Pediatric non-alcoholic fatty liver disease:
Increasing awareness in the primary care setting
By Hanna Sauer, RN, BSN
495 Cicada Court, Reno, NV 89521
(775) 303-4779 sauerhanna@gmail.com Abstract: Non-alcoholic fatty liver disease (NAFLD) can lead to cirrhosis and hepatocellular carcinoma in children and adolescents. Primary care providers have a unique position to identify and screen for the disease in its early stages. This article provides an overview of prevalence, expert guidelines, screening, treatment, and implications for the advanced practice registered nurse (APRN).
Introduction
Non-alcoholic fatty liver disease (NAFLD) is a major complication of childhood
…show more content…
According to a landmark article by Browning et al, prevalence of NAFLD was described as being highest in the Hispanic population and lowest among Black Americans, and Caucasians with an intermediate prevalence. The differences were thought to be related to insulin resistance, visceral adiposity, genetics and socioeconomic status9.
Overnutrition, specifically excessive consumption of fructose, is fundamental to NAFLD development10. Fructose metabolism, unlike glucose, occurs nearly exclusively in the liver and is preferentially selected for lipogenesis. The triglyceride production and storage that results from fructose ingestion is highly associated with central obesity, dyslipidemia, and insulin resistance11. This relevant finding is especially important to clinicians, as this modifiable risk factor may be easily addressed.
Screening Guidelines and Recommendations
The majority of children with NAFLD are asymptomatic. Occasionally patients may complain of vague abdominal pain, fatigue, or malaise, however, liver disease is usually found incidentally on physical exam or routine lab work1. Children may have mild to moderate hepatomegaly; however, the majority of these children are overweight or obese, making liver palpation a challenge. In addition to obesity and visceral adiposity, children with NAFLD often present with acanthosis nigricans on the back of their neck or intertrigenous areas, which is suggestive of insulin
Acanthosis nigricans is “a darkening and thickening of the skin in the back of the neck that can signal prediabetes”(Park 44). Then children who have these symptoms would be sent home with a letter, Park explains that it would be no different than sending them home if they had lice. Even though this is a good strategy for finding early symptoms, it is not a very effective preventative for obesity. To clarify, most parents will not know what to do with that information, some might even argue that it is wrong or that it is a lie. The only way I personally see this as being effective is if the parent after reading the letter takes their child to the doctor for an examination. Then for the doctor to set up a program that further addresses
In the presented case scenario, we have Mr. Gil Martin who is a 55-year-old Hispanic male. He comes in to the clinic today with complaints of weakness, fatigue, and loss of appetite. A student nurse will be precepting your assessment of Mr. Martin and when collecting subjective and objective data it is important to pay close detail to all findings. Ultimately this patient was diagnosis with cirrhosis, which is an abnormal liver condition that leads to irreversible scarring of the liver (National Institute of Health [NIH], 2017), so during assessment we should pay attention to details leading to this diagnosis.
Giving the fact that NAFLD is usually an asymptomatic disorder, it is often unrecognized in everyday clinical practice. Namely, most patients with NAFLD have no symptoms, and aminotransferase levels which are used as a marker of liver damage, are within normal values in almost half of all patients. NAFLD is strongly associated with type 2 diabetes mellitus (T2DM) and has been linked to increased cardiovascular disease (CVD) risk. It is characterized by insulin resistance and mitochondrial dysfunction6. Indeed, there is a gradual increase in the severity of insulin resistance in the range of NAFLD which may contribute to the evolution of liver damage. Also, it is associated with an increased risk of kidney disease in subjects with multiple CVD
The number one preventive measure of liver cirrhosis is to stop drinking alcoholic beverages. Abstinence from alcohol may be difficult for many alcoholics to do, but the result is beneficial for them. Ninety percent of the people with liver cirrhosis who stopped drinking alcohol lives another 5 years, and only seventy percent chance of living less than five years if they continue to drink alcohol (Penny, 2013). According to Leaper and Hamlin, “liver cirrhosis affects protein metabolism and the ability of the liver to store glycogen, which is required for energy (2011). Therefore, people who have cirrhosis are advised to eat foods high in protein and carbohydrates to maintain body’s functions. Limiting protein intake can cause malnutrition or
Additionally, many chronic liver diseases can lead to cirrhosis. For example, nonalcoholic fatty liver disease (NAFLD) can lead to cirrhosis and is associated with obesity, hyperlipidemia, metabolic syndrome and type 2 diabetes mellitus. Hereditary metabolic disorders such as hemochromatosis and Wilson disease can also lead to cirrhosis (McCance & Heuther, 2014). It seems the cause of cirrhosis is multifaceted. Additionally, many diseases can lead to cirrhosis and it is understandable why the etiology of cirrhosis has not been parsed out, especially because the cause can differ from a
It is also important that fibroid patients avoid refined sugar, white floor, alcohol consumption caffeine dosage, and cigarettes smoking which overwork the liver and lead to stagnation and fibroid growth.
