eSurgery

FATTY LIVER (NonAlcoholic Fatty Liver Disease)

This is an increasingly common finding diagnosed on an ultrasound of the liver. About 10-20% of the adult population have this condition. This condition is associated with obesity.

What is the condition?

This condition is due to to fat(triglycerides) accumulating in the cells of the liver(the hepatocytes). The liver cells can become damaged by the accumulation of the fat leading to cell injury, inflammation and scarring of the liver.

In a mild form, the only finding may be only on ultrasound. The liver appears “bright”(or in radiological terms – show increased echogenecity). Sometimes the liver function tests can show an elevation of the  liver enzyme levels(especially the ALT – aspartate aminotransferase).

In more severe cases, the liver becomes inflammed and one can get hepatitis of the liver. This is called Non-Alcholic Steato-hepatitis(NASH). This can lead to scarring of the liver and the development of chronic liver failure and increases the risk of getting liver cancer.

What other conditions can mimic/cause fatty liver?

Alcoholic liver disease(The AST is usually higher)

Hepatitis from Hepatitis B and  C

Side effects of medications – eg Tamoxifen, Amiodarone

Investigations

Liver function test(Billirubin, ALT, AST, GGT, ALP)

Blood sugar level

Fasting lipid profile

Hepatitis serology

Liver biopsy – to diagnose NASH

Treatment

Lifestyle measures

The treatment is usually the treatment of the obesity – losing weight by both diet and exercise.

Medications

Some agents being studied

Surgery

Laparoscopic gastric banding for the morbidly obese has been shown to be beneficial for patients with NASH.

Author’s note: In my practice, I see this a lot in patients who have had US of the upper abdomen in particular to exclude gallstones.

Disclaimer:

This article does not constitute medical advice

You should see a qualified medical practitioner for a formal opinion.

There are few varieties of these including sebaceous cysts, epidermal cysts and pilar cysts.

What are these?
These are lumps under the skin. Occasionally one can find a small punctum(opening) on the overlying skin(You might be able to see more easily this if you pinch the skin to dimple it). The cyst is lined by wall and it contains white cheesy material. Common sites include the body and scalp. There can be more than one present.

What happens to the cyst?
The cyst will usually enlarge with time – the largest I have seen on the scalp measured about 15cm wide!!  Sometimes, the lining will burst. This will lead to an inflammation in the surrounding tissue and overlying skin. This is often mistaken for an infection and treated with antibiotics. Rarely, the cyst can become infected primarily. It is best not to lance the cyst as this will cause scarring and make the surgery to excise the cyst completely more complicated

What other conditions can mimic a cyst?

Lipoma – esp if the overlying skin is thick, can sometimes be hard to distinguish

Other soft tissue tumour

What treatment is needed?
Surgery is usually recommended.  Local anaesthesia is injected around the cyst. An incision is made over the skin. The cyst wall is carefully dissected(often best with an artery forceps) and the cyst removed with its contents. The wound is closed with sutures – usually non-absorbable. These are left in for 7-14 days. A waterproof dressing is usually used to cover the wound.
What are the risks of surgery ?

1. Wound problems – scarring, infection, breakdown

2. Recurrence – sometimes a fragment of the cyst wall is stuck down in the surrounding scar tissue and the cyst may regrow.

1. Peptic ulcer disease / Gastritis/ Duodenitis
This pain is usually located in the centre of the upper abdomen(in the epigastric area). The pain is usually relieved by antacids if due to gastritis/duodenitis alone. Sometimes the pain can be referred to the back. Rarely the pain can be generalised and very severe if the peptic ulcer has perforated(ie the patient has peritonitis – this can be associated with a high fever. And classically on the CXR one can see gas under the diaphragm) However, perforated peptic ulcer is rare these days due to the increasing use of proton pump inhibitors(ie Losec, Nexium, Somac). Often this is associated with a Helicobacter pylori infection of the lining of the stomach. This can be diagnosed at gastroscopy through a biopsy of the stomach lining. Alternatively a breath test can be performed.

• Can duodenitis cause back pain on the right side?
  YES – one can get back pain from a duodenal ulcer on the posterior wall of the duodenum.

