Non-alcoholic fatty liver disease, more commonly abbreviated NAFLD, is a pathology in which fat begins to accumulate in the liver cells, and it ceases to perform its functions. If you do not take preventive measures and do not undergo a course of treatment, then there is a high probability of severe complications, including death. Dry statistics are disappointing, according to them, up to 40% of the adult population are faced with this disease in varying degrees gravity. The disease is no less dangerous than cirrhosis of the liver or fatty degeneration of the liver. It is extremely important to determine the disease in time, for which it is necessary to have the information that we have prepared for you below.

Non-alcoholic fatty liver disease occurs in 40% of the population

Types of NAFLD

In non-alcoholic fatty disease, a number of structural changes occur in the human liver, which include:

• steatosis;
• liver hepatosis;
• fatty hepatosis;
• nonalcoholic steatohepatitis.

Steatosis is characterized by excess fat in the liver.

Non-alcoholic steatohepatitis

NASH for short. There is not only the accumulation of fat, but also inflammatory processes, over time, leading to fibrosis and cirrhosis.

According to the medical classification, NAFLD is divided into primary and secondary.

Primary non-alcoholic fatty disease is a direct consequence of a violation of the body's response to insulin (insulin resistance).

Secondary NAFLD can occur for many reasons. Here are just a few of them:

Side effects of medication can be NAFLD

• side effects from taking medications;
• complications after surgery;
• diseases of the intestines and digestive system;
• not proper nutrition;
• diets, especially low-protein ones;
• starvation;
• sudden loss of body weight;
• body intoxication. Poisoning by mushrooms, organic solvent, phosphorus is especially dangerous.

Who is at risk

In medicine, the concept of metabolic syndrome, which combines a complex of hormonal, clinical and metabolic disorders.

In a special risk group are people suffering from:

• type 2 diabetes;
• obesity;
• high content triglycerides in the blood.

Type 2 diabetics have a 70 to 100% chance of developing fatty liver disease.

The bulk of NAFLD cases are diagnosed in middle-aged people between 40 and 60 years of age, with more than half of all cases occurring in women. However, the disease often occurs in children suffering from overweight.

The main causes leading to the disease

All risk factors can be divided into 2 groups: external and internal.

The external ones are:

• a diet dominated by fatty and fried foods;
• excessive consumption of sweets, since it is carbohydrates that contribute to the production and accumulation of fat in the liver;
• excessive passion for coffee;
• bad habits: alcohol, smoking, drug use;

The list of internal factors includes:

Non-alcoholic fatty liver disease may result from malnutrition and obesity

• obesity;
• complications after a number of pathologies, cirrhosis of the liver;
• hereditary factor;
• age and natural aging of the body;
• a large amount of "bad" cholesterol in the blood;
• dysbacteriosis.

What is important to know! The name of the disease contains the word "non-alcoholic", which implies an exception to the risk factors for alcohol. But it must be remembered that alcohol consumption may also play a role, adding to the non-alcoholic risk factor. At healthy person the percentage of fat in the liver is about 5%. Alcohol enhances the production fatty acids body and prevents their oxidation, disrupts the composition of the blood and the amount of triglycerides, develops cirrhosis of the liver.

Symptoms

Non-alcoholic fatty liver disease is very dangerous in that pathology is detected in most cases already at a late stage. This is related to the fact that the disease proceeds for a long time without symptoms or with minor deviations, to which most patients do not attach much importance.

At fatty hepatosis liver in initial stage only the following symptoms can be distinguished:

• weakness;
• fast fatiguability;
• decrease in working capacity;
• increased drowsiness;
• high arterial pressure;
• under the ribs on the right side, a feeling of slight discomfort and slight heaviness;
• hepatomegaly;
• the formation of "asterisks" of blood vessels.

With the development of the disease and the accumulation of a large amount of fat in the liver, the symptoms begin to become pronounced:

• strong pruritus;
• constant feeling of nausea;
• indigestion and stool;
• the skin and whites of the eyes turn yellow (jaundice);
• an increase in the abdomen becomes visually noticeable;
• pronounced cognitive impairment.

Diagnostics

To make a diagnosis of non-alcoholic fatty liver disease, or to deny it, after questioning and initial examination of the patient, the doctor prescribes a series of tests and diagnostic procedures. As we said earlier, NAFLD has practically no symptoms, and those symptoms that are present are inherent in very many other diseases and there is a need for differentiation.

Of the analyzes, the most informative is biochemical analysis blood, which contains a number of indicators by which you can assess the condition of the liver.

One of the most difficult tasks in diagnosis of NAFLD is the exclusion or evaluation of the influence of the alcohol component. There are a number of characteristic markers to evaluate, but such tests are not always able to give an unambiguous answer about the effect of alcohol on the development of the disease.

How to treat NAFLD

Treatment of non-alcoholic fatty liver disease should be comprehensive.

Medical therapy includes:

Treatment of non-alcoholic fatty liver disease should be comprehensive

• normalization of metabolism;
• prevention of oxidative stress;
• recovery normal microflora intestines;
• treatment of steatohepatosis;
• treatment of fibrosis and other associated pathologies.

Particularly necessary are restrictions on food and diet for those patients who are overweight, the fight against it is one of the key points in treatment. Weight loss by 10 percent, according to statistics, already leads to a significant improvement in well-being, the disease recedes and regresses. However, such a diet should be developed exclusively by a competent nutritionist, and its observance should be accompanied by intermediate medical supervision. An independent desire to lose weight and starvation can lead to catastrophic consequences and the flow of the disease into an acute stage and the manifestation of necrosis.

Regardless of whether the patient is obese or not, his diet should include a sufficient amount of vitamins and minerals, the amount of protein should be high enough, but fats of animal origin, on the contrary, should be excluded as much as possible.

A number of products have the ability to prevent the accumulation of fats in the liver and infiltrate them, normalizing a fatty liver. The most popular of them are oatmeal, wheat and buckwheat porridge, cottage cheese.

