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Dr Manoj K S, MD RD, DNB RD , DMRD .
Pioneer Metro Scans ,Trivandrum ,KIMS HEALTH ,Trivandrum
Insights from a single centre
A Comprehensive Fatty Liver
Program
Statistics
Aetiology
New terminology-AASLD
Steps in Evaluation
Evidence & Studies
Adv tech, Mobile Apps,AI
SLD Control Programs
World Stats
The Numbers
NAFLD is the most common chronic liver disease in the U.S.,
affecting roughly 25% of adults.
Most people with NAFLD have a fatty liver without
inflammation. However, 20% of people with NAFLD develop
NASH—liver inflammation that can seriously harm the organ.
It is estimated that over 115 million adults around the world are
impacted by NASH.About 5% of the US population, or about 15
million Americans, develops NASH .
Nonalcoholic fatty liver disease (NAFLD) is
a leading cause of liver disease
worldwide. It affects 25% of the global
adult population, with a range of 13.5% in
Africa and 31.8% in the Middle East
By 2030, the number of people in China with NASH is
expected to reach 48.26 million.
In Europe, Spain had 1.8 million cases in 2016, with the
number expected to increase 49% by 2030. German
cases of NASH stood at 3.33 million in 2016 and are
projected to climb 43% by 2030.
The Numbers -India
Globally and in Asia, around 25–29% of
the general population has NAFLD.4–7 In
India, the prevalence of NAFLD in the
general population varies from 9 to 53%
with geographical and rural–urban
differences in the prevalence.8–10 A
recent meta-analysis of studies published
from India reported a NAFLD prevalence
of 38.6% in adults and 35.4% in children.1
Indian National Association for Study of the Liver (INASL) Guidance Paper on Nomenclature, Diagnosis and
Treatment of Nonalcoholic Fatty Liver Disease (NAFLD). Ajay Duseja *, S. P. Singh et al Indian National
Association for Study of the Liver. Published by Elsevier B.V. All rights reserved. Journal of Clinical and
Experimental Hepatology | March–April 2023 | Vol. 13 | No. 2 | 273–302.
https://doi.org/10.1016/j.jceh.2022.11.014 © 2022
The NAFLD prevalence within this population was 49.8%
which is significantly higher than the global pooled
prevalence of 25%.
Aetiology
NASH -Progress
NAFLD is an overarching term that includes all disease grades and stages and
refers to a population in which ≥ 5% of hepatocytes display macrovesicular
steatosis in the absence of a readily identified alternative cause of steatosis (eg,
medications, starvation, monogenic disorders) in individuals who drink little or no
alcohol (defined as < 20 g/d for women and <30 g/d for men).
The spectrum of disease includes NAFL, characterized by macrovesicular hepatic
steatosis that may be accompanied by mild inflammation, and NASH, which is
additionally characterized by the presence of inflammation and cellular injury
(ballooning), with or without fibrosis, and finally cirrhosis, which is characterized by
bands of fibrous septa leading to the formation of cirrhotic nodules, in which the earlier
features of NASH may no longer be fully appreciated on a liver biopsy.
GUIDANCE PAPERS 2023
The NAFLD nomenclature is changing.
Consensus Nomenclature
7
Hepatic steatosis is defined as intracellular fat accumulation in the liver that constitutes at
least 5% of liver weight. Prolonged hepatic lipid storage may lead to liver metabolic
dysfunction, inflammation, and advanced forms of fatty liver disease
The NAFLD nomenclature is changing.
8
The NAFLD nomenclature is changing.
Decision Support Tool
9
Abnormal LFT No significant alcohol consumption
History & Examination Exclude drug induced liver injury
Exclude other aetiologies of liver
disease
Non Invasive Liver Tests Blood tests (raised GGT,AST,WST
Ultrasound confirmation of liver
steatosis
Investigate severity of liver fibrosis Enhanced liver fibrosis (ELF)
Magnetic resonance elastography
(MRE)
VCTE, SWE ,ARFI
Fibrosis-4 ( FIB-4) ,Fibrotest,AST
Platelet
ratio (APRI)
Liver Biopsy (NAS, SAF,NASH CRN NAFLD activity
score Score )
NASH
NAFLD
IMAGING
A simplified
Algorithm for
NASH diagnosis
NASH Clinical Research Network histological scoring system
NITs have emerged as
valuable tools for
predicting adverse liver
related outcomes -hitherto
an important function of
liver biopsies
Liver biopsies for grading
and staging of NASH are not
consistently performed in
clinical practice and should
be reserved for specific
clinical scenarios
AASLD Practice Guidelines on
the clinical assessment and
management of NAFLD
Hepatology 2023;77:1797-1835
Risk stratification and management algorithm in nonalcoholic fatty liver disease.
Shearwave
Elastography
has come in as
the deciding NIT
Serum Biomarkers
Repeat NITs in 3-6
months
Indian National Association for
Study of the Liver (INASL)
Guidance Paper on
Nomenclature, Diagnosis and
Treatment of Nonalcoholic Fatty
Liver Disease (NAFLD). Ajay
Duseja *, S. P. Singh et al Indian
National Association for Study of
the Liver. Published by Elsevier
B.V. All rights reserved. Journal of
Clinical and Experimental
Hepatology | March–April 2023 |
Vol. 13 | No. 2 | 273–302.
https://doi.org/10.1016/j.jceh.2022
.11.014 © 2022
Clinical Care Pathway for the Risk Stratification and Management of Patients With Nonalcoholic Fatty Liver Disease
Fasiha Kanwal Jay H. Shubrook Leon A. Adams Hashem B. El-Serag Kenneth Cusi
Published:September 20, 2021DOI:https://doi.org/10.1053/j.gastro.2021.07.049
> 50 Crore Indians have
Fatty Liver disease
> 50 Crore Indians are
Obese
India has a 40.3% obesity
prevalence rate. This rate varies
by region, with the south having
the highest rate at 46.51% and
the east having the lowest at
32.96%. Obesity is also higher
among women than men, and in
urban areas than rural areas
Centres for “Comprehensive Fatty Liver Assessment”need to be developed
A Comprehensive
Fatty Liver
Program
“Despite the astoundingly high burden of
NAFLD in India, only a fraction will ever
develop clinically significant liver disease.
Thus, risk stratification and guidance on
referral using noninvasive tests is the need of
the hour for optimal utilization of limited health
resources in the country. “
© 2022 Indian National Association for Study of the Liver.
https://doi.org/10.1016/j.jceh.2022.11.014
COMPONENTS
The biggest advantage of NITs is their ability to rule-in or rule-out significant fibrosis
(>F2 fibrosis), advanced fibrosis (F3-4 fibrosis), and cirrhosis (F4 fibrosis). Because of
the huge burden of NAFLD globally and in India, this stratification is very important
in deciding the referral of patients from primary and secondary healthcare levels to
tertiary care level.
