- Screening for NAFLD is recommended for high-risk groups including those with obesity, metabolic syndrome, prediabetes or diabetes.
- Initial screening involves assessing metabolic risk factors and obtaining liver enzymes or biomarkers of steatosis. Abdominal ultrasound or serum fibrosis markers can then help determine risk of steatosis or fibrosis.
- For those at medium or high risk, referral to a specialist is recommended to further evaluate disease severity and need for biopsy. Low risk patients should be followed up every 2 years with repeat screening.
Evidence based management of Non Alcoholic fatty liver diseaseJayastu Senapati
Non-Alcoholic Fatty Liver Disease (NAFLD) is a growing problem, with a prevalence of 9-32% in India. The document discusses the epidemiology, diagnosis, and treatment of NAFLD. For diagnosis, it recommends using diagnostic indices along with imaging and liver tests, with biopsy as a last resort. Treatment involves lifestyle changes like exercise and diet modification as the most important non-pharmacological approach. Pharmacological options and investigational therapies are also discussed.
Common liver Disease in Primary Care SettingChernHaoChong
- The document discusses common liver problems encountered in primary care, including abnormal liver function tests, abnormal findings on liver ultrasound, and viral hepatitis serology interpretations.
- Studies show that only a small percentage of abnormal liver function tests are actually due to liver disease, while the majority are caused by cancer, cardiovascular disease, or respiratory disease.
- Non-alcoholic fatty liver disease is increasingly common in Asia, with genetic factors playing a stronger role. Screening and management of metabolic complications is important when NAFLD/NASH is identified.
- Assessment for significant liver fibrosis or cirrhosis is important for high-risk NAFLD/NASH patients, while lifestyle modifications remain the first-line
This document summarizes non-alcoholic fatty liver disease (NAFLD) from an endocrinology perspective. It defines NAFLD and related terms, discusses the pathophysiology involving insulin resistance and lipotoxicity, epidemiology as a growing global problem, challenges in diagnosis and evaluation, and currently available treatment options focusing on lifestyle modification and insulin sensitizers. Key points covered include the need for accurate definitions to classify disease subtypes, the role of the adipose tissue-liver axis in disease progression, and limitations of non-invasive testing underscoring the continued need for liver biopsy in certain cases.
This document provides an overview of non-alcoholic fatty liver disease (NAFLD) including its definitions, risk factors, pathogenesis, diagnosis, complications, screening recommendations, and treatment options. It discusses how NAFLD is the most common liver disease in Western countries, closely linked to metabolic syndrome. The key aspects are that lifestyle modifications targeting 7-10% weight loss are the first-line treatment. Pharmacotherapy with pioglitazone or vitamin E may be considered for patients with NASH, especially those with significant fibrosis. Ongoing research is exploring additional novel pharmacologic treatments.
An updated review on nonalcoholic steatohepatitis, epidemiology, pathology, diagnosis, treatment modalities and current clinical trials are reviewed.
New England Journal of Medicine review article from November 2017 entitled "Cause, Pathogenesis, and Treatment of Nonalcoholic Steatohepatitis" was extensively cited, please see references on the last slide (DOI: 10.1056/NEJMra1503519).
This is purely for educational purposes; I do not diagnose, treat, or offer patient-specific advice by sharing these slides.
This document provides an overview of non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). It discusses the new nomenclature of metabolic dysfunction associated steatotic liver disease (MASLD) and metabolic dysfunction associated steatohepatitis (MASH). The document reviews the prevalence, risk factors, pathogenesis, clinical features, diagnostic approach and management options for NAFLD/NASH. It provides details on non-invasive and invasive testing methods as well as histological scoring systems used to evaluate NAFLD and NASH.
American Association of Clinical Endocrinology Clinical Practice [Autosaved]....vardhini14
This document provides clinical practice guidelines for the diagnosis and management of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) from the American Association of Clinical Endocrinology. It recommends screening high risk individuals, such as those with obesity or diabetes, for NAFLD. The fibrosis-4 index is the preferred initial blood test to assess liver fibrosis risk. Lifestyle modifications including 5-10% weight loss through diet and exercise are first-line management strategies. For patients with diabetes and NASH, treatment with pioglitazone, GLP-1 receptor agonists, or SGLT2 inhibitors may provide benefit. Referral to a specialist
Evidence based management of Non Alcoholic fatty liver diseaseJayastu Senapati
Non-Alcoholic Fatty Liver Disease (NAFLD) is a growing problem, with a prevalence of 9-32% in India. The document discusses the epidemiology, diagnosis, and treatment of NAFLD. For diagnosis, it recommends using diagnostic indices along with imaging and liver tests, with biopsy as a last resort. Treatment involves lifestyle changes like exercise and diet modification as the most important non-pharmacological approach. Pharmacological options and investigational therapies are also discussed.
Common liver Disease in Primary Care SettingChernHaoChong
- The document discusses common liver problems encountered in primary care, including abnormal liver function tests, abnormal findings on liver ultrasound, and viral hepatitis serology interpretations.
- Studies show that only a small percentage of abnormal liver function tests are actually due to liver disease, while the majority are caused by cancer, cardiovascular disease, or respiratory disease.
- Non-alcoholic fatty liver disease is increasingly common in Asia, with genetic factors playing a stronger role. Screening and management of metabolic complications is important when NAFLD/NASH is identified.