Help in the fight against NAFLD essential phospholipids, which are the basis of the drug "Essentiale forte N", which is always prescribed for NAFLD. Its use helps to reduce the rate of development connective tissue and normalizes lipid metabolism. This eliminates the reason why fat accumulates in the liver cells.

The patient needs to completely reconsider his lifestyle, follow the right diet and sufficient physical activity. However, there is also a caveat here: physical activity should be dosed, since excessive loads are very harmful, you need to play sports, but dosed. Patients are advised to consult with a specialist physiotherapy exercises and follow his recommendations, respecting differences from those tips that are fashionable to find on the Internet.

The prognosis of treatment is favorable only in the initial stages, and in the later stages, the risk of complete liver damage and death is very high.

Prevention

Prevention of NAFLD consists of maintaining a healthy and active lifestyle

Prevention of NAFLD consists in maintaining a healthy and active lifestyle, giving up bad habits, controlling your psycho-emotional state and minimizing the amount of stress.

It is necessary to control the level of cholesterol and take measures to reduce it.

Various biological food supplements (BAA) are widely advertised on the Internet and in the media, mostly imported, but there are also domestic production. Their ingredients are all the same essential phospholipids, carnitine and vitamins that help normalize fat metabolism and prevent liver cirrhosis. You need to be wary of such drugs and not consider them a panacea for liver diseases. If you decide to buy, then first consult with your doctor, and be sure to ask the seller for a license and certificate to make sure that the dietary supplement is legal and will not harm you instead of the expected benefit.

Conclusion

Despite the development of medicine, the course of the disease and full list The causes, or pathogenesis, that lead to the appearance of NAFLD are still not fully understood. It is only known about its connection with overweight, diabetes, diseases of the cardiovascular system.

No one is immune from this disease, and the number of people with fatty liver, to one degree or another, is amazing - this is almost every second inhabitant of our country. Non-alcoholic fatty liver disease is becoming a real problem of modern times and the more prosperous the country and the standard of living of the population, the more cases are diagnosed. Liver cirrhosis is diagnosed less frequently than NAFLD.

In the case of non-alcoholic fatty liver disease, everything is not as simple as, for example, in its lesions that occur with alcoholism. After all, even healthy correct image life does not give any guarantees, but can only reduce the likelihood of NAFLD. A huge problem is that the accumulation of fatty deposits in the liver does not manifest itself in any way until the violations become systemic, in which case, even with treatment, there is a high probability of death.

There is only one way out and it consists in periodically undergoing a preventive examination by a doctor and taking tests that can be used to judge the state of the liver and the appearance of abnormalities in it.

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fatty hepatosis. Steatosis of the liver. Fatty liver disease. Non-alcoholic steatohepatitis.

Non-alcoholic fatty liver disease (NAFLD) is one of the most common chronic pathologies. It can also be one of the signs of metabolic syndrome, type II diabetes and obesity.

For the first time the term "non-alcoholic steatohepatitis" was proposed in 1980. In the study of liver preparations of patients who did not drink alcohol in hepatotoxic doses, changes characteristic of alcoholic liver damage were found.

The term NAFLD contains three successive stages:

• non-alcoholic steatosis (fatty hepatosis);
• non-alcoholic (metabolic) steatohepatitis (NASH);
• cirrhosis as an outcome of NASH progression.

It is extremely rare for non-alcoholic steatohepatitis to progress to hepatocellular carcinoma.

According to the literature, adverse outcomes of this disease, in the absence or insufficient treatment, are not so rare. Almost half of the cases develop cirrhosis, and about 5% - hepatocellular carcinoma.
Very often, non-alcoholic fatty liver disease is detected by chance - during a biochemical blood test, or changes are detected on an ultrasound examination. abdominal cavity.

Relevance of the problem

The frequency of non-alcoholic fatty liver disease in the population is not reliably known due to the latent course and the difficulties associated with this fact in early diagnosis. However, according to recent studies, the prevalence of this disease in the form of steatosis can be over 25% (in some regions and more than 50%), and non-alcoholic steatohepatitis - up to 5%.

In diseases that are accompanied by insulin resistance ( metabolic syndrome, diabetes Type II, obesity, dyslipidemia), specific transformations in the liver are detected in approximately 75% of cases, and with concomitant obesity - up to 95%.

Nowadays, there is an increase in the incidence of morbid obesity among the population in the world, in particular in developed countries. This is facilitated by hypodynamia, improper and unbalanced nutrition. As a result, the number of cases of NAFLD is also on the rise.

Patients diagnosed with metabolic syndrome have the greatest risk of the onset and progression of this pathology.

According to WHO, in the structure of causes of death in the world in the first place - cardiovascular diseases. Patients suffering from NAFLD have an increased risk of pathology from the heart and blood vessels, which is confirmed by numerous studies in this area.

Most often, NAFLD affects women aged 40–60 years, as well as patients with manifestations of insulin resistance, in particular, metabolic syndrome. But the incidence is noted in different age categories. Children are no exception: this pathology is diagnosed in about 3% of all children, and in children with obesity, the disease rate reaches 55%.

Relationship of non-alcoholic hepatosis with metabolism

The pathogenesis of NAFLD is still being studied, but the following conclusions have already been made: one of the main roles in this is played by the phenomenon of insulin resistance. What is this disease and why is it dangerous?

Insulin resistance is a condition that is characterized by a decrease (up to complete absence) of the sensitivity of peripheral tissues of the body to the biological effects of insulin.

It does not matter where it comes from: in the process of synthesis by the pancreas (endogenous) or from the outside (exogenous). As a result, an increased concentration of insulin in the blood is created. It is known that insulin has a direct effect on carbohydrate and lipid metabolism, and also acts on the vascular endothelium.

As a result of a prolonged increase in the amount of insulin in the body, various metabolic disorders occur. As a result, type II diabetes mellitus may develop. cardiovascular disease etc.

The causes of insulin resistance are not fully understood. There is a frequent development of a decrease in the sensitivity of cellular receptors to insulin in people with overweight and a tendency to develop arterial hypertension. The reason is the tendency of adipose tissue to increased metabolic activity, for example, if body weight is 35–40% more than normal, then insulin sensitivity will decrease by 40%.