Indian National Association for Study of the Liver (INASL) Guidance Paper on Nomenclature, Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease (NAFLD). Ajay Duseja *, S.
P. Singh et al Indian National Association for Study of the Liver. Published by Elsevier B.V. All rights reserved. Journal of Clinical and Experimental Hepatology | March–April 2023 |
Vol. 13 | No. 2 | 273–302. https://doi.org/10.1016/j.jceh.2022.11.014 © 2022
Questionnaire
Physical measurements
Laboratory investigations
Ultrasound and Shearwave Elastography
MRI Fat quantification and MR Elastography
Serum and Imaging Biomarkers
Essential Steps
Sarcopenia ,Total Abdominal Muscle mass (TAM)
Risk scoring with all the above data
Mobile App and Online Data
VAT/SAT quantification
Additional Steps
Package -1
1. Questionnaire for preparing personal advise on Diet,
Exercise etc
2. Labs, Physical measurements
3. Ultrasound and Shearwave Elastography
4. Biomarkers
5. Risk scoring with all the above data
Visceral adipose tissue (VAT/SCAT)
6. Biomarkers
7. Risk scoring with all the above data
Package - 2
1. Questionnaire for preparing personal advise on
Diet, Exercise etc
2. Labs, Physical measurements
3. Ultrasound and Shearwave
4. MRI Fat quantification
5. Biomarkers
6. Risk scoring with all the above data
Visceral adipose tissue and Subcutaneous
adipose tissue
Package-3
1. Questionnaire for preparing personal advise on Diet, Exercise etc
2. Labs, Physical measurements
3. Ultrasound and Shearwave Elastography
4. MRI Fat quantification and MR Elastography
5. Visceral adipose tissue and Subcutaneous adipose tissue (VAT/SCAT)
6. Biomarkers
7. Risk scoring with all the above data
FATTY LIVER PROGRAM - PACKAGES
Package - 4
1. Questionnaire for preparing personal advise on Diet, Exercise
etc.
2. Labs, Physical measurements
3. Ultrasound and Shearwave Elastography
4. MRI Fat quantification and MR Elastography
5. Visceral adipose tissue and Subcutaneous adipose tissue
(VAT/SCAT)
6. Sarcopenia. Total abdominal muscle (TAM)
7. Biomarkers
8. Risk scoring with all the above data
9. Physician consultation
10. Apps
11. DEXA -whole body muscle / fat estimation
QUESTIONNAIRE
Comprehensive Fatty Liver Program
Patient Questionnaire
Beverages and Supplements:
What kind of beverages do you prefer to drink mostly?
Do you take any vitamin/mineral/nutritional supplements?
Do you take snacks in between meals?
Do you add sugar to meals?
Exercise and Physical Activity:
Do you exercise/practice any specific program?
Which physical exercise do you practice, and for how many hours
each time?
What are your personal barriers to exercise?
Are you able to carry out self-care activities yourself, or do you
feel sick?
Do you walk for at least 30 minutes daily/sometimes/never?
What household activities do you do at home?
What are your leisure activities?
If working, does your work require any physical activities?
How many days did you engage in moderate physical activities
like gardening in the past week?
Dietary Habits:
How many times a week do you eat bakery products?
How many times a week do you eat out?
What type of eating places do you frequently visit?
Do you skip meals? If yes, which one do you usually
skip?
What do you prefer to eat for dinner?
Do you control your diet as part of any ritual?
What food types are included in your diet
(vegetables, fruits, chicken, other meats)?
Habits and Lifestyle:
Do you smoke? If yes, how many cigarettes per day?
Do you drink alcohol? If yes, how often and how many drinks on
average?
How many hours do you sleep each night?
Do you snore loudly while sleeping?
Do you have any sleep disorders?
Do you feel drowsy during the daytime?
Medical History:
Do you have hypertension?
Do you have Diabetes mellitus?
Any history of dyslipidemia now?
Have you checked your cholesterol level
recently? Was it normal?
Have you ever had hepatitis?
Did you have any cardiovascular diseases
like heart attack or stroke?
Did you have any history of liver diseases?
Do you intake any medication/drug on a
regular basis?
Do you have a history of acanthosis
nigricans?
Have you ever had obesity problems?
Do you have a past history of any
metabolic syndrome such as
high blood pressure, high blood sugar,
excess body fat around the
waist, and abnormal cholesterol levels?
Family History:
Do any of your relatives suffer from diabetes mellitus?
Do any of your close relatives have hypertension?
Do any of your close relatives have cholesterol issues?
Do any of your relatives have cardiovascular diseases?
Do any of your close relatives suffer from any liver disease?
