Fatty liver, hepatitis and gallstones

Why are these three topics together?

A patient arrives with a result in hand: “grade 1 fatty liver”, “high liver enzymes”, or “gallstones”. All three are usually found by a routine blood test or an incidental ultrasound, and all three involve the upper right side of the abdomen. But their causes, risks and treatments differ. This page helps you read your result, know which questions to ask and understand when to act quickly.

Fatty liver

What it is. The NHS describes it as a common condition in which fat builds up in the liver, often together with being overweight. Its new name is MASLD, and the old name NAFLD is still used. NIDDK writes that this fat build-up is not related to heavy alcohol use. When alcohol is what causes it, doctors call it alcohol-related liver disease instead.

It is common. NIDDK says about 24 percent of adults in the United States have fatty liver. This figure is for the US and does not give a number for Iran or Tabriz.

Symptoms. The NHS says usually none. It is often found in a test done for another reason. Some people notice tiredness, feel run down, or have discomfort below the ribs on the right. So having no symptoms does not mean having no disease, and being tired is not proof of fatty liver.

Stages. The NHS counts four stages and says most patients stay in the first:

1. Fatty liver: there is fat, but no damage.
2. Inflammation (MASH in the new name, NASH in the old): the fat has caused inflammation but there is no serious damage yet.
3. Fibrosis: scarring of the liver, though it usually still works well.
4. Cirrhosis: severe damage that impairs liver function and can lead to internal bleeding, liver failure, liver cancer or blood infection.

NIDDK says only a small number of people with the inflammatory type progress, and scientists still do not know why some do and some do not. So the doctor needs to assess your risk of progression.

Who is at higher risk. The NHS lists being overweight, especially around the waist, a poor diet or low activity, type 2 diabetes, polycystic ovary syndrome, high blood pressure or high blood fats, and age over 50. NIDDK also names type 2 diabetes and obesity as major factors and writes that cardiovascular disease is the most common cause of death in people with it. In other words, paying attention to fatty liver also means paying attention to blood sugar, blood fats and blood pressure.

How it is assessed. The NHS: a medical history, weight and waist measurement, questions about alcohol to rule out alcohol-related liver disease, a blood test and sometimes an ultrasound, to confirm the fat build-up, exclude other causes, and assess liver damage and related conditions (for example kidney disease). The doctor may later ask for another test or imaging; this depends on the results and your risk.

Treatment. The NHS says the main treatment is lifestyle change, which can reduce liver fat, help repair damage, and lower the risk of heart disease, kidney disease, high blood pressure and diabetes:

• Food: NIDDK says replace saturated and trans fats with healthier fats (such as omega-3). Prefer vegetables, fruit and whole grains over refined flour. Limit sugar, especially the fructose in soft drinks, sweetened juice and sweet tea.
• Weight: NIDDK says the doctor recommends gradual weight loss if you are overweight. In its discussion of gallstones, the NHS lists rapid weight loss as a risk factor, so do not rush.
• Activity: the NHS suggests at least 150 minutes of activity a week.
• Alcohol: if you drink, NIDDK says cut down as much as possible because it can damage the liver further. The NHS also asks you to stop smoking.
• Follow-up: the NHS suggests an examination at least once a year and tests every 2 to 3 years.

If fibrosis or cirrhosis is present, the NHS says a liver specialist may prescribe medicine, and in very severe cases a transplant may be considered. If you need nutrition counselling, the support section introduces related services.

Hepatitis B and C

Hepatitis means inflammation of the liver and has many causes, from viruses to medicines and alcohol. Here we cover only the two viruses, B and C, because both can stay silent for years and then be found in a blood test.

Hepatitis B. WHO describes it as a viral infection of the liver that can be acute or chronic. Ways it spreads: mother to baby at birth, contact with blood or body fluids (especially in childhood through open wounds), sexual contact with an infected person, unsafe injections, and unclean tattoo or piercing equipment. WHO says most people have no symptoms at the start of infection. About 95 percent of infections in infancy or early childhood become chronic, compared with less than 5 percent in adulthood. Chronic infection can lead to cirrhosis and liver cancer. WHO says the vaccine is safe and effective, gives nearly 100 percent protection, and that a newborn’s first dose should be given within 24 hours of birth. A blood test is the only reliable way to diagnose it. Acute infection has no specific treatment, and chronic infection is controlled with oral antiviral medicine that often has to be continued for life.

Hepatitis C. WHO says it spreads through blood, meaning unsafe injections or medical procedures, untested blood, and injecting drugs with shared syringes. Sexual transmission and mother-to-baby transmission are less common. It does not spread through breast milk, food, water or casual contact. Most infected people have no symptoms in the first weeks. About 30 percent (15 to 45 percent) clear the virus on their own and about 70 percent develop chronic infection. Testing has two steps: first an antibody test, and if it is positive, a virus (RNA) test to confirm active infection, because someone who has cleared the virus stays antibody-positive. WHO says hepatitis C is curable: direct-acting antiviral medicines cure more than 95 percent of patients, usually in 12 to 24 weeks and with few side effects. There is no effective vaccine for C.

For both, a positive result means a need for closer assessment, not a verdict. The doctor decides on further tests and the treatment plan.

Gallstones

The NHS says they are small stones that form in the gallbladder (a small organ under the liver that helps digest fat) or in the bile ducts. They are common, most people who have them never have symptoms, and they are sometimes found on an ultrasound or X-ray done for another reason.

When a stone blocks a duct, the pain of “biliary colic” appears: pain that may be severe or constant, lasts from 30 minutes to several hours, is felt in the middle of the abdomen or under the right ribs, and may bring nausea or vomiting.

The NHS lists these risk factors: age over 40, being female, obesity, a high-fat, low-fibre diet, rapid weight loss, and conditions such as diabetes and Crohn’s disease. Assessment is by ultrasound and blood test. If a stone causes no symptoms, treatment is often not needed and only follow-up may be arranged. When there are symptoms, complications or a stone in the main bile duct, the main treatment is surgery to remove the gallbladder. For a stone in the main bile duct, a procedure with an endoscope to open the duct is sometimes needed. Until surgery, the doctor may advise a low-fat diet and avoiding trigger foods. Which path you need is for the surgeon or gastroenterologist to say.

What happens in a liver work-up?

The NHS says the assessment of fatty liver starts with a medical history, weight and waist measurement and questions about alcohol, then a blood test and sometimes an ultrasound. The doctor decides what further assessment you need. The first visit guide shows what to bring.

When to act urgently

Call 115 (Iran’s emergency number) right now: sudden, severe abdominal pain, pain that spreads to the back and comes with vomiting, a very high temperature or feeling very hot and shivery, and yellow skin or whites of the eyes if you have gallstones or there is also pain or fever (NHS, for gallstones). In liver disease: vomiting blood, black tarry stool, confusion or unusual drowsiness.

The same day: yellow skin or whites of the eyes without pain or fever (the NHS asks for an urgent appointment, and WHO lists it among the signs of acute hepatitis), abdominal pain that lasts more than 30 minutes (NHS), dark urine with pale stools, or an abdomen that has recently swollen.

Book an appointment soon: a fatty liver result or abnormal liver enzymes, a positive hepatitis result, gallstones with repeated attacks, or tiredness and pain under the right ribs that continue.

See the full list in urgent signs.

This page is for information and does not replace an examination.