Assessment of immunoresistance by the HOmeostasis Model Assessment (HOMA) index
In practical medicine, the HOMA index is used: fasting blood glucose (mmol/l) × insulin (μU/ml) / 22.5. At HOMA index above 1.64, a person is diagnosed with insulin resistance.

Tissue resistance to insulin underlies the metabolic syndrome, in addition, an increase in the number of visceral fat, arterial hypertension, failures in lipid, carbohydrate and purine metabolism.

There are clear criteria for diagnosing metabolic syndrome according to the International Diabetes Federation (IDF). Presence of abdominal obesity in combination with any two of the following conditions is required:

• an increase in triglycerides;
• lowering the fraction of "good" cholesterol - high density lipoproteins (HDL);
• development of arterial hypertension;
• there is impaired glucose tolerance or type II diabetes mellitus.

The treatment of metabolic syndrome is symptomatic, in addition, it is necessary to rebuild lifestyle and nutrition. The main points are:

• weight loss possible medicinal treatment obesity;
• physical activity is required, the fight against hypodynamia;
• therapy of arterial hypertension;
• treatment of impaired glucose tolerance and type II diabetes mellitus;
• correction of impaired lipid metabolism (dyslipoproteinemia).

Insulin resistance can exist without the presence of a complex that characterizes the metabolic syndrome. For example, 10% of people with this pathology do not have any metabolic disorders.

One of the manifestations of metabolic disorders, due to a decrease in the sensitivity of insulin receptors, is a violation of lipid metabolism (dyslipidemia).
Triglycerides accumulate in the liver tissue and cause the formation of steatosis. The degree of fatty infiltration depends on the percentage of hepatocytes that have accumulated fatty deposits:

1. soft - up to 30%;
2. moderate - from 30 to 60%;
3. expressed - more than 60%.

With the elimination of the causes that caused these disorders, the deposition of fat in hepatocytes is significantly reduced. Steatosis is a reversible process.

As the disease progresses, free fatty acids are released from the lipid tissue. These compounds, in combination with some other factors, contribute to the development of oxidative stress, which leads to inflammation and subsequent destruction of liver cells. There is a transition of steatosis to steatohepatitis.

NAFLD symptoms can also occur in people without clinical signs metabolic syndrome. In this case, the leading role belongs to the phenomenon of dysbiosis (violation of the qualitative composition of the intestinal microflora). This disrupts the formation of compounds that are responsible for the synthesis of "bad" very low density lipoproteins (VLDL).
Intestinal endotoxicosis, which occurs with dysbiosis, can be another cause of oxidative stress.

Clinical manifestations and diagnosis

The course of the disease in the vast majority of cases is asymptomatic, especially in the stage of steatosis. The impetus for further diagnostic search is accidentally identified elevated levels hepatic transaminases or ultrasound signs of fatty degeneration of the liver. Moreover, these surveys are often performed in preventive purposes or for other illnesses.

Sometimes the patient may complain of a non-specific nature: weakness, fatigue, unexpressed discomfort in the right hypochondrium. More specific complaints, such as nausea, vomiting, pruritus, severe pain, as well as icteric syndrome and manifestations of portal hypertension, occur already in advanced forms.

The patient's history should be carefully collected. It is worth asking the patient about alcohol abuse, uncontrolled intake of hepatotoxic drugs, infection with hepatitis viruses and other causes that can cause damage to hepatocytes.

During examination, in most patients, an enlarged liver is palpated, and in some, the spleen.

Laboratory examination

Enough informative biochemical study of blood. Based on the results of the analysis, it is possible to determine the level of involvement of the liver in the pathological process. Main biochemical indicators:

• Observed (ALT, AST, alkaline phosphatase, GGT and some others). The revealed increases in activity are most often moderate, no more than 3-5 times. The ALT/AST index usually does not exceed 2.
• Manifestations of dyslipidemia - an increase in the level of triglycerides and cholesterol with a predominance of "bad" lipoproteins (VLDL and LDL).
• Manifestations of disorders of carbohydrate metabolism - impaired glucose tolerance or diagnosed type II diabetes mellitus.
• In the case of advanced forms of NAFLD, the amount of bilirubin in the blood may increase, signs of a violation of protein metabolism (for example, a decrease in albumin) may appear, and prothrombin time may increase, etc.

You should be aware that in some patients, the activity of hepatic transaminases is within the normal range or only slightly increased, even with an advanced stage of the disease.

Instrumental examination

Applies ultrasonography, computed or magnetic resonance imaging. These methods help to assess the degree of fatty liver damage, identify hepatomegaly, help in the diagnosis possible complication- Portal hypertension.

It helps to differentiate steatosis from steatohepatitis, assess the degree and prevalence of fibrosis, and make a prognosis of the course of the disease. Unfortunately, this diagnostic method is not always available for various reasons.

Indications for a mandatory puncture biopsy are:

1. age (from 46 years) of manifestations of chronic liver cytolysis of unknown origin;
2. combination of chronic cytolysis unclear etiology with signs of metabolic syndrome.

How is non-alcoholic hepatitis treated?

There are as yet no specific criteria and standards for drug therapy for NAFLD.
The detected metabolic disorders are corrected. It is necessary to change the diet to a dietary one, increase activity or introduce sports loads, this will help prevent the development or progression of the process.

Any drug therapy should be carried out very carefully in such patients, especially drugs that have a potentially hepatotoxic effect (corticosteroids, amiodarone, tamoxifen, and others). Therefore, it is necessary to take into account the presence of NAFLD in the treatment of concomitant diseases.

The main methods of therapy

For overweight and obese individuals, dietary adjustments are necessary to reduce weight.
The calorie content of food is calculated using special methods, taking into account the initial body weight, age, gender, intensity of physical activity.

Weight loss should be gradual and gradual. A sharp decrease in body weight can provoke the development of acute non-alcoholic steatohepatitis due to the penetration of free fatty acids into the liver against the background of active breakdown of fat cells. A weekly weight loss of 600g for children and 1600g for adults is considered safe.