Through a Tablet the
Questionnaire
can be administered
Printed
Questionnaire
can be used
The
Questionnaire
can be administered
in person with trained staff
INVESTIGATIONS
Height
Weight
BMI
W H Ratio
Blood Pressure
Heart rate
PHYSICAL MEASUREMENTS
AST (SGOT)
ALT (SGPT)
GGT
GLOBULIN
ALBUMIN
A/G RATIO
BILIRUBIN
CBC
RBC PARAMETERS
WBC PARAMETERS
WBC PARAMETERS
PLATELET PARAMETERS
FBS/ PPBS
Lipid Profile
CHOLESTEROL
TRIGLYCERIDE
HDL
LDL
VLDL
HbA1c
Fasting serum insulin
GGT
BUN
S.Creatinine
LDH
INR
S.Ferritin
S.Ceruloplasmin
HOMA-IR
LAB TESTS
Fatty Liver - Special Lab
Tests
Homocysteine
High sensitive C-reactive protein (hsCRP)
Apolipoprotein A-I
Apolipoprotein B
Lp(a)-lipoprotein
Tumour necrosis factor-alfa (TNF-α)
Adiponectin l
Cytokeratin-18 (CK-18) fragment
Type IV collagen 7S domain
Hyaluronic acid (HA)
Fasting C-peptide
IMAGING
NORMAL
NAFLD GRADE I
NAFLD GRADE II
NAFLD GRADE III
NASH
CLD
ULTRASOUND
Probable NASH
NASH/Early CLD
cACLD
SHEARWAVE ELASTOGRAPHY
Total fat area TAT
Visceral Fat area VAT
Subcutanous fat area SAT
CT/MR BASED VAT/SAT/TAT
Grade 0: PDFF less than 6.4%
Grade 1 PDFF equal to or greater than 6.4% and less than 16.3%
Grade 2 PDFF equal to or greater than 16.3% and less than 21.7%
Grade 3 PDFF equal to or greater than 21.7%
MR FAT QUANTIFICATION
MR Elastographic Stiffness Stage of Fibrosis
Less than 2.5 Normal
2.5–2.9 Normal or chronic inflammation
2.9–3.5 Stage 1–2
3.5 - 4.0 Stage 2-3
4.0 - 5.0 Stage 3-4
More than 5.0 Stage 4
MR ELASTOGRAPHY
TECHNIQUES
U L T R A S O U N D S C A N
S H E A R W A V E E L A S T O G R A P H Y
SWE
HIGH RESOLUTION SONOGRAPHY
HIGH RESOLUTION SONOGRAPHY
HIGH RESOLUTION SONOGRAPHY
HIGH RESOLUTION SONOGRAPHY
MRI PDFF & MR ELASTOGRAPHY
MRI PDFF
PDFF Calculation Method
• Placement of one large single-section ROI in
the anterior, posterior, medial, and lateral
segments of the liver, avoiding bigger vessels
and bile ducts, has been proposed as an
acceptable alternative
Radiology: Volume 301: Number 2—November 2021 n radiology.rsna.org
MR FAT QUANTIFICATION
Sequence
Name TR TE TI FOV THICKNESS FREQUENCY PHASE NEX BANDWIDTH Scan Time Min
Ideal IQ-MR
PDFF Axial 6.5 3 42 10 160 160 1 111.1 01:00
T2 SSFSE
Coronal 1000 1.9 38 4 352 224 1 125 03:30
Prep scan 3 plane Localiser 02:00
Patient In-
Out time 03: 00
Total 09: 30
MR Fat quantification Sequences
10 MINUTE MRI : MR PDFF & MR ELASTOGRAPHY
MR PDFF Fat quantification -
Segment wise analysis
ROIs Placed in various segments and tabulated to find out average
Segment VII Segment VIII Segment V Segment VI
Segment II Segment III Segment IV Segment I
Right lobe Left lobe
Total Average
MR PDFF Fat quantification -
Segment wise analysis
Segment wise analysis helps to find out the regional variability , relatively spared areas etc
SLD Grading
Fatty liver was graded with PDFF according to the following
criteria:
Grade 0: PDFF less than 6.4%,
Grade 1: PDFF equal to or greater than 6.4% and less than 16.3%,
Grade 2: PDFF equal to or greater than 16.3% and less than 21.7%
Grade 3: PDFF equal to or greater than 21.7%
Ref : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3632805/
RESULTS
In more than 95 % subjects , the study could be completed in less than 10 minutes .
SLD
Grade I in 26 =54.1%
Grade II in 12 = 25%
Grade III in 10 = 20.8%
Two patients excluded after study since features of CLD noted
Higher number of patients with SLD Grade III observed , may be due to the clinical stetting -need not
reflect actual prevalence in population .
CT FAT QUANTIFICATION
LAI LIVER ATTENUATION INDEX
A non-contrast enhanced or plain CT scan
(NECT) diagnoses and quantifies HS based
on the attenuation values of spleen and liver
in HU.
This is called the liver attenuation index
(LAI).
LAI of above +5 indicates a normal liver,
while a LAI of 0 to −5 is indicative of 10–30%
steatosis .
NECT is more accurate than other CT
modalities. However, increased copper, iron,
or glycogen content, edema and inflammation
may lead to false-negative results
MR ELASTOGRAPHY
C T V A T / S A T
BIOMARKERS
NAFLD FIBROSIS SCORE (NFS)
NAFLD fibrosis score (NFS), is a composite score of age, hyperglycemia, body mass index, platelet
count, albumin, and aspartate aminotransferase and alanine aminotransferase (AST/ ALT) ratio and
was found to independently identify NAFLD patients with and without advanced fibrosis at initial
NAFLD diagnosis
NAFLD fibrosis score = -1.675 + 0.037 × age (year) + 0.094 × BMI (kg/m2) + 1.13 × IFG/diabetes
(yes = 1, no = 0) + 0.99 × AST/ALT ratio - 0.013 × platelet count (×109/L) - 0.66 × albumin (g/dL)[9].
People who have a NAFLD fibrosis score above 0.676 are the most likely to have advanced liver
fibrosis. If you have a score below -1.455, you're unlikely to have advanced liver fibrosis. The scores
in between are considered indeterminate
NAFLD FIBROSIS SCORE (NFS)
NAFLD Score < -1.455 = F0-F2
NAFLD Score -1.455 – 0.675 = indeterminate score
NAFLD Score > 0.675 = F3-F4
http://gihep.com/calculators/hepatology/nafld-fibrosis-score/
https://www.mdcalc.com/calc/3081/nafld-non-alcoholic-fatty-liver-
disease-fibrosis-score
FATTY LIVER INDEX (FLI)
The fatty liver index (FLI), which is an algorithm based on waist circumference, body mass
index (BMI), triglyceride, and gamma-
glutamyl-transferase (GGT), was initially developed to detect fatty liver in Western countries
FLI was calculated using the following formula:
FLI = [e(0.953 × ln(triglycerides) + 0.139 × BMI + 0.718 × ln(γGTP) + 0.053 × WC − 15.745)]/ [1 +
e(0.953 ×ln(triglycerides) +0.139 × BMI + 0.718 × ln(γGTP) + 0.053 × WC − 15.745)] × 100.
Repeated evaluations of NAFLD status based on FLI measurements could help physicians identify higher-risk groups in terms of mortality, MI, and
stroke. The association between FLI worsening or improvement and outcomes also suggests clinical benefits of the prevention and treatment of
NAFLD.
FIBROSIS 4 SCORE (FIB-4 )
The Fibrosis 4 score is a non-invasive scoring system based on several laboratory tests
(AST/ALT/Platelets) that help to non- invasively estimate the amount of scarring in the liver. This
score has been studied in liver disease due to Hepatitis C and NASH.
FIB-4 below 1.30 is considered as low-risk for advanced fibrosis; a value of FIB-4 over 2.67
is considered as high-risk for advanced fibrosis; and FIB-4 values between 1.30 and 2.67
are considered as intermediate-risk of advanced fibrosis for ages 36-64. For ages > 64 the cut-
off for low-risk goes to < 2.
http://gihep.com/calculators/hepatology/fibrosis-4-score/
https://www.mdcalc.com/calc/2200/fibrosis-4-fib-4-index-liver- fibrosis
APRI SCORE
APRI has been previously validated as an efficient score to predict liver fibrosis in viral hepatitis patients
with a cut-off of 0.5 for fibrosis and 1.5 for cirrhosis.