- Assessment for significant liver fibrosis or cirrhosis is important for high-risk NAFLD/NASH patients, while lifestyle modifications remain the first-line
This document summarizes non-alcoholic fatty liver disease (NAFLD) from an endocrinology perspective. It defines NAFLD and related terms, discusses the pathophysiology involving insulin resistance and lipotoxicity, epidemiology as a growing global problem, challenges in diagnosis and evaluation, and currently available treatment options focusing on lifestyle modification and insulin sensitizers. Key points covered include the need for accurate definitions to classify disease subtypes, the role of the adipose tissue-liver axis in disease progression, and limitations of non-invasive testing underscoring the continued need for liver biopsy in certain cases.
This document provides an overview of non-alcoholic fatty liver disease (NAFLD) including its definitions, risk factors, pathogenesis, diagnosis, complications, screening recommendations, and treatment options. It discusses how NAFLD is the most common liver disease in Western countries, closely linked to metabolic syndrome. The key aspects are that lifestyle modifications targeting 7-10% weight loss are the first-line treatment. Pharmacotherapy with pioglitazone or vitamin E may be considered for patients with NASH, especially those with significant fibrosis. Ongoing research is exploring additional novel pharmacologic treatments.
An updated review on nonalcoholic steatohepatitis, epidemiology, pathology, diagnosis, treatment modalities and current clinical trials are reviewed.
New England Journal of Medicine review article from November 2017 entitled "Cause, Pathogenesis, and Treatment of Nonalcoholic Steatohepatitis" was extensively cited, please see references on the last slide (DOI: 10.1056/NEJMra1503519).
This is purely for educational purposes; I do not diagnose, treat, or offer patient-specific advice by sharing these slides.
This document provides an overview of non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). It discusses the new nomenclature of metabolic dysfunction associated steatotic liver disease (MASLD) and metabolic dysfunction associated steatohepatitis (MASH). The document reviews the prevalence, risk factors, pathogenesis, clinical features, diagnostic approach and management options for NAFLD/NASH. It provides details on non-invasive and invasive testing methods as well as histological scoring systems used to evaluate NAFLD and NASH.
American Association of Clinical Endocrinology Clinical Practice [Autosaved]....vardhini14
This document provides clinical practice guidelines for the diagnosis and management of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) from the American Association of Clinical Endocrinology. It recommends screening high risk individuals, such as those with obesity or diabetes, for NAFLD. The fibrosis-4 index is the preferred initial blood test to assess liver fibrosis risk. Lifestyle modifications including 5-10% weight loss through diet and exercise are first-line management strategies. For patients with diabetes and NASH, treatment with pioglitazone, GLP-1 receptor agonists, or SGLT2 inhibitors may provide benefit. Referral to a specialist
The document discusses the proposal to change the name of non-alcoholic fatty liver disease (NAFLD) to metabolic associated fatty liver disease (MAFLD). It notes that NAFLD's name does not accurately capture the metabolic nature of the disease. The name change was proposed by an international panel of experts and aims to reduce stigmatization and increase consideration of the disease. If adopted, MAFLD would be used instead of NAFLD to describe fatty liver disease associated with metabolic dysfunction. The document supports the name change as a way to properly frame the growing epidemic of this liver disease.
This document provides information on non-alcoholic fatty liver disease (NAFLD). It defines NAFLD and discusses its spectrum, including steatosis and non-alcoholic steatohepatitis (NASH). Risk factors, epidemiology, pathogenesis, diagnosis and treatment options are summarized. Liver biopsy remains the gold standard for diagnosing NASH, but transient elastography and biomarkers can help identify patients at risk of advanced fibrosis who may require biopsy. Lifestyle modifications targeting weight loss and insulin resistance are the primary treatment approach.
Non-alcoholic fatty liver disease (NAFLD) is becoming increasingly prevalent worldwide, affecting up to 30% of the global population. NAFLD is closely associated with obesity and type 2 diabetes. While initially characterized by excess fat accumulation in the liver (steatosis), some patients can progress to develop more severe non-alcoholic steatohepatitis (NASH) and liver fibrosis. Accurate staging of fibrosis is important for predicting outcomes but liver biopsy is invasive and not always practical. Non-invasive tests (NITs) using blood tests or imaging can help stratify patients' risk of advanced fibrosis as an alternative to biopsy. Lifestyle modifications addressing diet and exercise are recommended for managing NAFL
This document provides an overview of benign prostatic hyperplasia (BPH), including its definition, epidemiology, clinical manifestations, complications, differential diagnosis, evaluation, and management. BPH involves noncancerous enlargement of the prostate and commonly causes lower urinary tract symptoms. It predominantly affects older men. Evaluation involves assessment of symptoms, physical exam including digital rectal exam, and tests like prostate-specific antigen. Management includes watchful waiting, lifestyle changes, medications like alpha-blockers and 5-alpha-reductase inhibitors, and potentially surgery for severe or treatment-resistant cases. Screening for prostate cancer with PSA is not universally recommended.
The document discusses non-alcoholic fatty liver disease (NAFLD), which includes a spectrum of conditions from simple steatosis to non-alcoholic steatohepatitis (NASH) and cirrhosis. NAFLD is strongly associated with obesity and metabolic syndrome. The prevalence of NAFLD is increasing globally and varies from 5-30% in different regions. Diagnosis requires imaging and liver biopsy. Treatment focuses on lifestyle modifications and medications to improve insulin resistance.
- Non-alcoholic fatty liver disease (NAFLD) has been renamed to metabolic dysfunction associated steatotic liver disease (MASLD) to better reflect its pathogenesis.