Key points:

• decrease in daily energy value(calorie) diet;
• limiting the mass fraction of fats in the diet (up to 30%);
• the use of foods with a high content of polyunsaturated fatty acids;
• cutting back on foods rich in cholesterol;
• exclusion of fried foods;
• for patients with type II diabetes or impaired glucose tolerance, consume foods with a low glycemic index;
• exclusion of alcohol and other bad habits;
• the inclusion in the diet of foods rich in fiber, which have natural antioxidant properties.

Preparations

Combined schemes are used for the treatment of non-alcoholic hepatosis. For each situation, treatment may vary. The main list of drug categories:

• Drugs that increase the sensitivity of insulin receptors: biguanides (metformin) and thiazolidinediones (rosiglitazone, pioglitazone). Have a positive effect in patients with insulin resistance. However, research is still ongoing for the widespread use of these drugs for the treatment of NAFLD.
• lipid-lowering drugs. They are divided into two subgroups - fibrates and statins. They are prescribed for people with lipid metabolism disorders who are not amenable to therapy by other means.
• Antioxidants and hepatoprotectors. This group of agents includes tocopherol acetate, N-acetylcysteine, betaine, silibinin, etc. Considering the important role of oxidative stress in the progression of NAFLD, the use of antioxidants gives a positive result. There is evidence that the combination of antioxidants and hepatoprotectors reduces the manifestations of dyspepsia and favors the regression of pathological changes in the liver.

Restoration of microflora

Particular attention is paid to the intestines and the restoration of normal microbiocenosis. Given the important role of bacterial hepatoendotoxins in intestinal dysbiosis in the pathogenetic chain of NAFLD development, correction of the intestinal microflora is recommended. For this purpose, probiotics are used in most cases. Antibacterial and antiseptic drugs for dysbiosis are used according to very strict indications.

Treatment of concomitant diseases and syndromes is recommended. Dispensary observation such patients includes monitoring the levels of biochemical and metabolic parameters, anthropometric measurements once every 6 months, ultrasound of the abdominal organs once a year.
According to the survey, if necessary, the therapy is adjusted.

In conclusion, it should be said that research is still ongoing to develop optimal approaches to the treatment and prevention of NAFLD. All risk factors that can lead to liver damage should be considered and all possible measures should be taken to minimize these manifestations.

Fatty liver disease is characterized by the accumulation of fatty deposits in the liver. They are formed in cells, as a result, the normal development of hepatocytes (structural elements of the liver) is disrupted. Healthy cells are replaced by products over time fat metabolism. With the progression of the disease, scars form in the liver tissue (fibrosis is formed). The liver ceases to perform its biological functions, patients feel unwell, specific symptoms begin to appear.

This disease has many names, at the moment the medically accepted name sounds like fatty liver disease. For reasons, two types of the disease are distinguished: alcoholic hepatosis and non-alcoholic. Non-alcoholic fatty liver disease (NAFLD) occurs for a variety of reasons.

According to WHO, this disease affects up to 25% of the population in developed countries. Experts sound the alarm and say that the current situation can be called an epidemic. At the moment, NAFLD is classified as a disease of civilization, that is, a disease, the progression of which is directly related to the level of well-being.

Stages of development of the disease

There are three main stages of progressive disease. The first stage is called steatosis. It is characterized by fatty degeneration of liver cells. Excess fats enter the cells, and their excretion slows down.

When a certain percentage of fatty compounds accumulate in the cells, the second stage begins - steatohepatitis. Characterized by the development inflammatory process in the liver.

The third, last stage is characterized by the replacement of liver cells with connective tissue cells. Accordingly, the liver partially loses its main functions, fibrosis develops, and then cirrhosis.

The development of non-alcoholic fatty liver disease is similar to the development of alcoholic fatty liver disease. The disease goes through the same three stages. The difference is in the causes of the disease and the rate of development of the pathological process, non-alcoholic hepatosis progresses more slowly.

Causes of fatty liver disease

Since the disease is not fully understood, it is customary to talk about several risk factors for the development of the disease:

• Overweight, especially obesity. It has been proven that overweight people are 60% more susceptible to this disease. In the case of the extreme stage of obesity, this figure increases to 90%. The data are relevant for both the adult population and obese children.
• Excessive deposition of abdominal fat in people of normal weight also increases the risk of developing NAFLD.
• Insulin resistance. This risk factor is relevant for patients with type 2 diabetes, as well as for people with severe obesity.
• Some diseases of the digestive tract, leading to an imbalance in the intestinal microflora, indigestion.
• Long-term use of drugs with a hepatotoxic effect.

Experts note that this list of risk factors does not explain the sharp increase in the incidence in recent years. There is currently a popular hypothesis supported by the WHO. It says that the main cause of the disease is the excessive consumption of carbohydrates, especially fructose, which is popular with dieters.

Symptoms of non-alcoholic hepatosis

There are general symptoms and specific signs characteristic of this disease.

Common symptoms include:

• Unreasonable fatigue, increased fatigue.
• Feeling of fullness and discomfort in the right hypochondrium, slight pain.
• Decreased appetite.

Specific symptoms of fatty liver disease appear as the disease progresses:

• Periodic nausea, possible vomiting.
• Pain and discomfort in the liver.
• Yellowing of the skin and sclera.

At the first stage, the patient may not notice the manifestations of the disease at all. It is possible to identify the disease at the initial stage with the help of instrumental diagnostics.

Diagnosis and treatment of non-alcoholic fatty liver disease

To make a diagnosis, a number of examinations are used:

• Ultrasound of the abdominal organs.
• Liver elastography.
• Laboratory diagnostics (clinical and biochemical blood tests).
• Computed tomography of the abdominal organs.

Treatment for NAFLD begins only after a diagnosis has been made.

The therapy is conservative. Prescribe a diet, exclude all harmful and provoking factors. The main treatment for fatty liver disease is to take drugs that protect liver cells from further destruction.