APRI score interpretation:
Significant fibrosis: APRI threshold of 0.7 (77% sensitive and
72% specific)
Severe fibrosis: APRI threshold of 1.0 (61% sensitive and 64%
specific)
Cirrhosis: APRI threshold of 1.0 (76% sensitive and 72%
specific).
APRI SCORE
There are no universal cut-off values for the APRI score, as it is not
sufficiently sensitive to rule out significant diseases (especially with
midrange values). The lower the APRI score (<0.5), the greater the
negative predictive value, and ability to rule out cirrhosis.
The higher the value (>1.5) the greater the positive predictive value and ability to rule in cirrhosis
https://www.mdcalc.com/calc/3094/ast-platelet-ratio-index-apri
https://www.omnicalculator.com/health/apri
THE COMPOSITE INDEX
SERUM BIOMARKERS
SCORE
NAFLD Fibrosis score
Fatty liver index
FIB-4
(APRI) AST to Platelet Ratio
TOTAL
FATTY LIVER : COMPOSITE INDEX
IMAGING BIOMARKERS -MODALITY
SCORE
ULTRASOUND
SHEARWAVE ELASTOGRAPHY
CT/MR BASED VAT/SAT/TAT
MR FAT QUANTIFICATION
MR ELASTOGRAPHY
TOTAL
FATTY LIVER : COMPOSITE INDEX
QUESTIONNAIRE BASED SCORE
DIET
EXERCISE
HABITS
MEDICAL HISTORY
FAMILY HISTORY
TOTAL
FATTY LIVER : COMPOSITE INDEX
COMPREHENSIVE SCORE CARD
App for combining the various tests and results
https://life-bee.com/
MOBILE APP
LITERATURE REVIEW
The Combination of MR
Elastography and Proton Density
Fat Fraction Improves Diagnosis of
Nonalcoholic Steatohepatitis
Salem Alsaqal, MD et al
J. MAGN. RESON. IMAGING 2022;56:368–379
© 2021 The Authors. Journal of Magnetic Resonance Imaging published by
Wiley Periodicals LLC on behalf of
International Society for Magnetic Resonance in Medicine
Magnetic resonance-based
biomarkers in nonalcoholic fatty
liver disease and nonalcoholic
steatohepatitis
Cyrielle Caussy, Lars Johansson
Endocrinol Diab Metab. 2020;3:e00134.
| 1 of 9 https://doi.org/10.1002/edm2.134
Multiparametric MRI in
Patients With Nonalcoholic
Fatty Liver Disease
Jelte J. Schaapman, MD et al
© 2020 The Authors. Journal of Magnetic Resonance Imaging
J. MAGN. RESON. IMAGING 2021;53:1623–1631.
. DOI: 10.1002/jmri.27292
Emmanuel Anandraj Selvaraj etal
Journal of Hepatology 2021 vol. 75 j 770–785
Diagnostic accuracy of elastography and magnetic
resonance imaging in patients with NAFLD
• The following index tests were assessed in this
review: VCTE (FibroScan®, Echosens, Paris,
France), pSWE (Virtual Touch Quantification
(VTQ); Siemens Healthineers, Erlangen,
Germany), 2DSWE (Aixplorer®; SuperSonic
Imagine, Aix-enProvence, France), MRE
(Resoundant, Rochester, USA), cT1 measured
using LMS (Perspectum, Oxford, UK), DWI, and
deMIL
Diagnostic accuracy of elastography and magnetic
resonance imaging in patients with NAFLD
• In conclusion, in patients with NAFLD where liver stiffness can
be measured successfully, VCTE, MRE, pSWE and 2DSWE have
a good diagnostic accuracy for the assessment of fibrosis, but
only MRE and pSWE meet the minimum acceptable criteria of
at least 80% sensitivity and specificity for the diagnosis of
advanced fibrosis. These promising results however, are likely
tobe overestimates of the true diagnostic accuracy as
intention-todiagnose analyses and validation of pre-specified
cut-offs are lacking from the literature. Future studies, like the
LITMUS Imaging Study being conducted in Europe and the USA
currently, should also evaluate the newer 2DSWE and MRI
techniques, and provide data on head-to-head comparisons of
the various techniques
https://www.jci.org/articles/view/162513
https://pubs.rsna.org/doi/10.1148/radiol.231007
AI
NEW TECHNOLOGIES
HEPATORENAL RATIO QUANTITATIVE
ULTRASOUND METHOD
ATTENUATION COEFFICIENT QUANTITATIVE
ULTRASOUND METHODS
TECHNIQUES BASED ON CALCULATION OF
THE ATTENUATION COEFFICIENT
CAP
Controlled attenuation parameter
2-D attenuation imaging (ATI)
Attenuation coefficient (ATT)
US-guided attenuation parameter
(UGAP)
US-derived fat fraction (UDFF)
Fibroscan system (Echosens, Paris,
France)
Aplio i800 systems (Canon Medical
Systems, Japan)
Aloka-Arietta systems (Fujifilm)
LOGIQ E9 series (General Electric,
USA)
Acuson S3000 or Sequoia US platform
(Siemens Healthineers)
ULTRASOUND-GUIDED ATTENUATION
PARAMETER (UGAP)
Ultrasound-guided attenuation parameter (UGAP) technology from GE
Controlled attenuation parameter (CAP) by Echosens
Attenuation imaging (ATI) technique by Canon
ATT technology from Hitachi.