Wilson disease is one of the common metabolic liver disorders prevailing worldwide. The diagnosis is always difficult in children [1]. It is also a chronic liver disease for which effective therapy is available therefore, early diagnosis is crucial. However because of its varied range of clinical manifestation, at times the diagnosis is clinically challenging. Early
Humans simply can not live without the liver; it is even in the name “Liver”. The liver is composed of four lobes and is located in the right side of the body. As the heaviest organ, the liver performs a plethora of functions simultaneously. It acts as a refinery by filtering and purifying blood. Moreover, the liver stores carbohydrates by converting it to simple sugars. The liver also takes a major part in digestion by producing bile. Bile is an essential component in processing fats. Bile is originally made in the liver but is stored in the gallbladder. Furthermore, the liver also takes part in the body’s immunity and the production of important blood proteins. Blood is transported to the liver via two vessels: the hepatic artery (blood from the heart), and the hepatic portal vein (blood from the guts). Blood leaves the kidney through the hepatic vein that leads to the heart. For such an important organ, it is no surprise that having a defective
Currently, liver biopsy remains the gold-standard for the diagnosis of NASH as it serves as the only means of distinguishing hepatic steatosis from steatohepatitis through examination of liver histology. According to current AGA guidelines, a liver biopsy should only be considered in patients with NAFLD who are at increased risk to have steatohepatitis and advanced fibrosis, such as those who have metabolic
There are several factors which your doctor will consider in treating liver metastases, and is usually done by a multi-disciplinary team including a liver surgeon, and medical oncologist. The choice of treatment may depend on patient’s health condition, type of primary cancer, and size, location and number of metastatic liver tumours.
Over time the liver is unable to metabolize the alcohol and leads the liver to form fibrous tissue, develop nodules, and the liver shrinks and has a nodular uneven appearance (Pearson, 2015). Biliary cirrhosis is another type of liver disease that is characterized by the inability of bile to be excreted, causing build up within the liver which eventually destroys the cells within the liver. The third type of cirrhosis is known as posthepatic cirrhosis and is the result of a patient having hepatitis B or C resulting from an unknown cause. This type of cirrhosis causes the liver to shrink and become nodular and fibrous resulting in destruction of the liver cells. Risk factors for all three types of cirrhosis include high risk behaviors such as consuming excessive amounts of alcohol, drug use (primarily IV), unsafe sexual behaviors leading to the development of hepatitis B or C. Clinical manifestations of cirrhosis include portal hypertension, which is caused by the portal vein becoming inflamed and casing blood to be rerouted to adjoining lower pressure vessels, splenomegaly, ascites which is the enlargement of the stomach due to a collection of fluid in the abdominal cavity, esophageal varices, which are enlarged, thin walled veins that form in the esophagus, portal, systemic encephalopathy, which is due to neurotoxins being rerouted into the blood, hepatorenal syndrome caused by imbalanced blood flow, and spontaneous bacterial peritonitis, which is a contamination of the peritoneal cavity (Pearson,
The liver is an organ that converts food into energy, absorbs vitamins from a person's diet, removes toxins from the blood, and makes important proteins. Alcoholic liver disease happens when the liver becomes damaged due to alcohol consumption and stops working properly.
In Western countries prevalence of NAFLD in the general population is about 20-30%. Among general population about 2-3% is estimated to have non-alcoholic steatohepatitis (NASH), which may gradually progress to liver cirrhosis and hepatocarcinoma. Life style habits are the main cause of increase in prevalence of NHFLD especially in males. The most important risk factors for NAFLD are male gender, increasing age, obesity, insulin resistance and metabolic syndrome. The prevalence of NAFLD is 80-90% in obese adults, 30-50% in patients with diabetes and up to 90% in patients with hyperlipidemia. Even among children the prevalence of NAFLD 3-10% and in obese children the prevalence may increase up to
The liver disorders discussed were that of a fatty liver and alcoholic liver disease. A fatty liver is a disorder that is characterized by the accumulation of triglycerides within liver cells, causing the liver to enlarge up to three times its normal size. The accumulation of triglycerides in the liver will cause the liver to have a yellow appearance. A fatty liver can be caused several ways, such as obesity, protein energy malnutrition, metabolic disorders, and chronic alcohol consumption. The treatment for a fatty liver depends on the cause for the fatty liver. For example, if a fatty liver is caused by chronic alcohol consumption, then the patient would need to stop consuming alcohol in order to reverse the damage.
Liver or kidney failure, liver cancer or neurological crises commonly bring about deaths by the age of 10 in the absence of treatment. Fortunately, with prompt diagnosis combinded with nitisinone treatment and diet management, outlook is positive with a 90% and higher survival rate. On receival of treatment, affected children are able to grow to their normal size and have better liver and kidney functions. A more normal bone structure is also