The essence of the treatment is to protect the remaining liver cells and reduce weight. With a decrease in body weight of only 5%, patients notice a noticeable improvement. It is important to reduce weight gradually, a sharp weight loss can lead to an exacerbation of the disease. Accordingly, the treatment of liver hepatosis is a whole range of conservative measures aimed at regressing the disease and improving the patient's well-being.

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Prevention of NAFLD

The main recommendation for the prevention of this disease is to maintain healthy lifestyle life. In the first place is maintaining a normal weight and proper nutrition. It is important to exclude as many risk factors as possible: monitor body weight, do not overeat, get rid of bad habits.

Among the preventive measures are also maintaining an active lifestyle, moderate physical activity and proper drinking regimen.

Non-alcoholic liver steatosis (non-alcoholic fatty liver disease (NAFLD), fatty liver, fatty liver, fatty infiltration) - primary disease liver or a syndrome formed by excessive accumulation of fats (mainly triglycerides) in the liver. If we consider this nosology from a quantitative point of view, then "fat" should be at least 5-10% of the weight of the liver, or more than 5% of hepatocytes should contain lipids (histologically).

If you do not intervene during the course of the disease, then in 12-14% of NAFLD it transforms into steatohepatitis, in 5-10% of cases - into fibrosis, in 0-5% of cases fibrosis turns into cirrhosis of the liver; in 13% of cases, steatohepatitis immediately transforms into cirrhosis of the liver.

These data make it possible to understand why this problem is of general interest today, if the etiology and pathogenesis are clear, then it will be clear how to most effectively treat this common pathology. It is already clear that in some patients this may turn out to be a disease, and in others it may be a symptom or syndrome.

The recognized risk factors for developing NAFLD are:

• obesity;
• type 2 diabetes mellitus;
• fasting (dramatic weight loss > 1.5 kg/week);
• parenteral nutrition;
• presence of ileocecal anastomosis;
• excess bacterial growth in the intestines;
• many medications(corticosteroids, antiarrhythmic drugs, anticancer drugs, non-steroidal anti-inflammatory drugs, synthetic estrogens, some antibiotics, and many others).

The listed risk factors for NAFLD show that a significant part of them are components of the metabolic syndrome (MS), which is a complex of interrelated factors (hyperinsulinemia with insulin resistance - type 2 diabetes mellitus (T2DM), visceral obesity, atherogenic dyslipidemia, arterial hypertension, microalbuminuria, hypercoagulation, hyperuricemia, gout, NAFLD). MS is the basis of the pathogenesis of many cardiovascular diseases and indicates their close relationship with NAFLD. Thus, the range of diseases that forms NAFLD is noticeably expanding and includes not only steatohepatitis, fibrosis, cirrhosis of the liver, but also arterial hypertension, ischemic disease heart disease, myocardial infarction and heart failure. At least if the direct links of these conditions require further study of the evidence base, their mutual influence is undoubted.

Epidemiologically, there are: primary (metabolic) and secondary NAFLD. The primary form includes most of the conditions that develop with various metabolic disorders (they are listed above). The secondary form of NAFLD includes conditions that are formed by: alimentary disorders (overeating, starvation, parenteral nutrition, malnutrition - kwashiorkor); medicinal effects and relationships that are realized at the level of hepatic metabolism; hepatotropic poisons; syndrome of excessive bacterial growth of the intestine; diseases small intestine accompanied by a syndrome of impaired digestion; resection of the small intestine, small intestine fistula, functional pancreatic insufficiency; liver diseases, including genetically determined ones, acute fatty disease of pregnant women, etc.

If the doctor (researcher) has morphological material (liver biopsy), then three degrees of steatosis are morphologically distinguished:

• 1st degree - fatty infiltration< 33% гепатоцитов в поле зрения;
• 2nd degree - fatty infiltration of 33-66% of hepatocytes in the field of view;
• 3rd degree - fatty infiltration> 66% of hepatocytes in the field of view.

Having given the morphological classification, we must state that these data are conditional, since the process is never uniformly diffuse, and at each specific moment we consider a limited tissue fragment, and we are sure that in another biopsy we will get the same most, no, and, finally, the 3rd degree of fatty infiltration of the liver should have been accompanied by functional liver failure (at least for some components: synthetic function, detoxification function, biliary capacity, etc.), which is practically not characteristic of NAFLD.

The above material shows the factors and metabolic states that may be involved in the development of NAFLD, and as modern model pathogenesis, the theory of "two blows" was proposed:

the first is the development of fatty degeneration;
the second is steatohepatitis.

With obesity, especially visceral, the intake of free fatty acids (FFA) into the liver increases, and liver steatosis develops (the first blow). Under conditions of insulin resistance, lipolysis in adipose tissue increases, and excess FFA enters the liver. As a result, the amount of fatty acids in the hepatocyte increases dramatically, and fatty degeneration of hepatocytes is formed. Simultaneously or sequentially, oxidative stress develops - a "second blow" with the formation of an inflammatory reaction and the development of steatohepatitis. This is largely due to the fact that the functional capacity of mitochondria is depleted, microsomal lipid oxidation in the cytochrome system is activated, which leads to the formation of reactive oxygen species and an increase in the production of pro-inflammatory cytokinins with the formation of inflammation in the liver, hepatocyte death due to the cytotoxic effects of TNF-alpha1 - one of the main inducers of apoptosis. The subsequent stages in the development of liver pathology and their intensity (fibrosis, cirrhosis) depend on the remaining factors in the formation of steatosis and the lack of effective pharmacotherapy.

Diagnosis of NAFLD and conditions of its progression (hepatic steatosis, steatohepatitis, fibrosis, cirrhosis)

Fatty degeneration of the liver is formally a morphological concept, and it would seem that diagnosis should be reduced to a liver biopsy. However, such a decision was not made by international gastroenterological associations and the issue is being discussed. This is due to the fact that fatty degeneration is a dynamic concept (it can be activated or undergo regression, it can be both relatively diffuse and focal). The biopsy specimen is always represented by a limited area, and the interpretation of the data is always rather arbitrary. If biopsy is recognized as a mandatory diagnostic criterion, then it should be performed quite often; the biopsy itself is fraught with complications, and the research method should not be more dangerous than the disease itself. The absence of a biopsy decision is not a negative factor, especially since today liver steatosis is a clinical and morphological concept with many factors involved in pathogenesis.