- MASLD includes hepatic steatosis in the presence of cardiometabolic risk factors like obesity, diabetes, and dyslipidemia.
- Risk factors, pathogenesis, clinical features, diagnosis, and management of MASLD were discussed with emphasis on lifestyle modifications, weight loss, treatment of cardiometabolic conditions, and potential pharmacotherapy.
This document discusses the epidemiology, pathogenesis, and histopathology of fatty liver disease. It covers both non-alcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD). For NAFLD, key points include its increasing prevalence due to the rise in obesity and diabetes. The pathogenesis involves insulin resistance leading to lipid accumulation in the liver. Histologically, NAFLD is graded based on steatosis, lobular inflammation, and hepatocyte ballooning. For ALD, heavy drinking can lead to steatosis in most people, while a subset develop alcoholic steatohepatitis. The pathogenesis of ALD also involves oxidative stress and cytokine pathways. Liver biopsy remains the gold standard
This document provides an overview of current treatment and updates on non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). It begins with definitions of NAFLD and NASH. It then discusses the prevalence of NAFLD globally and in Asian countries. Risk factors and the pathogenesis involving the gut microbiota and a potential role in lean NASH are reviewed. Current methods for diagnosis including laboratory tests, imaging, serum biomarkers, and liver biopsy are summarized. Current treatment options including lifestyle modifications, metformin, pioglitazone, and vitamin E are mentioned. Several newer potential treatment approaches are also listed. The role of transient elastography in management is
Abnormal LFTs rate of deco and NAFLD.pptxzeus70441
1) The document discusses abnormal liver function tests (LFTs) and non-alcoholic fatty liver disease (NAFLD) in a population study conducted in East London. The study found that 31.6% of adults had LFTs tested, and of those 14.5% had at least one abnormal result.
2) NAFLD is discussed as a common cause of abnormal LFTs and liver disease. Risk factors for NAFLD include certain ethnicities, diabetes, hypertension, and increased BMI. NAFLD can progress to non-alcoholic steatohepatitis (NASH), which in some cases can lead to cirrhosis or liver cancer.
3)
This document summarizes the management of pancreatic carcinoma. It discusses the anatomy, epidemiology, risk factors, hereditary syndromes, pathophysiology including pre-cancerous lesions, types of pancreatic cancer, staging, prognostic factors, diagnostic techniques, treatment including surgery, chemotherapy, targeted therapy, radiotherapy and historical prospective studies. It provides a comprehensive overview of pancreatic carcinoma covering all relevant aspects of the disease.
This document provides an overview of nonalcoholic fatty liver disease (NAFLD). It defines NAFLD and discusses its prevalence, risk factors, pathogenesis involving insulin resistance and lipid peroxidation, natural history including progression to nonalcoholic steatohepatitis (NASH) and fibrosis, clinical features such as elevated liver enzymes and asymptomatic presentation, diagnosis using imaging and biopsy, and treatment options focusing on weight loss through diet and exercise. The pathogenesis involves fat accumulation due to insulin resistance followed by lipid peroxidation and inflammation. Sustained weight loss through lifestyle changes is the primary treatment recommendation.
Fatty liver disease with Diabetes Mellitus [BANGLADESH]drsamianik
A 52-year-old female with diabetes and hypertension for several years was found to have fatty liver disease based on elevated liver enzymes and ultrasound findings. She had overweight and mild liver enlargement but no signs of cirrhosis. Fatty liver disease is common in people with diabetes and obesity, as excess fat can accumulate in the liver. Lifestyle changes like weight loss and exercise through diet modification are the primary treatments recommended. Medical therapies for diabetes may also help improve fatty liver condition.
This document provides an overview of prostate cancer including epidemiology, risk factors, screening recommendations, clinical presentation, diagnosis, staging and risk stratification. Some key points:
- Prostate cancer is the second most common cancer in men worldwide. Incidence and mortality increases with age.
- Risk factors include age, family history, metabolic syndrome, certain dietary factors and medications.
- Screening is recommended for men aged 55-69 with a PSA test and digital rectal exam. Screening intervals depend on PSA levels.
- Diagnosis involves PSA testing, digital rectal exam, and biopsy. Staging uses the Gleason score and TNM system to determine risk level and treatment options
This document summarizes alcoholic liver disease, including alcoholic hepatitis, fibrosis, and cirrhosis. It discusses the incidence and risk factors of alcoholic liver disease globally. Screening tools for alcohol misuse and the management of alcohol withdrawal syndrome are presented. The diagnosis, evaluation of severity, and treatment of alcoholic hepatitis are covered in detail. Non-invasive tests and the role of liver biopsy are also summarized.
Non-Alcoholic Fatty Liver Disease (NAFLD)Sariu Ali
Nonalcoholic fatty liver disease (NAFLD) is defined as hepatic steatosis without significant alcohol consumption or other known liver diseases. It includes nonalcoholic fatty liver (NAFL) characterized by hepatic fat accumulation without inflammation or fibrosis, and nonalcoholic steatohepatitis (NASH) characterized by fat accumulation with inflammation and hepatocyte injury. NAFLD is strongly associated with obesity and metabolic syndrome. Lifestyle interventions including weight loss and exercise are recommended first-line treatment, while pioglitazone and vitamin E may improve liver histology in non-diabetic adults with NASH. Liver biopsy is needed to distinguish NASH from NAFL and assess fibrosis to guide management.
1) The document discusses MASLD (Metabolic dysfunction associated steatotic liver disease), formerly known as NAFLD. It provides epidemiological data showing a high prevalence of 38.6% in Indian adults.
