatty liver and it will tell us like there are even grades of fatty liver in the ultrasound the radiologist whenever they are telling they will try to you know based on their based on their appearance of the liver with respect to spleen and kidney the grade 1, grade 2 and grade 3 also then in some patients we also consider doing an MR elastography or even CT scan there also best modalities but MR elastography is something which will give us more information about the fat content also and also the liver stiffness so sometimes when we kind of we have very obese patients wherein we can't do this ultrasound or next what I will be discussing is the fibroscan investigation in them we ask them to go for a MR elastography wherein it will give us the exact information for us be how much is the fat accumulation in the liver and how much is the stiffness or how much the liver has become really stiff and how much the liver has functioned in size but offline the very recent advances in the science and technology we have got a machine called fibroscan because of fibroscan we are able to avoid very very like required cases of liver biopsy we are not at all doing liver biopsy in any of these patients unless and until it is really required because this fibroscan which is a simple machine which is similar to ultrasound and even easier than that to do it up so we just be keeping a probe on the liver by 10 times that machine will analyze the fat content as what we call CAP value that is controlled attenuation parameter and we also get LSM that is liver stiffness measurement based on these two values we can tell the patient about what stage of fatty liver they are in how much the liver has become stiff really then what are the treatment medicines which are available according to the whatever stage they are in and these values can be different with respect to the different etiology also like for a fatty liver it is a different cut-ups for alcoholics it is different for viral markers, viral diseases it is a different thing and for also for cholesterol what we call deep jaundice patient of this different cut-ups but once this liver stiffness measurement usually that value will be between 2 to 6 but once it starts going 7 and above then we call as it has gone into the f25 doses where it is really important and we need to pay more attention for it and liver biopsy usually we do not do it in a cases in a straightforward cases of fatty liver but whenever there is a diagnostic dilemma or we think that just a fatty liver is not explaining the blood reports and the scan reports then we might consider doing a liver biopsy that is a one day procedure where the patient gets admitted for a day in hospital and with the needle we just poke into the liver and remove a piece of tissue and send it for the microscope but routinely we do not do it now because of the availability of the fibroscan and MR-elastography but whenever there is a dilemma we are not able to explain especially in young patients or the values of the liver tests are very very high sometimes we do consider doing the liver biopsy so after understanding how do you diagnose and how we understood all about this clinical manifestation now the most important part let us come to how to treat it and more than important how to prevent it from the progression to the cirrhotic stage the first and foremost for all this what we call as a metabolic syndrome which includes everything which includes diabetes which includes cholesterol issues the bad cholesterol has been high or it can be even hypertension and even it can be fatty liver it is always going to be the dietary and the lifestyle changes the dietary changes with respect to the fatty liver is basically to target your weight loss at least like say 10% of your normal weight that should be done gradually for a period of 6 months so you need to cut down your fat content refined sugars those things have to be cut down cut down the red meat like you can have a white meat and also you can have the high protein like chicken and fish but you try to cut down the red meat and most important is the exercise it is with the research it has been recommended that every day 30 minutes of aerobic exercise aerobic exercises means it includes running it includes jogging it includes cycling this kind of swimming also these aerobic exercises we should be able to do it like 30 minutes every day for at least 5 days a week so it becomes 150 minutes of aerobic regular exercises per week has been documented to decrease the progression also and it helps in reversing the fatty liver also next most important is to cut down stop smoking and stop alcohol intake whoever patient is obtained from fatty liver and always try to associate with the manage the diabetic patients and also manage like this diabetes hypertension and cholesterol issues should be strictly monitored and all these patients this screen for cardiovascular what we call like do an ECG and echo and check for those complications also next coming to the medications we have some medicines which are already approved but there is a lot of research going on in this field the next probably in a year or two we will have very good molecules to treat these fatty liver patients so we still use some of the medicines and most importantly we use vitamin A so vitamin E vitamin E is something which is very very rich in antioxidants which will help in recovering the kind of stopping that inflammation or the damage which is already going on in the liver and also it helps to kind of revert back the liver to normal stages and some of the diabetic medicines like bioglitter zone and saroglitter also after doing all the blood tests and the scanning like the fibroscan and all we assess the stages of that and based on the stages we kind of pilot these medicines on a patient to patient basis and follow up them over a period of 3 months to 6 months and repeat the values then again check for them and try to target always to have a normal liver blood test and also to decrease to revert back the values what we have got in the fibroscan and some of the medicines as I told you there are obetapolic acid and some new medicines are there but still they are in research but they are not proved as of now for day to day usage of OBD next most important I told you to take care of all the comorbidities whatever we have told and most important next comes on to obesity obesity management is the cornerstone for all this