From the data presented above, it can be seen that diagnostics can begin at different stages diseases: steatosis → steatohepatitis → fibrosis → cirrhosis, and the diagnostic algorithm should include methods that determine not only fatty degeneration, but also its stage.

So, at the stage of liver steatosis, the main symptom is hepatomegaly (detected by chance or during a dispensary examination). The biochemical profile (aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (AP), gamma-glutamyl transpeptidase (GGT), cholesterol, bilirubin) determines the presence or absence of steatohepatitis. With an increase in the level of transaminases, it is necessary to conduct virological studies (which will either confirm or reject the viral forms of hepatitis), as well as the diagnosis of other forms of hepatitis: autoimmune, biliary, primary sclerosing cholangitis. Ultrasound examination not only establishes an increase in the size of the liver and spleen, but also signs of portal hypertension (by the diameter of the splenic vein and the size of the spleen). Less commonly used (and perhaps well-known) is the assessment of fatty infiltration of the liver, which consists in measuring the “attenuation column”, the dynamics of which at different time intervals can be used to judge the degree of fatty degeneration (Fig.) (ultrasound technique is described) .

Earlier models of ultrasonic devices evaluated densitometric indicators (by the dynamics of which it was possible to judge the dynamics and degree of steatosis). Currently, densitometric indicators are obtained using computed tomography of the liver. Considering the pathogenesis of NAFLD, assess the general examination, anthropometric indicators (determination of body weight and waist circumference - OT). Since MS occupies a significant place in the formation of steatosis, it is necessary to evaluate in the diagnosis: abdominal obesity - WC > 102 cm in men, > 88 cm in women; triglycerides > 150 mg/dl; high density lipoproteins (HDL):< 40 мг/дл у мужчин и < 50 мл/дл у женщин; артериальное давление (АД) >130/85 mmHg st; body mass index (BMI)> 25 kg / m 2; fasting glycemia > 110 mg/dl; glycemia 2 hours after glucose load 110-126 mg/dL; Type 2 diabetes, insulin resistance.

The data presented above are recommended by WHO and the American Association of Clinical Endocrinologists. An important diagnostic aspect is also the establishment of fibrosis and its degree. Despite the fact that fibrosis is also a morphological concept, it is determined by various calculated indicators. From our point of view, the Bonacini discriminant score scale, which determines the fibrosis index (FI), is a convenient method corresponding to the stages of fibrosis. We spent comparative study calculated index of IF with the results of biopsies. These indicators are presented in table. 1 and 2.

Practical value of IF:

1) IF, assessed on a discriminant counting scale, significantly correlates with the stage of liver fibrosis according to needle biopsy data;
2) the study of IF allows with a high degree probability to assess the stage of fibrosis and use it for dynamic monitoring of the intensity of fibrosis in patients with chronic hepatitis, NAFLD and other hepatic diffuse diseases, including for evaluating the effectiveness of ongoing therapy.

And finally, if a puncture biopsy of the liver is performed, then it is usually prescribed in case of differential diagnosis tumor formations, including focal forms of steatosis. At the same time, in the liver tissue of these patients, the following are detected:

• fatty degeneration of the liver (large-drop, small-drop, mixed);
• centrilobular (less often portal and periportal) inflammatory infiltration by neutrophils, lymphocytes, histiocytes;
• fibrosis (perihepatocellular, perisinusoidal and perivenular) of varying severity.

The diagnosis of NAFLD (liver steatosis) is formulated on the basis of a combination of the following symptoms and provisions:

• obesity;
• malabsorption syndrome (as a consequence of the imposition of ileojejunal anastomosis, biliary-pancreatic stoma, extended resection of the small intestine);
• long-term (more than two weeks parenteral nutrition).

Diagnosis also involves the exclusion of the main hepatic nosological forms:

• alcoholic liver damage;
• viral damage (B, C, D, TTV);
• Wilson-Konovalov's disease (the level of circuloplasmin in the blood is examined);
• congenital alpha1-antitrypsin deficiency disease);
• hemachromatosis;
• autoimmune hepatitis;
• drug-induced hepatitis (drug history and withdrawal possible drug that forms intermediate density lipoproteins (IDLs)).

Thus, the diagnosis is formed from the definition of hepatomegaly, the definition of pathogenetic factors contributing to steatosis, and the exclusion of other diffuse forms of liver damage.

Healing principles

Since the main factor in the development of non-alcoholic liver steatosis is excess body weight (BW), a decrease in BW is a fundamental condition for the treatment of patients with NAFLD, which is achieved by changing lifestyle, including dietary measures and physical activity, including in cases where it is necessary in the decrease in MT is absent. The diet should be hypocaloric - 25 mg / kg per day with restriction of animal fats (30-90 g / day) and a decrease in carbohydrates (especially quickly digestible) - 150 mg / day. Fats should be predominantly polyunsaturated, which are found in fish, nuts; it is important to consume at least 15 g of fiber from fruits and vegetables, as well as foods rich in vitamin A.

In addition to diet, you need at least 30 minutes of daily aerobic exercise. physical activity(swimming, walking, gym). Physical activity itself reduces insulin resistance and improves quality of life.

The second important component of therapy is the impact on the metabolic syndrome and insulin resistance in particular. Of the drugs focused on its correction, metformin is the most studied. At the same time, it was shown that treatment with metformin leads to an improvement in laboratory and morphological parameters of inflammatory activity in the liver. Insulin sensitizers are used in type 2 DM, and a meta-analysis did not show any benefit of their effect on insulin resistance.

The third component of therapy is the exclusion of the use of hepatotoxic medicines and drugs that cause liver damage (the main morphological substrate of this damage is liver steatosis and steatohepatitis). In this regard, taking a drug history and avoiding the drug(s) that damage the liver is important.