EXTENDED SPECTRUM
EXTENDED SPECTRUM : EVALUATION OF CARDIO-
METABOLIC PROFILE
• Cardiac computed tomography (CCT)
for
• Carotid artery intima-media thickness (IMT)
• Epicardial adipose tissue Volume (EAT
volume )
EXTENDED SPECTRUM : OBESITY & BODY COMPOSITION
DEXA CT
MRI
EXTENDED SPECTRUM : GENOMICS
Genetic variant Effect
PNPLA3 I148M Increases hepatic fat content, and risk of hepatic steatosis,
fibrosis, and HCC
TM6SF2 E167K Increases levels of hepatic triglyceride content, ALT, and
increased risk of hepatic fibrosis
MBOAT7 rs614738 Increases hepatic triglyceride content, and risk of hepatic
steatosis, fibrosis, and HCC
GCKR rs780094 Increased hepatic steatosis and fibrosis
F A T T Y L I V E R V I D E O S
F A T T Y L I V E R H A N D B O O K
A N D R O I D M O B I L E A P P
Learning Centre
You Tube Videos
S L D C O N T R O L
P R O G R A M S
AI Based Programs are emerging
4 BASKETS
SUBSTITUTE CEREALS
PLANT PROTEINS
ADD MORE VEGETABLES
HEALTHY OILS,ANIMAL PROTEINS ,
NUTS,FRUITS ,HEALTHY SNACKS
DIFFERENT TYPE ACTIVITIES
AEROBIC EXERCISES
WEIGHT TRAINING/MUSCLE BUILDING
RELAXATION /FUN NATURE THERAPY
Shearwave Elastography holds the key
MRI Fat Quantification/MRE is the best
Fatty Liver Program can be introduced in any hospital /institution
Followup is essential
A Diet/Exercise/Relaxation program should be
an integral part
USG having SWE and utilising Serum Biomarkers
Acknowledgements
IMA Trivandrum Branch
IMA National Conference Org Committee
Dr Sreejith N Kumar
Dr N.Sulphi
Dr Vijayakrishnan
Dr Althaf Ali
Pioneer Metro Scans ,Tvm
KIMS Health Tvm
Thank You ALL

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A Comprehensive Fatty Liver Program .pptx

  • 1. Dr Manoj K S, MD RD, DNB RD , DMRD . Pioneer Metro Scans ,Trivandrum ,KIMS HEALTH ,Trivandrum Insights from a single centre A Comprehensive Fatty Liver Program
  • 2. Statistics Aetiology New terminology-AASLD Steps in Evaluation Evidence & Studies Adv tech, Mobile Apps,AI SLD Control Programs
  • 3. World Stats The Numbers NAFLD is the most common chronic liver disease in the U.S., affecting roughly 25% of adults. Most people with NAFLD have a fatty liver without inflammation. However, 20% of people with NAFLD develop NASH—liver inflammation that can seriously harm the organ. It is estimated that over 115 million adults around the world are impacted by NASH.About 5% of the US population, or about 15 million Americans, develops NASH . Nonalcoholic fatty liver disease (NAFLD) is a leading cause of liver disease worldwide. It affects 25% of the global adult population, with a range of 13.5% in Africa and 31.8% in the Middle East By 2030, the number of people in China with NASH is expected to reach 48.26 million. In Europe, Spain had 1.8 million cases in 2016, with the number expected to increase 49% by 2030. German cases of NASH stood at 3.33 million in 2016 and are projected to climb 43% by 2030.
  • 4. The Numbers -India Globally and in Asia, around 25–29% of the general population has NAFLD.4–7 In India, the prevalence of NAFLD in the general population varies from 9 to 53% with geographical and rural–urban differences in the prevalence.8–10 A recent meta-analysis of studies published from India reported a NAFLD prevalence of 38.6% in adults and 35.4% in children.1 Indian National Association for Study of the Liver (INASL) Guidance Paper on Nomenclature, Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease (NAFLD). Ajay Duseja *, S. P. Singh et al Indian National Association for Study of the Liver. Published by Elsevier B.V. All rights reserved. Journal of Clinical and Experimental Hepatology | March–April 2023 | Vol. 13 | No. 2 | 273–302. https://doi.org/10.1016/j.jceh.2022.11.014 © 2022 The NAFLD prevalence within this population was 49.8% which is significantly higher than the global pooled prevalence of 25%.
  • 5. Aetiology NASH -Progress NAFLD is an overarching term that includes all disease grades and stages and refers to a population in which ≥ 5% of hepatocytes display macrovesicular steatosis in the absence of a readily identified alternative cause of steatosis (eg, medications, starvation, monogenic disorders) in individuals who drink little or no alcohol (defined as < 20 g/d for women and <30 g/d for men). The spectrum of disease includes NAFL, characterized by macrovesicular hepatic steatosis that may be accompanied by mild inflammation, and NASH, which is additionally characterized by the presence of inflammation and cellular injury (ballooning), with or without fibrosis, and finally cirrhosis, which is characterized by bands of fibrous septa leading to the formation of cirrhotic nodules, in which the earlier features of NASH may no longer be fully appreciated on a liver biopsy.
  • 7. The NAFLD nomenclature is changing. Consensus Nomenclature 7 Hepatic steatosis is defined as intracellular fat accumulation in the liver that constitutes at least 5% of liver weight. Prolonged hepatic lipid storage may lead to liver metabolic dysfunction, inflammation, and advanced forms of fatty liver disease
  • 8. The NAFLD nomenclature is changing. 8
  • 9. The NAFLD nomenclature is changing. Decision Support Tool 9
  • 10. Abnormal LFT No significant alcohol consumption History & Examination Exclude drug induced liver injury Exclude other aetiologies of liver disease Non Invasive Liver Tests Blood tests (raised GGT,AST,WST Ultrasound confirmation of liver steatosis Investigate severity of liver fibrosis Enhanced liver fibrosis (ELF) Magnetic resonance elastography (MRE) VCTE, SWE ,ARFI Fibrosis-4 ( FIB-4) ,Fibrotest,AST Platelet ratio (APRI) Liver Biopsy (NAS, SAF,NASH CRN NAFLD activity score Score ) NASH NAFLD IMAGING A simplified Algorithm for NASH diagnosis
  • 11. NASH Clinical Research Network histological scoring system NITs have emerged as valuable tools for predicting adverse liver related outcomes -hitherto an important function of liver biopsies Liver biopsies for grading and staging of NASH are not consistently performed in clinical practice and should be reserved for specific clinical scenarios AASLD Practice Guidelines on the clinical assessment and management of NAFLD Hepatology 2023;77:1797-1835
  • 12. Risk stratification and management algorithm in nonalcoholic fatty liver disease. Shearwave Elastography has come in as the deciding NIT Serum Biomarkers Repeat NITs in 3-6 months Indian National Association for Study of the Liver (INASL) Guidance Paper on Nomenclature, Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease (NAFLD). Ajay Duseja *, S. P. Singh et al Indian National Association for Study of the Liver. Published by Elsevier B.V. All rights reserved. Journal of Clinical and Experimental Hepatology | March–April 2023 | Vol. 13 | No. 2 | 273–302. https://doi.org/10.1016/j.jceh.2022 .11.014 © 2022
  • 13. Clinical Care Pathway for the Risk Stratification and Management of Patients With Nonalcoholic Fatty Liver Disease Fasiha Kanwal Jay H. Shubrook Leon A. Adams Hashem B. El-Serag Kenneth Cusi Published:September 20, 2021DOI:https://doi.org/10.1053/j.gastro.2021.07.049