2) Pathogenesis involves insulin resistance leading to increased free fatty acid flux to the liver and mitochondrial dysfunction. Lifestyle interventions including weight loss through diet and exercise can help resolve steatosis and improve fibrosis.
3) For patients at high risk of progression, pharmacotherapy with vitamin E, pioglitazone or saroglitazar may be considered. Bariatric surgery can be effective for weight loss but is not routinely recommended for NASH currently. Surveillance is advised for those
The document discusses the proposal to change the name of non-alcoholic fatty liver disease (NAFLD) to metabolic associated fatty liver disease (MAFLD). It notes that NAFLD's name does not accurately capture the metabolic nature of the disease. The name change was proposed by an international panel of experts and aims to reduce stigmatization and increase consideration of the disease. If adopted, MAFLD would be used instead of NAFLD to describe fatty liver disease associated with metabolic dysfunction. The document supports the name change as a way to properly frame the growing epidemic of this liver disease.
This document provides information on non-alcoholic fatty liver disease (NAFLD). It defines NAFLD and discusses its spectrum, including steatosis and non-alcoholic steatohepatitis (NASH). Risk factors, epidemiology, pathogenesis, diagnosis and treatment options are summarized. Liver biopsy remains the gold standard for diagnosing NASH, but transient elastography and biomarkers can help identify patients at risk of advanced fibrosis who may require biopsy. Lifestyle modifications targeting weight loss and insulin resistance are the primary treatment approach.
Non-alcoholic fatty liver disease (NAFLD) is becoming increasingly prevalent worldwide, affecting up to 30% of the global population. NAFLD is closely associated with obesity and type 2 diabetes. While initially characterized by excess fat accumulation in the liver (steatosis), some patients can progress to develop more severe non-alcoholic steatohepatitis (NASH) and liver fibrosis. Accurate staging of fibrosis is important for predicting outcomes but liver biopsy is invasive and not always practical. Non-invasive tests (NITs) using blood tests or imaging can help stratify patients' risk of advanced fibrosis as an alternative to biopsy. Lifestyle modifications addressing diet and exercise are recommended for managing NAFL
This document provides an overview of benign prostatic hyperplasia (BPH), including its definition, epidemiology, clinical manifestations, complications, differential diagnosis, evaluation, and management. BPH involves noncancerous enlargement of the prostate and commonly causes lower urinary tract symptoms. It predominantly affects older men. Evaluation involves assessment of symptoms, physical exam including digital rectal exam, and tests like prostate-specific antigen. Management includes watchful waiting, lifestyle changes, medications like alpha-blockers and 5-alpha-reductase inhibitors, and potentially surgery for severe or treatment-resistant cases. Screening for prostate cancer with PSA is not universally recommended.
The document discusses non-alcoholic fatty liver disease (NAFLD), which includes a spectrum of conditions from simple steatosis to non-alcoholic steatohepatitis (NASH) and cirrhosis. NAFLD is strongly associated with obesity and metabolic syndrome. The prevalence of NAFLD is increasing globally and varies from 5-30% in different regions. Diagnosis requires imaging and liver biopsy. Treatment focuses on lifestyle modifications and medications to improve insulin resistance.
- Non-alcoholic fatty liver disease (NAFLD) has been renamed to metabolic dysfunction associated steatotic liver disease (MASLD) to better reflect its pathogenesis.
- MASLD includes hepatic steatosis in the presence of cardiometabolic risk factors like obesity, diabetes, and dyslipidemia.
- Risk factors, pathogenesis, clinical features, diagnosis, and management of MASLD were discussed with emphasis on lifestyle modifications, weight loss, treatment of cardiometabolic conditions, and potential pharmacotherapy.
This document discusses the epidemiology, pathogenesis, and histopathology of fatty liver disease. It covers both non-alcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD). For NAFLD, key points include its increasing prevalence due to the rise in obesity and diabetes. The pathogenesis involves insulin resistance leading to lipid accumulation in the liver. Histologically, NAFLD is graded based on steatosis, lobular inflammation, and hepatocyte ballooning. For ALD, heavy drinking can lead to steatosis in most people, while a subset develop alcoholic steatohepatitis. The pathogenesis of ALD also involves oxidative stress and cytokine pathways. Liver biopsy remains the gold standard
This document provides an overview of current treatment and updates on non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). It begins with definitions of NAFLD and NASH. It then discusses the prevalence of NAFLD globally and in Asian countries. Risk factors and the pathogenesis involving the gut microbiota and a potential role in lean NASH are reviewed. Current methods for diagnosis including laboratory tests, imaging, serum biomarkers, and liver biopsy are summarized. Current treatment options including lifestyle modifications, metformin, pioglitazone, and vitamin E are mentioned. Several newer potential treatment approaches are also listed. The role of transient elastography in management is
Abnormal LFTs rate of deco and NAFLD.pptxzeus70441
1) The document discusses abnormal liver function tests (LFTs) and non-alcoholic fatty liver disease (NAFLD) in a population study conducted in East London. The study found that 31.6% of adults had LFTs tested, and of those 14.5% had at least one abnormal result.
2) NAFLD is discussed as a common cause of abnormal LFTs and liver disease. Risk factors for NAFLD include certain ethnicities, diabetes, hypertension, and increased BMI. NAFLD can progress to non-alcoholic steatohepatitis (NASH), which in some cases can lead to cirrhosis or liver cancer.