Since bacterial overgrowth syndrome (SIBO) plays an important role in the formation of hepatic steatosis, it must be diagnosed and corrected (preparations with antibacterial action - preferably non-absorbable; probiotics; motility regulators, liver protectors), and the choice of therapy depends on the initial pathology , which forms the SIBR.

The issue of using liver protectors is not entirely correct today. There are works that show their low efficiency, there are works that show them high efficiency. It seems that their use does not take into account the stage of NAFLD. If there are signs of steatohepatitis, fibrosis, cirrhosis of the liver, then their use seems reasonable. I would like to present analytical data, on the basis of which and depending on the number of factors involved in the pathogenesis of NAFLD, one can choose a hepatoprotector (Table 3).

From the presented table it can be seen (the most used protectors are introduced, if desired, it can be expanded by introducing other protectors) that ursodeoxycholic acid preparations (Ursosan) act on the maximum number of pathogenetic links of liver damage.

We would like to present the results of treatment with Ursosan in patients with NAFLD. 30 patients were studied (15 of them were based on obesity, 15 on MS; there were 20 women, 10 men; age from 30 to 65 years (mean age 45 ± 6.0 years).

The selection criteria were: an increase in the level of AST — 2-4 times; ALT - 2-3 times; BMI > 31.1 kg/m 2 in men and BMI > 32.3 kg/m 2 in women. Patients received Ursosan at a dose of 13-15 mg/kg of body weight per day; 15 patients for 2 months, 15 patients continued taking the drug up to 6 months. The results of treatment are presented in table. 4-6.

The exclusion criteria were: the viral nature of the disease; concomitant pathology in the stage of decompensation; taking drugs that are potentially capable of forming (maintaining) fatty degeneration of the liver.

Group 2 continued to receive Ursosan at the same dose for 6 months (with normal biochemical parameters). At the same time, appetite stabilized, body weight gradually (1 kg/month) decreased. According to ultrasound data, the structure and size of the liver did not change significantly, the dynamics continued along the “decay column” (Table 6).

Thus, according to our data, the use of hepatic protectors in patients with NAFLD in the stage of steatohepatitis is effective, which is reflected in the normalization of biochemical parameters and a decrease in fatty infiltration of the liver (according to ultrasound data, a decrease in the “attenuation column” of the signal), which in general is an important rationale for their use.

Literature

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O. N. Minushkin, doctor of medical sciences, professor

FSBI UNMC Office of the President of the Russian Federation, Moscow

What is it and can you get rid of it? It all depends on the patient and his willpower. After all, it is not so easy to change your lifestyle and improve nutrition. But these simple changes will bring the body back to normal and save it from the occurrence of liver disease.

If liver dysfunction is detected, the cause of the disease should be established, and, starting from it, treatment should be started. Timely diagnosis not prevent. The risk category includes women, as well as men who drink alcohol.

What is steatosis?

Fatty degeneration of the liver, or as it is also called steatosis, is a pathology. With this disease, fat, in the form of drops, is collected in hepatocytes. With the accumulation of a large amount of fat, the hepatocyte bursts, and the fat enters the space between the cells, thereby creating a cyst, which prevents the liver from functioning normally.

This disease occurs at any age, even in children. But most often occurs after the age of forty-five years. Individuals of the weaker sex are more prone to non-alcoholic steatosis. Representatives of the stronger sex - steatosis, which appeared as a consequence of regular intake alcoholic beverages. Steatosis can be both an independent disease and a consequence of another disease (diabetes mellitus, etc.).

Diagnostics

To obtain reliable results, one should complex diagnostics. First of all, such studies should be carried out to help avoid steapatogenesis:

• Tests for the presence of steatosis, which help to assess the condition of the liver and reliably establish the diagnosis. It is advised to take a biochemical blood test, which will assess the rate of iron metabolism. In combination with it, a genetic test is carried out in order to exclude hemochromatosis. They also donate blood for serology, which helps determine the presence of any form viral hepatitis. In people with steatosis, there are normal performance bilirubin, albumin and prothrombin. But serum tragsaminase and alkaline phosphatases increase somewhat. If the causative agent of the disease is alcohol, then the amount of ji-glutamyl transpeptidase increases.
• Ultrasound diagnosis is a necessary study for such a disease. Can go as an independent analysis, and in combination with others. Determines the size of the liver, the occurrence of tumors. It is advised to conduct an ultrasound of the spleen, because with a disease of the second and third degree, it increases in size.
• A biopsy is a puncture in which the material taken is examined under a microscope and the presence of fat is determined.
• Tomography helps to establish the density of the tissue and determine all the changes that have occurred in the liver.

Hepatic steatosis of the first degree is the accumulation of fat in the cells, which does not lead to the destruction of their structure.

Second-degree steatosis is the occurrence of fatty tumors between tissue cells, which leads to serious consequences.

Moderate steatosis is the appearance of cysts, which are based on neutral fats that do not destroy the structure of the cell.

Causes and symptoms of the disease

The main cause of steatosis is called a metabolic disorder and an imperfect hormonal background. As a result, diabetes mellitus appears and the amount of lipids in the blood increases. And this leads to heart problems.

Also, the causes of pathology can be:

• Bad habits;
• Overeating and excess weight;
• Hepatitis viruses;
• Poor nutrition;
• metabolic syndrome;
• An increase in the number of liver enzymes;
• Genetics;
• The use of non-steroidal anti-inflammatory drugs.

In some cases, the symptoms of steatosis do not show themselves. Then it can be detected only during specialized diagnostics. The most common symptoms of the disease are weakness of the body, nausea, a sharp increase in the size of the liver, pain under the right hypochondrium.
Very often, patients are exposed to various kinds of infections. This is due to low immunity.

Types of steatosis

Liver steatosis can manifest itself in the following forms:

diffuse steatosis

It occurs when fat deposits do not occur in the second and third lobes of the liver, but are distributed diffusely (over the entire surface of the organ).

