The Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease, Nonalcoholic Steato Hepatitis, Cirrhosis, & Hepatoma

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Peter Buch, MD, AGAF, FACP Related seminars and products

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Peter Buch, MD, AGAF, FACP, is a double board-certified clinical gastroenterologist with 35 years of experience, leads a team that treats all GI conditions, sits on editorial boards for numerous professional journals, is a highly sought-after international presenter, and hosts ReachMD GI Insights, a podcast that highlights the latest developments in gastroenterology. 
 

Dr. Buch has a passion for teaching. His style is case-based, practical, interactive, and evidence supported. Dr. Buch’s expertise has been shared with experienced clinicians and advanced-level students. He teaches at the University of Connecticut School of Medicine, the University of New England College of Osteopathic Medicine, and the Frank H Netter School of Medicine/Quinnipiac University. 

 

Speaker Disclosures:
Financial: Dr. Peter S. Buch has employment relationships with the University of Connecticut School of Medicine, the University of New England College of Osteopathic Medicine, and the Frank H Netter, MD School of Medicine. He receives compensation as a professional speaker and is a podcast host with ReachMD/GI Insight. Dr. Buch receives a speaking honorarium and recording royalties from PESI, Inc. He has no relevant financial relationships with ineligible organizations.
Non-financial: Dr. Peter S. Buch serves on the FDA and Patient Care Committees at the American College of Gastroenterology. He serves as an editor of peer-reviewed journals. He is a member of the International Association of Medical Science Educators, the AGA Academy of Educators, the American Gastroenterological Association (AGAF), the American College of Physicians (FACP), the Hartford County Medical Association, the American College of Gastroenterology (FACG), and the Connecticut State Medical Society.

 

Content Disclosure:

Dr. Buch references the use of antidepressants for Irritable Bowel Syndrome, and the controversial use of Fibrotest to evaluate patients with fatty liver disease who may have fibrosis of the liver. Dr. Buch indicates he wishes to present a fair and balanced approach to practitioners regarding such practices.

 

 

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Objectives

1. Differentiate clinically between Nonalcoholic Fatty Liver Disease (NAFLD), Nonalcoholic Fatty Liver (NAFL) and Nonalcoholic Steato Hepatitis (NASH). 
2. Determine at risk individuals for NAFL and NASH. 
3. Measure progression of disease from NAFL to NASH to cirrhosis. 
4. Evaluate the appropriate treatment options. 

Outline

Changing Terminology 

• Metabolic Dysfunction Associated Steatotic Liver Disease (MASLD) 
• Metabolic Dysfunction Associated Steatohepatitis (MASH) 

Evaluation of a Patient with Mildly Elevated Liver Function Tests 

• Alcohol ingestion 
• Medication use 
• Herbs 
• Illicit drug use 

Necessary Testing 

• CBC 
• HBsAg, HBcAb, HBsAb 
• HCV Ab and RNA confirmation 
• Fe/TIBC and Ferritin 
• Ultrasound of biliary tree and pancreas     

Risk Factors for Nonalcoholic Fatty Liver Disease (NAFLD) 

• Obesity 
• Type 2 diabetes 
• Dyslipidemia 
• High blood pressure 
• Metabolic syndrome 
• Dramatic increase in obesity and NAFLD expected by 2030 

NAFLD Diagnosis 

• First - rule out other causes of liver disease 
• Especially consider alcohol 
• Medications 
• Food supplements 
• Hepatitis B, C 

Techniques to Determine Alcohol Consumption 

• CAGE questions 
• AUDIT questions 
• Nonjudgmental zone 

Usefulness of Labs to Determine Alcohol Consumption 

• AST:ALT ratio 
• GGTP 
• PEth test 

Importance of Nonalcoholic Steatohepatitis (NASH) in Primary Care 

• Risk of cirrhosis 
• NASH will become the major cause of hepatocellular cancer by 2025 

Progression of NAFLD 

• From NAFLD to NASH to cirrhosis to hepatoma 
• Only a portion of patients progress to the next stage 

Non-Invasive Tests to Check for Progression of Liver Disease 

• Fibrosis-4 Score (FIB-4) 
• What it is and how it is utilized? 
• What is the sensitivity and specificity? 
• Fibrosure/Fibrotest 
• ELF Test 

Imaging in Nonalcoholic Fatty Liver Disease  

• Ultrasound 
• Fibroscan 
• Magnetic Resonance Elastography 

When is a Liver Biopsy Still Needed to Make the Diagnosis 

• If there is more than one liver disease 
• If diagnosis is in doubt  

Why Patients with NAFLD have a 10% Higher Mortality Rate 

• Cardiovascular disease 
• Cirrhosis/hepatoma is not the main cause of early morbidity/mortality 

Standard Ways of Treating NAFLD  

• Exercise and weight loss 
• Hepatitis A and B vaccinations 
• Avoid alcohol 
• Coffee as a treatment modality? 
• Which diet is best? 
• Mediterranean 
• Ketogenic 

How do we approach NAFLD in lean individuals? 

• Weight loss? 
• Exercise? 

Medications used to treat NASH 

• Vitamin E 
• Studies to date 
• Risks/benefits/alternatives 
• Pioglitazone 
• Risks/benefits/alternatives 
• GLP-1 receptor agonists 
• Effective for weight loss 
• Not yet proven to reduce fibrosis in NASH 
• Improvement in cardiovascular mortality 
• Renal dysfunction 

Bariatric Surgery for NASH 

• The data 
• When it is covered by 3rd party payers 

Target Audience

• Nurses
• Physicians