3)
This document summarizes the management of pancreatic carcinoma. It discusses the anatomy, epidemiology, risk factors, hereditary syndromes, pathophysiology including pre-cancerous lesions, types of pancreatic cancer, staging, prognostic factors, diagnostic techniques, treatment including surgery, chemotherapy, targeted therapy, radiotherapy and historical prospective studies. It provides a comprehensive overview of pancreatic carcinoma covering all relevant aspects of the disease.
This document provides an overview of nonalcoholic fatty liver disease (NAFLD). It defines NAFLD and discusses its prevalence, risk factors, pathogenesis involving insulin resistance and lipid peroxidation, natural history including progression to nonalcoholic steatohepatitis (NASH) and fibrosis, clinical features such as elevated liver enzymes and asymptomatic presentation, diagnosis using imaging and biopsy, and treatment options focusing on weight loss through diet and exercise. The pathogenesis involves fat accumulation due to insulin resistance followed by lipid peroxidation and inflammation. Sustained weight loss through lifestyle changes is the primary treatment recommendation.
Fatty liver disease with Diabetes Mellitus [BANGLADESH]drsamianik
A 52-year-old female with diabetes and hypertension for several years was found to have fatty liver disease based on elevated liver enzymes and ultrasound findings. She had overweight and mild liver enlargement but no signs of cirrhosis. Fatty liver disease is common in people with diabetes and obesity, as excess fat can accumulate in the liver. Lifestyle changes like weight loss and exercise through diet modification are the primary treatments recommended. Medical therapies for diabetes may also help improve fatty liver condition.
This document provides an overview of prostate cancer including epidemiology, risk factors, screening recommendations, clinical presentation, diagnosis, staging and risk stratification. Some key points:
- Prostate cancer is the second most common cancer in men worldwide. Incidence and mortality increases with age.
- Risk factors include age, family history, metabolic syndrome, certain dietary factors and medications.
- Screening is recommended for men aged 55-69 with a PSA test and digital rectal exam. Screening intervals depend on PSA levels.
- Diagnosis involves PSA testing, digital rectal exam, and biopsy. Staging uses the Gleason score and TNM system to determine risk level and treatment options
This document summarizes alcoholic liver disease, including alcoholic hepatitis, fibrosis, and cirrhosis. It discusses the incidence and risk factors of alcoholic liver disease globally. Screening tools for alcohol misuse and the management of alcohol withdrawal syndrome are presented. The diagnosis, evaluation of severity, and treatment of alcoholic hepatitis are covered in detail. Non-invasive tests and the role of liver biopsy are also summarized.
Non-Alcoholic Fatty Liver Disease (NAFLD)Sariu Ali
Nonalcoholic fatty liver disease (NAFLD) is defined as hepatic steatosis without significant alcohol consumption or other known liver diseases. It includes nonalcoholic fatty liver (NAFL) characterized by hepatic fat accumulation without inflammation or fibrosis, and nonalcoholic steatohepatitis (NASH) characterized by fat accumulation with inflammation and hepatocyte injury. NAFLD is strongly associated with obesity and metabolic syndrome. Lifestyle interventions including weight loss and exercise are recommended first-line treatment, while pioglitazone and vitamin E may improve liver histology in non-diabetic adults with NASH. Liver biopsy is needed to distinguish NASH from NAFL and assess fibrosis to guide management.
1) The document discusses MASLD (Metabolic dysfunction associated steatotic liver disease), formerly known as NAFLD. It provides epidemiological data showing a high prevalence of 38.6% in Indian adults.
2) Pathogenesis involves insulin resistance leading to increased free fatty acid flux to the liver and mitochondrial dysfunction. Lifestyle interventions including weight loss through diet and exercise can help resolve steatosis and improve fibrosis.
3) For patients at high risk of progression, pharmacotherapy with vitamin E, pioglitazone or saroglitazar may be considered. Bariatric surgery can be effective for weight loss but is not routinely recommended for NASH currently. Surveillance is advised for those
10 Benefits an EPCR Software should Bring to EMS Organizations Traumasoft LLC
The benefits of an ePCR solution should extend to the whole EMS organization, not just certain groups of people or certain departments. It should provide more than just a form for entering and a database for storing information. It should also include a workflow of how information is communicated, used and stored across the entire organization.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
Kosmoderma Academy, a leading institution in the field of dermatology and aesthetics, offers comprehensive courses in cosmetology and trichology. Our specialized courses on PRP (Hair), DR+Growth Factor, GFC, and Qr678 are designed to equip practitioners with advanced skills and knowledge to excel in hair restoration and growth treatments.
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Mercurius is named after the roman god mercurius, the god of trade and science. The planet mercurius is named after the same god. Mercurius is sometimes called hydrargyrum, means ‘watery silver’. Its shine and colour are very similar to silver, but mercury is a fluid at room temperatures. The name quick silver is a translation of hydrargyrum, where the word quick describes its tendency to scatter away in all directions.