Fatty steatosis

It affects not only the increase in the size of the liver, but also its color. With this type of disease, it changes to yellowish or red-brown. The result is the death of liver cells. It is asymptomatic, it is possible to determine fatty stetosis only after undergoing an ultrasound examination.

Alcoholic steatosis

called alcohol intoxication. The second name is fatty degeneration of the liver. There are many reasons for the manifestation of the disease in this form. The most important is the use of drinks containing alcohol. The progress of the disease is directly related to the dose of alcohol consumed: the larger it is, the sooner pathological processes occur.

The consequences are completely reversible and curable. But if the recommendations are not followed, alcoholic steatosis turns into a serious illness. It occurs in two forms: macro- and microvesicular. The first one is chronic manifestation diseases, the second - an acute form.

Non-alcoholic steatosis

They are called differently: infiltration, fatty degeneration or non-alcoholic fatty disease. If timely treatment is not carried out, then this type of steatosis can develop into steatohepatitis, fibrosis or cirrhosis. Occurs due to excess weight, diabetes or anastomosis. Also, it can accompany people who are losing weight dramatically or their parenteral nutrition.

Non-alcoholic steatosis can also occur as a result of a large number of bacteria in the intestine or taking certain medications. It is difficult to determine the disease with the help of diagnostics. All indicators are normal, only slightly increased activity of serum transaminases. A reliable diagnosis can only be made after magnetic resonance imaging.

focal steatosis

With it, the disease can be determined only in the case of a slight increase in the activity of the enzymes of cholestasis and cytolysis. Diagnosis can be carried out only under the condition of instrumental studies. If the tumor is benign, then it will have smooth and clear contours, of different sizes.

Which doctor should I contact?

When pain in the area of ​​​​the liver, it is advised to first of all consult a therapist. After carrying out the necessary diagnostics, he will refer you to a more narrow-profile specialist. If steatosis is in the initial stage, then the general practitioner is quite capable of prescribing treatment himself.

If the patient is quite sure that the pain in the right hypochondrium is a problem with the liver, then you can safely go to the gastroenterologist. He treats not only diseases gastrointestinal tract but also the liver.

If it is impossible to establish a reliable diagnosis, you should contact a specialist such as a hepatologist. He has a deeper knowledge of various treatment methods that help to reliably establish a diagnosis and choose a course of treatment. The downside is that not all clinics have such a doctor.

Medical treatment

The course of treatment of steatosis is selected for each patient individually, based on the causes and types of the disease. The cause can be determined by diagnosing the level of cholesterol, ceruloplasmin and the amount of enzymes. The following groups of drugs are prescribed:

• Lipotropic, which affect metabolism. This includes folic acid, lipoic acid, all B vitamins.
• Hepatoprotectors that protect hepatocytes from damage. These are drugs Hepa-Merz, Ursohol, Essentiale, Heptral, Karsil.
• Statins and fibrates, which normalize lipid volume and prevent fat from accumulating on the walls of blood vessels.
• Thiazolindiones, which regulate the amount of sugar in the blood. This group includes Prioglitazoline, Rosiglitazoline.

Helps with fatty steatosis such a tool as Metformin. The principle of its action is to prevent the production of glucose by cells. Based on this, sugar and fat metabolism is regulated.

It is very important to take funds based on milk thistle: Karsil, Legalon, Gepabene and Silymarin. They remove the symptoms and affect a faster cure.

Treatment with folk remedies

There are many herbs that cleanse and restore the liver. The main ones are milk thistle and calendula. They are used in the form of oils, decoctions and infusions. Also, effective plants are:

• Corn silk;
• Immortelle;
• St. John's wort;
• Rose hip;
• horsetail;
• Dill seeds;
• Mint;
• Nettle.

With liver steatosis, it is advised to eat several apricot kernels per day, since they contain high level vitamin B5.

To prepare a decoction of milk thistle, you need to take it and dandelion root in the same proportion (one spoon each). Steam half a liter of water in a thermos. Leave for twenty minutes. Take a glass twice a day.

This recipe will also help: cut off the top of the pumpkin and peel it from the seeds. Pour honey inside. To insist fourteen days. After - drain the honey and use it in a spoon three times a day.

Take a cocktail on an empty stomach. For him, mix milk and carrot juice (one hundred milliliters of each substance).

With steatosis, it is advised to use a rosehip decoction, a glass twenty minutes before meals.

Possible Complications

Since the liver is an organ that leaves an imprint on the work of other systems, the treatment of steatosis should begin as soon as possible.

First of all, the digestive system suffers, as bile stagnation begins and stones form. Unpleasant changes occur in the cardiovascular system. Blood pressure rises, shortness of breath and varicose veins occur. Vision and skin elasticity may decrease.

There is a violation of the hormonal balance, as well as a decrease in immunity.

Diet

To compile the recommended menu, it is advised to visit a specialist. But first of all, you need to reduce the calorie content of your diet. Nutrition should be balanced, namely the ratio of food 1:1:4 (proteins, fats, carbohydrates). You need to eat three to four times a day with a five-hour break.

Products to be excluded:

• Roast;
• Bold;
• smoked;
• soda;
• legumes;
• caffeinated drinks;
• seasonings;
• Ice cream;
• Nuts;
• Alcohol.

With steatosis, the patient should include in his diet dairy products, stewed and boiled fish, vegetables, fruits and flour (not confectionery).

Prevention

Prevention of steatosis in the first place is a review of lifestyle. Food should be of high quality and useful. Special attention should be paid to physical activity - walking, playing sports and gymnastics. Alcohol can be consumed in a minimal amount, and it is better to refuse it altogether.

And finally

For those who are interested in whether steatosis can be cured, there is only one answer - it all depends on the patient and his desire. In order to avoid problems in the work of the liver, you need to reconsider your lifestyle, adjust the regimen, activity and nutrition.

Those who suffer from a more severe stage. It is advised to completely abandon alcohol and conduct diagnostics in a timely manner to determine at what stage the disease is. And do not forget to visit the doctor periodically.

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