  • 14. > 50 Crore Indians have Fatty Liver disease > 50 Crore Indians are Obese India has a 40.3% obesity prevalence rate. This rate varies by region, with the south having the highest rate at 46.51% and the east having the lowest at 32.96%. Obesity is also higher among women than men, and in urban areas than rural areas
  • 15. Centres for “Comprehensive Fatty Liver Assessment”need to be developed
  • 16. A Comprehensive Fatty Liver Program “Despite the astoundingly high burden of NAFLD in India, only a fraction will ever develop clinically significant liver disease. Thus, risk stratification and guidance on referral using noninvasive tests is the need of the hour for optimal utilization of limited health resources in the country. “ © 2022 Indian National Association for Study of the Liver. https://doi.org/10.1016/j.jceh.2022.11.014
  • 17. COMPONENTS The biggest advantage of NITs is their ability to rule-in or rule-out significant fibrosis (>F2 fibrosis), advanced fibrosis (F3-4 fibrosis), and cirrhosis (F4 fibrosis). Because of the huge burden of NAFLD globally and in India, this stratification is very important in deciding the referral of patients from primary and secondary healthcare levels to tertiary care level. Indian National Association for Study of the Liver (INASL) Guidance Paper on Nomenclature, Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease (NAFLD). Ajay Duseja *, S. P. Singh et al Indian National Association for Study of the Liver. Published by Elsevier B.V. All rights reserved. Journal of Clinical and Experimental Hepatology | March–April 2023 | Vol. 13 | No. 2 | 273–302. https://doi.org/10.1016/j.jceh.2022.11.014 © 2022
  • 18. Questionnaire Physical measurements Laboratory investigations Ultrasound and Shearwave Elastography MRI Fat quantification and MR Elastography Serum and Imaging Biomarkers Essential Steps
  • 19. Sarcopenia ,Total Abdominal Muscle mass (TAM) Risk scoring with all the above data Mobile App and Online Data VAT/SAT quantification Additional Steps
  • 20. Package -1 1. Questionnaire for preparing personal advise on Diet, Exercise etc 2. Labs, Physical measurements 3. Ultrasound and Shearwave Elastography 4. Biomarkers 5. Risk scoring with all the above data Visceral adipose tissue (VAT/SCAT) 6. Biomarkers 7. Risk scoring with all the above data Package - 2 1. Questionnaire for preparing personal advise on Diet, Exercise etc 2. Labs, Physical measurements 3. Ultrasound and Shearwave 4. MRI Fat quantification 5. Biomarkers 6. Risk scoring with all the above data Visceral adipose tissue and Subcutaneous adipose tissue Package-3 1. Questionnaire for preparing personal advise on Diet, Exercise etc 2. Labs, Physical measurements 3. Ultrasound and Shearwave Elastography 4. MRI Fat quantification and MR Elastography 5. Visceral adipose tissue and Subcutaneous adipose tissue (VAT/SCAT) 6. Biomarkers 7. Risk scoring with all the above data FATTY LIVER PROGRAM - PACKAGES Package - 4 1. Questionnaire for preparing personal advise on Diet, Exercise etc. 2. Labs, Physical measurements 3. Ultrasound and Shearwave Elastography 4. MRI Fat quantification and MR Elastography 5. Visceral adipose tissue and Subcutaneous adipose tissue (VAT/SCAT) 6. Sarcopenia. Total abdominal muscle (TAM) 7. Biomarkers 8. Risk scoring with all the above data 9. Physician consultation 10. Apps 11. DEXA -whole body muscle / fat estimation
  • 22. Comprehensive Fatty Liver Program Patient Questionnaire Beverages and Supplements: What kind of beverages do you prefer to drink mostly? Do you take any vitamin/mineral/nutritional supplements? Do you take snacks in between meals? Do you add sugar to meals? Exercise and Physical Activity: Do you exercise/practice any specific program? Which physical exercise do you practice, and for how many hours each time? What are your personal barriers to exercise? Are you able to carry out self-care activities yourself, or do you feel sick? Do you walk for at least 30 minutes daily/sometimes/never? What household activities do you do at home? What are your leisure activities? If working, does your work require any physical activities? How many days did you engage in moderate physical activities like gardening in the past week? Dietary Habits: How many times a week do you eat bakery products? How many times a week do you eat out? What type of eating places do you frequently visit? Do you skip meals? If yes, which one do you usually skip? What do you prefer to eat for dinner? Do you control your diet as part of any ritual? What food types are included in your diet (vegetables, fruits, chicken, other meats)?
  • 23. Habits and Lifestyle: Do you smoke? If yes, how many cigarettes per day? Do you drink alcohol? If yes, how often and how many drinks on average? How many hours do you sleep each night? Do you snore loudly while sleeping? Do you have any sleep disorders? Do you feel drowsy during the daytime? Medical History: Do you have hypertension? Do you have Diabetes mellitus? Any history of dyslipidemia now? Have you checked your cholesterol level recently? Was it normal? Have you ever had hepatitis? Did you have any cardiovascular diseases like heart attack or stroke? Did you have any history of liver diseases? Do you intake any medication/drug on a regular basis? Do you have a history of acanthosis nigricans? Have you ever had obesity problems? Do you have a past history of any metabolic syndrome such as high blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol levels? Family History: Do any of your relatives suffer from diabetes mellitus? Do any of your close relatives have hypertension? Do any of your close relatives have cholesterol issues? Do any of your relatives have cardiovascular diseases? Do any of your close relatives suffer from any liver disease?
  • 24. Through a Tablet the Questionnaire can be administered Printed Questionnaire can be used The Questionnaire can be administered in person with trained staff
  • 26. Height Weight BMI W H Ratio Blood Pressure Heart rate PHYSICAL MEASUREMENTS
  • 27. AST (SGOT) ALT (SGPT) GGT GLOBULIN ALBUMIN A/G RATIO BILIRUBIN CBC RBC PARAMETERS WBC PARAMETERS WBC PARAMETERS PLATELET PARAMETERS FBS/ PPBS Lipid Profile CHOLESTEROL TRIGLYCERIDE HDL LDL VLDL HbA1c Fasting serum insulin GGT BUN S.Creatinine LDH INR S.Ferritin S.Ceruloplasmin HOMA-IR LAB TESTS
  • 28. Fatty Liver - Special Lab Tests Homocysteine High sensitive C-reactive protein (hsCRP) Apolipoprotein A-I Apolipoprotein B Lp(a)-lipoprotein Tumour necrosis factor-alfa (TNF-α) Adiponectin l Cytokeratin-18 (CK-18) fragment Type IV collagen 7S domain Hyaluronic acid (HA) Fasting C-peptide
  • 30. NORMAL NAFLD GRADE I NAFLD GRADE II NAFLD GRADE III NASH CLD ULTRASOUND
  • 32. Total fat area TAT Visceral Fat area VAT Subcutanous fat area SAT CT/MR BASED VAT/SAT/TAT
  • 33. Grade 0: PDFF less than 6.4% Grade 1 PDFF equal to or greater than 6.4% and less than 16.3% Grade 2 PDFF equal to or greater than 16.3% and less than 21.7% Grade 3 PDFF equal to or greater than 21.7% MR FAT QUANTIFICATION
  • 34. MR Elastographic Stiffness Stage of Fibrosis Less than 2.5 Normal 2.5–2.9 Normal or chronic inflammation 2.9–3.5 Stage 1–2 3.5 - 4.0 Stage 2-3 4.0 - 5.0 Stage 3-4 More than 5.0 Stage 4 MR ELASTOGRAPHY
  • 36. U L T R A S O U N D S C A N S H E A R W A V E E L A S T O G R A P H Y
  • 37. SWE
  • 38.