The droplets have a tendency to conglomerate to one big mass, but on being shaken they fall apart into countless little droplets again. It is used to ignite explosives, like mercury fulminate, the explosive character is one of its general themes.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
2. What is NAFLD
• HS involving > 5% of the
hepatocytes,associated with insulin
resistance without other causes of HS
EASL–EASD–
EASO (2016)
• HS defined by imaging or histology
without other causes of HS
AASLD
• Fat accumulation in the liver
exceeding 5% of its weight
WGO
J Hepatol 2016 vol. 64 j 1388–1402, Hepatology 2018;67:328-57, J Clin Gastroenterol 2014;48:467-73
3. What is NAfLD
• The diagnosis of NAFLD is based on the
following
1. Presence of hepatic steatosis, in addition to
2. lack of significant alcohol consumption
3. Exclusion of other liver diseases
6. Purpose to screen NAFLD
• Identify persons who are at risk of disease
progression and liver fibrosis (predictor of disease
outcomes)
• Early intervention can halt or reverse disease
progression
8. Who to screen
Does not recommend
screening of
General populations
EASL–
EASD–
EASO
(2016)
AASLD
WGO Italian
American
Association
of
Endocrine
Chinese
11. Who to Screen
• High Risk Population
EASL–EASD–
EASO (2016)
• High Risk Population
WGO (2014)
AACE (2022)
• No screening
AASLD (2018)
J Hepatol 2016 vol. 64 j 1388–1402, Endocrine Practice 28 (2022) 528-62, Hepatology 2018;67:328-57, J Clin Gastroenterol 2014;48:467-73
• High Risk Population
12. High risk population
• Insulin resistance
• Metabolic risk factors (obesity, MetS)
• Age > 50 years
• Persistent elevated Liver enzymes
EASL–EASD–
EASO (2016)
• Central obesity, T2 DM, dyslipidemia,
MetS, altered LEs, and fatty liver on US
WGO (2014)
• May consider..
AASLD
13. High Risk Population
• Obesity
• ≥2 risk factors of MetS
• Prediabetes or T2DM,
• Hepatic steatosis on any imaging
• Persistently elevated plasma
aminotransferase levels (over 6
months)
• Undergoing bariatric surgery
AACE
Endocrine Practice 28 (2022) 528-62
14. General recommendation
• All guidelines require the exclusion of patients with
secondary causes of liver steatosis including
– steatogenic drugs,
– excessive alcohol consumption
15. Alcohol threshold
• Weekly
• > 196 g in women
• > 294 g in men
• for previous 2 years
USA
• Weekly
• > 140 g in women and > 210 g in men
• Daily
• > 20 g in women and > 30 g in men
Other
guidelines
16. Screening Methods
•Ultrasound (First Line)
•Liver enzymes and/or
•Steatosis biomarkers
•Assessment of dietry and physical
habits
EASL–EASD–
EASO (2016)
• Fib-4
AACE
Journal of Hepatology 64 (2016)1388–1402 Endocrine Practice 28 (2022) 528-62
19. US and scores (easl)
• US has limited sensitivity and does
• not reliably detect steatosis when <20% [27,28] or in individuals
• with high body mass index (BMI) (>40 kg/m2) [29]. Despite
• observer dependency, US (or computed tomography [CT] or
• MRI) robustly diagnoses moderate and severe steatosis and provides
• additional hepatobiliary information, hence it should be
• performed as a first-line diagnostic test.
• 3). The best-validated steatosis scores are the fatty
• liver index (FLI), the SteatoTest and the NAFLD liver fat score;
• they have all been externally validated in the general population
• or in grade 3 obese persons and variably predict metabolic, hepatic
• and cardiovascular outcomes/mortality. These scores are
• associated with IR and reliably predict the presence, not the
• severity, of steatosis [30].
20. Steatosis Biomarkers (EASL)
• Define
• Fatty Liver Index, SteatoTest, NAFLD Fat score
• Liver tests: ALT
• AST, cGT. 3Any increase in ALT, AST or cGT.
23. Easl fibrsosi (NFS)
• NFS predicts incident diabetes,
• and changes in NFS are associated with mortality. The tests
• perform best at distinguishing advanced (PF3) vs. non-advanced
• fibrosis but not significant (PF2) or any (PF1) fibrosis vs. no
• fibrosis [36]. Importantly, the negative predictive values (NPVs)
• for excluding advanced fibrosis are higher than the corresponding
• positive predictive values (PPVs) [36,37]; therefore, non-invasive
• tests may be confidently used for first-line risk stratification to
• exclude severe disease. However, predictive values depend on
• prevalence rates and most of these studies have been conducted
• in tertiary centres where the pre-test probability of advanced
• fibrosis is higher than in the community
29. Easl followup
• The optimal follow-up of patients with NAFLD is as yet
undetermined.
• Risk of progression of both the hepatic disease and the
• underlying metabolic conditions as well as the cost and workload
• for healthcare providers need to be considered. Monitoring
• should include routine biochemistry, assessment of comorbidities
• and non-invasive monitoring of fibrosis. NAFL patients without
• worsening of metabolic risk factors, should be monitored at
• 2–3-year intervals. Patients with NASH and/or fibrosis should
• be monitored annually, those with NASH cirrhosis at 6-month
• intervals. If indicated on a case-by-case basis, liver biopsy could
• be repeated after 5 years.
30.
31. U/S or Fib 4
• Endo It is reasonable to perform a risk stratification (FIB-4) without
the need for a liver US for the diagnosis of hepatic steatosis (ie, in
the 3 at-risk groups, the chance of having hepatic steatosis is very
high
• and 70%).5,9-11,52,102-104 It is important to perform a complete
• medical history and routine clinical chemistries that allow clinicians
• to rule out secondary causes of liver steatosis (Table 4) and
• elevated plasma aminotransferase levels (Table 5). A thorough
• workup should be performed to rule out competing causes for
• steatosis, in addition to excluding significant alcohol consumption.
32.
