An ultrasound on a 51-year-old man with mild alanine amino­transferase (ALT) elevation (77 units/L) showed gross, grade 3 fatty infiltration of the liver. He does not drink alcohol or use IV drugs, nor does he complain of abdominal pain. A hepatitis panel was negative, and random glucose was normal. Of what significance is the ultrasound finding? Does it require follow-up? — Leigh Bears, NP, New London, Conn.

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Nonalcoholic fatty liver disease (NAFLD) is rapidly emerging as one of the most common “incidental findings” identified with radiographic testing. One in four adults is found to have the condition when undergoing abdominal ultrasound.

Although common, NAFLD is anything but benign. Liver biopsy reveals advanced fibrosis in up to 50% of those with NAFLD, and up to 16% have cirrhosis. The mild elevation of ALT described here suggests mild liver inflammation.

NAFLD commonly occurs in the presence of such conditions as diabetes mellitus, obesity, hyperlipidemia, hypertriglyceridemia and hypothyroidism as well as with rapid weight loss, such as that seen with starvation diets, and with a number of pharmacologic agents. Since treatment of underlying conditions is necessary, these entities should be considered when managing patients with NAFLD.

Liver biopsy is the gold standard for diagnosing NAFLD. Ultrasound analysis is not very specific because other liver diseases, such as iron overload (hemochromatosis), can resemble fatty liver. Fortunately, a biopsy is generally not necessary unless the condition resists treatment. Since the patient described has already been tested for diabetes, he should now be evaluated for thyroid disease and hyperlipidemia/hypertriglyceridemia.

A thorough medication history should also be obtained. In addition, if he is overweight, a referral to a dietitian for gradual weight loss is in order. Liver enzymes should be rechecked after three to six months and, if still elevated, liver biopsy should be considered. A biopsy showing fibrosis often provides much-needed incentive for lifestyle modification. For more information, refer to Sleisenger M, Fordtran J, eds. Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 7th ed. Philadelphia, Pa: WB Saunders; 2002:1393-1401.—Bruce D. Askey, MSN, CRNP (157-10)

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