  • 43. MRI PDFF & MR ELASTOGRAPHY
  • 45.
  • 46.
  • 47. PDFF Calculation Method • Placement of one large single-section ROI in the anterior, posterior, medial, and lateral segments of the liver, avoiding bigger vessels and bile ducts, has been proposed as an acceptable alternative Radiology: Volume 301: Number 2—November 2021 n radiology.rsna.org MR FAT QUANTIFICATION
  • 48.
  • 49.
  • 50. Sequence Name TR TE TI FOV THICKNESS FREQUENCY PHASE NEX BANDWIDTH Scan Time Min Ideal IQ-MR PDFF Axial 6.5 3 42 10 160 160 1 111.1 01:00 T2 SSFSE Coronal 1000 1.9 38 4 352 224 1 125 03:30 Prep scan 3 plane Localiser 02:00 Patient In- Out time 03: 00 Total 09: 30 MR Fat quantification Sequences 10 MINUTE MRI : MR PDFF & MR ELASTOGRAPHY
  • 51. MR PDFF Fat quantification - Segment wise analysis ROIs Placed in various segments and tabulated to find out average
  • 52. Segment VII Segment VIII Segment V Segment VI Segment II Segment III Segment IV Segment I Right lobe Left lobe Total Average MR PDFF Fat quantification - Segment wise analysis Segment wise analysis helps to find out the regional variability , relatively spared areas etc
  • 53. SLD Grading Fatty liver was graded with PDFF according to the following criteria: Grade 0: PDFF less than 6.4%, Grade 1: PDFF equal to or greater than 6.4% and less than 16.3%, Grade 2: PDFF equal to or greater than 16.3% and less than 21.7% Grade 3: PDFF equal to or greater than 21.7% Ref : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3632805/
  • 54. RESULTS In more than 95 % subjects , the study could be completed in less than 10 minutes . SLD Grade I in 26 =54.1% Grade II in 12 = 25% Grade III in 10 = 20.8% Two patients excluded after study since features of CLD noted Higher number of patients with SLD Grade III observed , may be due to the clinical stetting -need not reflect actual prevalence in population .
  • 56. LAI LIVER ATTENUATION INDEX A non-contrast enhanced or plain CT scan (NECT) diagnoses and quantifies HS based on the attenuation values of spleen and liver in HU. This is called the liver attenuation index (LAI). LAI of above +5 indicates a normal liver, while a LAI of 0 to −5 is indicative of 10–30% steatosis . NECT is more accurate than other CT modalities. However, increased copper, iron, or glycogen content, edema and inflammation may lead to false-negative results
  • 58.
  • 59. C T V A T / S A T
  • 60.
  • 62. NAFLD FIBROSIS SCORE (NFS) NAFLD fibrosis score (NFS), is a composite score of age, hyperglycemia, body mass index, platelet count, albumin, and aspartate aminotransferase and alanine aminotransferase (AST/ ALT) ratio and was found to independently identify NAFLD patients with and without advanced fibrosis at initial NAFLD diagnosis NAFLD fibrosis score = -1.675 + 0.037 × age (year) + 0.094 × BMI (kg/m2) + 1.13 × IFG/diabetes (yes = 1, no = 0) + 0.99 × AST/ALT ratio - 0.013 × platelet count (×109/L) - 0.66 × albumin (g/dL)[9]. People who have a NAFLD fibrosis score above 0.676 are the most likely to have advanced liver fibrosis. If you have a score below -1.455, you're unlikely to have advanced liver fibrosis. The scores in between are considered indeterminate
  • 63. NAFLD FIBROSIS SCORE (NFS) NAFLD Score < -1.455 = F0-F2 NAFLD Score -1.455 – 0.675 = indeterminate score NAFLD Score > 0.675 = F3-F4 http://gihep.com/calculators/hepatology/nafld-fibrosis-score/ https://www.mdcalc.com/calc/3081/nafld-non-alcoholic-fatty-liver- disease-fibrosis-score
  • 64. FATTY LIVER INDEX (FLI) The fatty liver index (FLI), which is an algorithm based on waist circumference, body mass index (BMI), triglyceride, and gamma- glutamyl-transferase (GGT), was initially developed to detect fatty liver in Western countries FLI was calculated using the following formula: FLI = [e(0.953 × ln(triglycerides) + 0.139 × BMI + 0.718 × ln(γGTP) + 0.053 × WC − 15.745)]/ [1 + e(0.953 ×ln(triglycerides) +0.139 × BMI + 0.718 × ln(γGTP) + 0.053 × WC − 15.745)] × 100. Repeated evaluations of NAFLD status based on FLI measurements could help physicians identify higher-risk groups in terms of mortality, MI, and stroke. The association between FLI worsening or improvement and outcomes also suggests clinical benefits of the prevention and treatment of NAFLD.
  • 65. FIBROSIS 4 SCORE (FIB-4 ) The Fibrosis 4 score is a non-invasive scoring system based on several laboratory tests (AST/ALT/Platelets) that help to non- invasively estimate the amount of scarring in the liver. This score has been studied in liver disease due to Hepatitis C and NASH. FIB-4 below 1.30 is considered as low-risk for advanced fibrosis; a value of FIB-4 over 2.67 is considered as high-risk for advanced fibrosis; and FIB-4 values between 1.30 and 2.67 are considered as intermediate-risk of advanced fibrosis for ages 36-64. For ages > 64 the cut- off for low-risk goes to < 2. http://gihep.com/calculators/hepatology/fibrosis-4-score/ https://www.mdcalc.com/calc/2200/fibrosis-4-fib-4-index-liver- fibrosis
  • 66. APRI SCORE APRI has been previously validated as an efficient score to predict liver fibrosis in viral hepatitis patients with a cut-off of 0.5 for fibrosis and 1.5 for cirrhosis. APRI score interpretation: Significant fibrosis: APRI threshold of 0.7 (77% sensitive and 72% specific) Severe fibrosis: APRI threshold of 1.0 (61% sensitive and 64% specific) Cirrhosis: APRI threshold of 1.0 (76% sensitive and 72% specific).