33. elastography
• Endo As mentioned earlier, VCTE (Table 1 and Algorithm Fig. 2) is
the
• most broadly used noninvasive method for LSM and, thus, for
• establishing the risk of liver fibrosis158-160 and for eventually
• excluding cirrhosis.158 At a fixed sensitivity, a cutoff LSM of 6.5 kPa
• excluded advanced fibrosis with an NPV of 0.91, and a cutoff LSM of
• 12.1 kPa excluded cirrhosis with an NPV of 0.99.158 Minor
limitations
• of VCTE include overestimation of LSMs at higher stages of
• fibrosis and unsuccessful LSMs with inappropriate use of probes in
individuals with overweight and obesity, which can be circumvented
• using the right probe in individuals with higher BMI.
34. elastography
• Endo A European study in 450 adults who underwent TE and a liver biopsy
• using an LSM Youden cutoff value for clinically significant fibrosis
• (F2) of 8.2 kPa demonstrated NPVs of 78% in persons from diabetes
• clinics and 97% in the general population.159 Another study in
• 1073 persons with NAFLD among 10 European tertiary liver centers
• confirmed these cutoffs, reporting that a cutoff of 8.0 kPa had a 93%
• sensitivity to exclude advanced fibrosis (F3-F4).163 Similarly, a
• recent systematic review further supported the cutoff of 8.0 kPa for
• screening for clinically significant liver fibrosis.164 For practical
• purposes then, people with an LSM of <8.0 kPa determined using
• TE are considered low risk for clinically significant fibrosis (F2)
• and are best managed in the nonspecialty clinics with repeat surveillance
• testing in 2 to 3 years.
35. eAsl elsto
• Among imaging techniques, transient elastography performs
• better for cirrhosis (F4) than for advanced fibrosis (F3). Elastography
• has a higher rate of false-positive than false-negative results
• and higher NPV than PPV [38], hence the ability to diagnose
• bridging fibrosis or cirrhosis is insufficient for clinical
decisionmaking.
• The main shortcoming of transient elastography is unreliable
• results in the presence of high BMI and/or thoracic fold
• thickness. In a large, unselected European series, up to 20% of
• examinations had unreliable results [39], mainly in obese NAFLD
• [38]. The XL probe should be used in these patients to reduce the
• failure rate, which remains high (35%) [40].
40. US
• The accuracy of liver US for the detection of
• moderate and severe steatosis was >80% in a meta-analysis when
• compared with liver histology.129 However, this was based on data
• from hepatology clinics and does not represent the population with
• less severe disease observed in primary care or endocrinology
clinics,
• where liver US was shown to have suboptimal sensitivity for mildto-
• moderate steatosis (below a liver fat content of 12.5%)
• compared with 1H-MRS and liver biopsy in 146 individuals.24 Liver
• US is also highly operator dependent and does not inform about the
• severity of liver fibrosis (unless cirrhosis is present)
41. US endocrine guideline
• Hepatic steatosis may be assessed by
• means of simple noninvasive liver steatosis scores (fatty liver index,
• US fatty liver index, and hepatic steatosis index), although these
• diagnostic modalities have inherent limitations.11,115,152 A liver US is
• not recommended for routine clinical diagnosis.115 Instead, TE is
• preferred over liver US,
• The accuracy of liver US for the detection of
• moderate and severe steatosis was >80% in a meta-analysis when
• compared with liver histology.129 However, this was based on data
• from hepatology clinics and does not represent the population with
• less severe disease observed in primary care or endocrinology clinics,
• where liver US was shown to have suboptimal sensitivity for mildto-
• moderate steatosis (below a liver fat content of 12.5%)
• compared with 1H-MRS and liver biopsy in 146 individuals.24 Liver
• US is also highly operator dependent and does not inform about the
• severity of liver fibrosis (unless cirrhosis is present)
42. Fib 4 (endocrin)
• 2.2.1. Clinicians should use liver fibrosis
prediction
• calculations to assess the risk of NAFLD with
liver fibrosis. The
• preferred noninvasive initial test is the
fibrosis-4 index (FIB-4).
43. EaSl Diagnostic algorithm and follow-
up
• The incidental discovery of steatosis should lead to comprehensive
• evaluation of family and personal history of NAFLDassociated
• diseases and the exclusion of secondary causes of
• steatosis. Metabolic work-up has to include a careful assessment
• of all components of MetS [63]. Similarly, the presence of obesity/
• T2DM or the incidental finding of raised liver enzymes in patients
• with metabolic risk factors should prompt non-invasive screening
• to predict steatosis, NASH and fibrosis (Table 3).
• Surrogate markers of fibrosis (NFS, FIB-4, ELF or FibroTest)
• should be calculated for every NAFLD patient, in order to rule out
• significant fibrosis (PF2). If significant fibrosis cannot be ruled
• out, patients should be referred to a Liver Clinic for transient elastography;
• if significant fibrosis is confirmed, the final diagnosis
• should be made by liver biopsy (Fig. 1). All cases with diabetes or
• diabetes risk should be referred to a Diabetes Clinic for optimal
• management. Those at increased diabetes risk should be included
• in a structured lifestyle modification program. Obesity should
• prompt the inclusion of the patient in a structured weight loss programand/
• orreferral toanobesity specialist. Finally, all casesshould
• receive comprehensive cardiovascular disease (CVD) work-up.
