LIVER INVOLVEMENT IN INDIVIDUALS WITH OBESITY.pptx

hepatic steatosis

1. LIVER INVOLVEMENT IN INDIVIDUALS WITH OBESITY: BY DR A.MAHESH 1 ST YEAR PG MODERATOR : DR S.SHANKAR DM GASTROENTEROLGY

2. INTRODUCTION: Overweight and obesity are malnutrition states which harm the health of a person due to abnormal or excessive fat accumulation’ People of all ages and socioeconomic statuses are affected by obesity, which is a complex condition influenced by a myriad of social and psychological factors, The worldwide prevalence of obesity has tripled in four decades resulting in an obese population of over 650 million and is associated with more deaths worldwide than in underweight states. Obesity is now recognized as a separate disease on its own which can result in or further aggravate several conditions including type 2 diabetes mellitus, hypertension, dyslipidemia, cardiovascular disease, liver dysfunction, respiratory and musculoskeletal disorders, subfertility, psychological problems, and certain type of cancers. Nonalcoholic fatty liver disease(NAFLD) is a commonly encountered health condition that results in chronic liver disease. In India prevalence of NAFLD is between 5 and 28% of which 15-20% is contributed by the obese population.

3. Steatosis is a hallmark feature of NAFLD, which is a result of the imbalance in the rate of fatty acid uptake, de novo fatty acid synthesis, and the rate of oxidation and export of fatty acids (triglyceride and LDL) from the liver. Sometimes steatosis leads to lipotoxicity , which cause apoptosis, necrosis, generation of oxidative stress, and inflammation which over a long term, activates a fibrogenic response that eventually results in end-stage liver disease. There is primary association of adipose tissue, namely central obesity, with increased visceral fat and the pathogenesis of NAFLD, as it is more lipolytic potential compared to subcutaneous fat. There is a 20% increase in hepatocellular fat with a 1% increase in subcutaneous fat while hepatocellular fat doubles with a1% increase in intra-abdominal adipose tissue. The presence of NAFLD is closely associated with MS and NAFLD is also a strong determent of future development of MS.

4. NONALCOHOLIC FATTY LIVER DISEASE: NAFLD is considered the hepatic manifestation of metabolic syndrome and shares a strong association with type2 diabetes mellitus, OSA, and cardiovascular disease (CVD). Although CVD is the leading cause of death in patients with NAFLD, the subset of patients who meet histopathological criteria for NASH are those at greater risk of liver related morbidity and mortality. DEFINITIONS AND ASSOCIATIONS: Macro vesicular fat accumulation in > 5% of hepatocytes is the defining feature of NAFLD.

5. HISTOLOGICAL FEATURES OF NAFLD : Alcohol –associated steatosis and steatohepatitis are histologically indistinguishable from NASH, although expert pathologists describe more fibro-occlusive venous lesions and bile stasis in alcohol associated steatohepatitis.

6. Paediatric NAFLD is somewhat distinct histologic entity marked by portal based chronic inflammation and fibrosis with less frequent findings of hepatocyte ballooning and Mallory- denk bodies PATHOGENESIS: The “2 hit hypothesis” proposed by Day and colleagues has provided a framework for our current understanding of the increasingly complicated pathway to hepatic steatosis, steatohepatitis and fibrosis Dysregulation of fatty acid metabolism leads to steatosis, which is associated with several cellular adaptations and altered signalling pathways that render hepatocytes vulnerable to 2 hit. The 2 hit may be 1 or more environmental or genetic perturbations that cause hepatocytes necrosis and inflammation.

7. DIAGNOSTIC APPROACH TO PATIENTS WITH SUSPECTED NAFLD:

8. BARD SCORE, NAFLD SCORE AND Fib4 score :

9. STUDY DESIGN : Observational cross sectional study STUDY DURATION : 1 year PLACE : SSG hospital, Vadodara. Inclusion criteria : Age above 18 years BMI >25kg/m2 for both genders ( class 1 =25-29.9kg/m2, class 2 = 30- 34.9kg/m2, class 3 = 35-39,9kg/m2) Abdominal obesity (WC >90cm in males and >68.5cm in females, WHR >0.95 in males and >0.80 in females) . Exclusion criteria : Age below 18 years Chronic alcoholics and alcoholic liver disease Viral hepatitis infection Drug induced hepatitis Genetic liver disease Diabetes mellitus Hypertension Pregnant/postpartum females

10. LIMITATIONS : This is a cross sectional study and hence, follow-up of patients is not done. The patient population is largely limited to western India and hence, further multicentre studies are required to asses the generalizability of our results. Non-availability of fibro scan. CONCLUSION: I n the present study female gender, especially in the postmenopausal state and sedentary life style were found to be risk factors for development of liver disease. The risk of liver disease increase with increasing BMI, WC>100cm in males, >95cm in females, and neck circumference >40cm. Abdominal obesity in women can be considered has an independent risk factor for NAFLD. Raised CRP and SGOT could be used as a markers for liver disease in obesity. Triglycerides, LDL, cholesterol, FBS, PP2BS were positively correlated while HDL, serum protiens , and albumin were negatively correlated with liver disease. NAFLD fibrosis score and BARD score has significant association with liver disease and hence can be used to non invasively asses the liver involvement in obese individuals. Those with MS have very high risk of developing NAFLD.

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