like metabolic symptoms obesity management always starts within self with respect to the exercise and food management always but in case if your BMI is very high like say more than 40 or more than 35 with all other comorbidities like sugar, BP, cholesterol and up we do have some options for these patients to explain we can cut down their weight by decreasing the size of the stomach that we can do it either endoscopically also now or we can do it laparoscopically also endoscopy it is a very simple normal procedure like the way we do normal endoscopies but yeah it will be a procedure within we do not be doing any incision or any scar on your abdomen completely an endoscopy procedure we have balloons basically we can place a balloon inside the stomach where we can significantly decrease the patient's intake of food and we can reduce the size of the stomach by doing endoscopic sleeve gastroplasty which can also be done by laparoscopy also but endoscopy feasibility is much better for a patient for a tolerance so these are the 2-3 methods like sleeve surgery, reducing the size of the stomach or placing a balloon to kind of help the patient to decrease the food intake we can help them to cut down their weight over a period of next 3-6 months and it will reflect on management of all the other conditions also it will take care of his diabetes it will take care of his hypertension it will take care of obstructive sleep apnea and it will take care of his fatty liver also now most important is what are the safety measures this patient should take see once the patient develops fatty liver and progresses to have this NASH what we call non-alcoholic steatohepatitis or even a chronic liver disease always better to vaccinate these patients after testing for hepatitis B and also for we can give a routine vaccines what we give for flu and all because these patients immunity will be on a lesser side so it's always better to vaccinate them for influenza or even pneumococcal vaccines also and these patients should strictly advise them not to take any medicines without the prescription of a doctor and after learning from them that they don't have any side effects with respect to the liver please try to avoid the over the counter medications as much as possible and third thing is even whatever medicine you are taking please watch it take a decision from your doctor then only you take this medicines next the prevention from the beginning itself like say when the patients are already like when they are healthy and active in the age group of 20s and 30 it's always better to start adopting a good healthy practices in terms of regular exercise not gaining weight and also very nutritious diet including salads, fruits very good protein sources like chicken and fish if they are non vegetarian it's always better to kind of inculcate these habits from the beginning itself so that we don't even end up developing this fatty liver and its complications this fatty liver diagnosis or even a prevention is very important because all these patients who are in the age of 20, 30 or 40s in the next 15 to 20 years if they don't take care this can progress this can progress slowly in the background to become a chronic liver disease which is a very very bad thing this can have this can lead to very poor quality of life it will have an economic burden it will have a lot of social impact so understanding all these things I think we should be able to kind of take care of it from the beginning itself try to prevent it from even developing and if we have already fatty liver so that we adopt all this lifestyle and good habit and good exercise routine daily so that we can kind of further prevent it to progression to that worst possible things what I was telling you can be decompensation of liver disease where in ascites can be there they can have blood omitting they can have altered sensorium or agitated behavior they are not able to concentrate on a day to day they should not have this increased risk for heart attacks or stroke taking care of other complications also like other diseases like diabetes, cholesterol hypertension is the same lifestyle basically that will help you to even if you are already on these medicines this routine healthy things will help you to decrease the dosage or even you can kind of discuss with your physician to kind of decrease it or even sometimes you are able to stop the medicines with a very good healthy lifestyle and also we can develop we can prevent them from progression to other non-hypatic issues like polyps in the colon or this one so with this I will try to conclude my talk about the nature of whatever the fatty liver disease is what is fatty liver then how does it present what are the tests we can do then how to manage this mostly without medicines with medicines anyway there are options whenever required we give it and always what are the preventive and safety measures we take it that is more important if you ask me now looking at some of the questions from the audience Ayush has asked he is a non-alcoholic and his SGPT level is always 55 from 3 to 4 years but says that nothing to worry see Ayush once the value of SGPT is 55 it is usually the maximum range of SGPT value is 39 in means like less than 40 once it is 55 means it is in the second stage what we call as a non-alcoholic state of hepatitis so there is some damage has happening in the liver because of the excess fat but it is always better for you to kind of get the viral markers that is hepatitis B and hepatitis C test and also get a fibroscan then fibroscan will exactly give information about how much is the fat accumulation in the liver and how much the liver has become stiff over a period of time based on that you can decide you will be started on a medicine by whichever gastroenterologist you can see or else you can adopt a healthy lifestyle measures whatever I have discussed with you and you can relook these values after the duration of 3 or 6 months so that it will help you to kind of achieve but your target should be always this LFT should become normal and the fibroscan values whatever you are going to get it after that we can tell you what are the target levels you should be able to achieve thank you so much for this knowledge about very common and very much rising in incidence this fat liver in a general public I will be happy to take back any questions if anything you can post on our facebook web page thank you thank you anasad