44. EAsl
• Biomarkers and scores of fibrosis, as well as transient
• elastography, are acceptable non-invasive procedures
• for the identification of cases at low risk of advanced
• fibrosis/cirrhosis (A2). The combination of biomarkers/
• scores and transient elastography might confer
• additional diagnostic accuracy and might save a
• number of diagnostic liver biopsies (B2)
• • Monitoring of fibrosis progression in clinical practice
• may rely on a combination of biomarkers/scores and
• transient elastography, although this strategy requires
• validation (C2)
• • The identification of advanced fibrosis or cirrhosis by
• serum biomarkers/scores and/or elastography is less
• accurate and needs to be confirmed by liver biopsy,
• according to the clinical context (B2)
• • In selected patients at high risk of liver disease
• progression, monitoring should include a repeat liver
• biopsy after at least 5-year follow-up (C2)
Editor's Notes
In 1968, Wilson and Jungner formulated basic criteria for the usefulness of screening
procedures for a particular disease in a paper by the WHO[30,31]. These criteria
include peculiarities of the disease (significant burden of disease in the population and
knowledge of etiology and stages of disease) and of reaching a diagnosis (simple test
acceptable to patients) as well as organizational requirements (available facilities for
diagnosis and therapy). In general, these criteria already apply for NAFLD for some
time.
However, the authors also point out that efficient therapy as well as cost-effectiveness
of screening must be present[30]. Here, important new developments have
occurred in recent years that make screening for NAFLD much more justified than in
the past.
The general progress in diagnosing and treating liver disease led an expert group
2016 to the proposal that screening for liver fibrosis (independent from the underlying
disease) may now be feasible even for the general population[32
Not fullfilled by NAFLD thus no universal screening algorithm
It should also be emphasized that the purpose
of screening for NAFLD is to identify persons who are at risk of
disease progression and liver fibrosis, the most important predictor
of liver and overall outcomes. Screening is important because early
intervention can halt or reverse disease progression. In a recent
study in persons with T2D, screening for NAFLD followed by
intensive lifestyle interventions or pioglitazone was cost-effective,
providing further support for screening recommendations
In a large population-based, cross-sectional study from Barcelona, the authors found elevated liver stiffness (as defined with TE > 6.8 kPa) in 9% of the participants, and NAFLD was the leading etiology (followed by alcohol risk consumption)[44]. Risk
factors for elevated liver stiffness included obesity, type 2 diabetes and the presence of metabolic syndrome (each with a prevalence of elevated liver stiffness in 20%–30%).
This study convincingly underlines the importance of NAFLD in the general population but especially in the known risk groups. While the prevalence of NAFLD in the general population is quite high (20%-30%), only approximately 7%-10% of NAFLD patients develop relevant complications of this disease, such as advanced fibrosis, cirrhosis or hepatocellular carcinoma (HCC)[45,46] (Figure 1). Thus, screening
the entire population cannot (yet) be justified because too many patients would suffer overdiagnosis and possibly overtherapy. For advanced testing or invasive diagnostic measures such as liver biopsy, which applies to a selected patient population of still
3%-5%, primary testing to rule out low-risk individuals appears mandatory.
Journal of Hepatology 2016 vol. 64 j 1388–1402 (EASL )
All individuals with steatosis should be screened for features of MetS, independent of liver enzymes. All
individuals with persistently abnormal liver enzymes should be screened for NAFLD, because NAFLD is the
main reason for unexpectedly elevated liver enzymes
(A1)
• In subjects with obesity or MetS, screening for NAFLD by liver enzymes and/or ultrasound should be part of
routine work-up. In high risk individuals (age >50 years, T2DM, MetS) case finding of advanced disease
(i.e. NASH with fibrosis) is advisable (A2)
Endocrine Practice 28 (2022) 528e562
Endocrine Practice 28 (2022) 528-62
with obesity, the prevalence of NASH is between 25% and 30%, while approximately
30% to 40% of persons with diabetes have NASH.
recent study indicated that in outpatient family medicine, internal medicine, and endocrine clinics, approximately 70% of persons with T2D have NAFLD (steatosis), and approximately 15% have clinically significant liver fibrosis (stages F2),9 consistent ith population based study in USA
alcohol thresholds are similar in most guidelines but not identical. In fact, USA 2012/2018[2,15] uses
alcohol units instead of grams, resulting in higher thresholds (> 196 g in women and > 294 g in men weekly)
as opposed to other guidelines (> 20 g in women and > 30 g in men daily or > 140 g in women and > 210 g in
men weekly).
Journal of Hepatology 64 (2016)1388–1402 Endocrine Practice 28 (2022) 528-62
US is the preferred first-line diagnostic procedure for imaging of NAFLD, as it provides additional diagnostic information (A1)
• Whenever imaging tools are not available or feasible (e.g. large epidemiological studies), serum biomarkers and scores are an acceptable alternative for the diagnosis of steatosis (B2)
A high-calorie diet, excess (saturated) fats, refined carbohydrates, sugar-sweetened beverages, a high fructose intake and a Western
diet [9] have all been associated with weight gain and obesity,
and more recently with NAFLD. High fructose consumption may
increase the risk of NASH and advanced fibrosis,
A combination
of the FIB-4 followed by VCTE (description under Q2.3) seems to be
the best approach. If the FIB-4 score is >1.3, then a second level test,
such asVCTE or ELF, should be performed (AlgorithmFig. 2). Using the
FIB-4 as a first-line test, followed by VCTE, can help stratify persons in
the “indeterminate zone” and greatly reduce the number of referrals
to the specialist.130,134,137,147,148,153 Of note, higher cutoffs for the FIB-4,
in the range of 1.9 to 2.0 (rather than >1.3), have been suggested with
older age ( 65 years) to determine advanced fibrosis