  • 67. APRI SCORE There are no universal cut-off values for the APRI score, as it is not sufficiently sensitive to rule out significant diseases (especially with midrange values). The lower the APRI score (<0.5), the greater the negative predictive value, and ability to rule out cirrhosis. The higher the value (>1.5) the greater the positive predictive value and ability to rule in cirrhosis https://www.mdcalc.com/calc/3094/ast-platelet-ratio-index-apri https://www.omnicalculator.com/health/apri
  • 69. SERUM BIOMARKERS SCORE NAFLD Fibrosis score Fatty liver index FIB-4 (APRI) AST to Platelet Ratio TOTAL FATTY LIVER : COMPOSITE INDEX
  • 70. IMAGING BIOMARKERS -MODALITY SCORE ULTRASOUND SHEARWAVE ELASTOGRAPHY CT/MR BASED VAT/SAT/TAT MR FAT QUANTIFICATION MR ELASTOGRAPHY TOTAL FATTY LIVER : COMPOSITE INDEX
  • 71. QUESTIONNAIRE BASED SCORE DIET EXERCISE HABITS MEDICAL HISTORY FAMILY HISTORY TOTAL FATTY LIVER : COMPOSITE INDEX
  • 73. App for combining the various tests and results https://life-bee.com/ MOBILE APP
  • 74.
  • 76. The Combination of MR Elastography and Proton Density Fat Fraction Improves Diagnosis of Nonalcoholic Steatohepatitis Salem Alsaqal, MD et al J. MAGN. RESON. IMAGING 2022;56:368–379 © 2021 The Authors. Journal of Magnetic Resonance Imaging published by Wiley Periodicals LLC on behalf of International Society for Magnetic Resonance in Medicine
  • 77. Magnetic resonance-based biomarkers in nonalcoholic fatty liver disease and nonalcoholic steatohepatitis Cyrielle Caussy, Lars Johansson Endocrinol Diab Metab. 2020;3:e00134. | 1 of 9 https://doi.org/10.1002/edm2.134
  • 78. Multiparametric MRI in Patients With Nonalcoholic Fatty Liver Disease Jelte J. Schaapman, MD et al © 2020 The Authors. Journal of Magnetic Resonance Imaging J. MAGN. RESON. IMAGING 2021;53:1623–1631. . DOI: 10.1002/jmri.27292
  • 79. Emmanuel Anandraj Selvaraj etal Journal of Hepatology 2021 vol. 75 j 770–785
  • 80. Diagnostic accuracy of elastography and magnetic resonance imaging in patients with NAFLD • The following index tests were assessed in this review: VCTE (FibroScan®, Echosens, Paris, France), pSWE (Virtual Touch Quantification (VTQ); Siemens Healthineers, Erlangen, Germany), 2DSWE (Aixplorer®; SuperSonic Imagine, Aix-enProvence, France), MRE (Resoundant, Rochester, USA), cT1 measured using LMS (Perspectum, Oxford, UK), DWI, and deMIL
  • 81. Diagnostic accuracy of elastography and magnetic resonance imaging in patients with NAFLD • In conclusion, in patients with NAFLD where liver stiffness can be measured successfully, VCTE, MRE, pSWE and 2DSWE have a good diagnostic accuracy for the assessment of fibrosis, but only MRE and pSWE meet the minimum acceptable criteria of at least 80% sensitivity and specificity for the diagnosis of advanced fibrosis. These promising results however, are likely tobe overestimates of the true diagnostic accuracy as intention-todiagnose analyses and validation of pre-specified cut-offs are lacking from the literature. Future studies, like the LITMUS Imaging Study being conducted in Europe and the USA currently, should also evaluate the newer 2DSWE and MRI techniques, and provide data on head-to-head comparisons of the various techniques
  • 83. AI
  • 87. TECHNIQUES BASED ON CALCULATION OF THE ATTENUATION COEFFICIENT CAP Controlled attenuation parameter 2-D attenuation imaging (ATI) Attenuation coefficient (ATT) US-guided attenuation parameter (UGAP) US-derived fat fraction (UDFF) Fibroscan system (Echosens, Paris, France) Aplio i800 systems (Canon Medical Systems, Japan) Aloka-Arietta systems (Fujifilm) LOGIQ E9 series (General Electric, USA) Acuson S3000 or Sequoia US platform (Siemens Healthineers)
  • 89. Ultrasound-guided attenuation parameter (UGAP) technology from GE
  • 90. Controlled attenuation parameter (CAP) by Echosens
  • 91. Attenuation imaging (ATI) technique by Canon
  • 93.
  • 94.
  • 96. EXTENDED SPECTRUM : EVALUATION OF CARDIO- METABOLIC PROFILE • Cardiac computed tomography (CCT) for • Carotid artery intima-media thickness (IMT) • Epicardial adipose tissue Volume (EAT volume )
  • 97. EXTENDED SPECTRUM : OBESITY & BODY COMPOSITION DEXA CT MRI
  • 98. EXTENDED SPECTRUM : GENOMICS Genetic variant Effect PNPLA3 I148M Increases hepatic fat content, and risk of hepatic steatosis, fibrosis, and HCC TM6SF2 E167K Increases levels of hepatic triglyceride content, ALT, and increased risk of hepatic fibrosis MBOAT7 rs614738 Increases hepatic triglyceride content, and risk of hepatic steatosis, fibrosis, and HCC GCKR rs780094 Increased hepatic steatosis and fibrosis
  • 99. F A T T Y L I V E R V I D E O S F A T T Y L I V E R H A N D B O O K A N D R O I D M O B I L E A P P Learning Centre
  • 101. S L D C O N T R O L P R O G R A M S AI Based Programs are emerging
  • 102. 4 BASKETS SUBSTITUTE CEREALS PLANT PROTEINS ADD MORE VEGETABLES HEALTHY OILS,ANIMAL PROTEINS , NUTS,FRUITS ,HEALTHY SNACKS
  • 103. DIFFERENT TYPE ACTIVITIES AEROBIC EXERCISES WEIGHT TRAINING/MUSCLE BUILDING RELAXATION /FUN NATURE THERAPY
  • 104. Shearwave Elastography holds the key MRI Fat Quantification/MRE is the best Fatty Liver Program can be introduced in any hospital /institution Followup is essential A Diet/Exercise/Relaxation program should be an integral part USG having SWE and utilising Serum Biomarkers
  • 105. Acknowledgements IMA Trivandrum Branch IMA National Conference Org Committee Dr Sreejith N Kumar Dr N.Sulphi Dr Vijayakrishnan Dr Althaf Ali Pioneer Metro Scans ,Tvm KIMS Health Tvm Thank You ALL

Editor's Notes

  1. Arun
  2. Arun