2. Gallstones – Biliary colic : the pain is usually upper abdomen and to the right. Sometimes the pain is felt all the way round in the back as well. In the initial stages it is usually common not to be able to find any comfortable position at all. A fatty meal can sometimes trigger an attack. This pain can last from minutes to a few hours.
If the stone remains stuck in the gallbladder neck, the pain may persist and the gallbladder becomes acutely inflammed(Acute cholecystitis). At this stage, the pain in constant and the one has to lie still to be comfortable. If the stone remains stuck at the end of the bile duct, one can become jaundiced or develop acute pancreatitis(a serious condition in which the pancreas is inflamed and can potentially be life threatening)

3. Appendicitis - the pain is initially central and then moves to the right side of the abdomen above the groin(the location is called the Right Iliac fossa – it is often abbreviated to RIF in medical notes). There is also often a loss of appetite and nausea. This is also associated with fever. One is tender in to the RIF on palpation. However if the appendix is behind the caecum(ie retrocaecal) the pain may not be as severe and the tenderness may be mild. This is why a retrocaecal appendix is hard to diagnose.

4. Gynaecological pathology (eg Retrograde menstruation, bleeding ectopic pregnancy, torsion of the ovary, rupture of an ovarian cyst/follicle, pelvic inflammatory disease, endometriosis) – the pain can be in either right or left iliac fossa but it is usually lower down and closer to the groin crease that the pain from an appendix (if on the right side to).

5. Urological pathology – Infection of the urinary tract (eg bladder) besides causing a stinging pain when passing urine may also cause pain above the pubic bone and also in the loin(if the infection spreads to the kidneys). Kidney stones can also cause pain in the loin going around into the groin. Testicular problems/trauma may also cause pain to be felt around the belly button!

6. Diverticulitis – the pain is usually in the left iliac fossa. This is usually associated with fever. Diverticular disease itself can also cause a milder pain or discomfort. Sometimes if the sigmoid colon is very loopy, the pain can be felt on the right side and mistaken for an appendicitis!

7. Bowel blockage / obstruction (eg from adhesions, bowel cancer or stuck hernia) – typically the pain comes and goes in waves, usually central or just above the pubic bone. This is associated with nausea, vomiting, abdominal distension, inability to pass flatus and constipation. (the last three symptoms being more for obstruction of the large bowel)

8. Complicated hernia – a hernia with its contents becoming stuck can become painful when the blood supply to the contents(eg fat or bowel) becomes compromised. It is important to check the groin for any inguinal or femoral hernia in anyone with abdominal pain. Rarely a hiatus hernia can cause pain(this is if the stomach becomes strangulated above the diaphragm – this is associated with an inablilty to swallow saliva and not being able to pass down a nasogastric tube)

9. Pain referred from elsewhere and other medical causes – Pneumonia affecting the lower lobes of the lungs, heart attack, metabolic causes (eg very high blood calcium levels, severe diabetes – diabetic ketoacidosis), back problems, shingles, Familial Mediterranean fever, vasculitis, sickle cell anaemia. In young children, mesenteric adenitis(inflammation of the lymph glands in the abdomen) can also cause abdominal pain. This is associated usually with a cold and high fever.

10. Pancreatitis – inflammation of the pancreas (usually from either alcohol or gallstones). This can cause pain in front going through to the back. Often associated with vomiting which tends to relieve the pain.

11. Coeliac disease – this is a hereditary condition that is quite common(about 1 in 100 Australians suffer from it although majority are undiagnosed. Often, there may not be a known family history. Coeliac disease can cause a wide range of symptoms including abdominal pain.

• Can coeliac disease cause pain in upper right abdomen?
  Coeliac disease can cause nonspecific abdominal pain. It can cause pain in the upper right abdomen but there are other pathology that can cause pain there too such as gallstones and hepatitis. It is important to see a doctor to discuss this further.

12. Inflammatory Bowel Disease – Ulcerative colitis, Crohn’s disease. They can present as abdominal pain(ie toxic megacolon, terminal ileitis). The pain in the right iliac fossa may also mimic appendicitis.

13. Infection of the bowel – eg Pseudomembranous colitis(often have diarrhoea, and is associated with prior antibiotics use and often in frail elderly hospitalized patients), Yersinia gastroenteritis(associated with diarrhoea and bleeding).

14. Cancer / Malignancy – This can occur in any abdominal organ. The common ones are colon cancer, stomach cancer, oesophageal cancer, liver cancer and pancreatic cancer. Generally cancer does not cause pain until it is quite advanced.

Sometimes though no cause of abdominal pain can be found despite numerous investigations.

It is important that one sees a doctor urgently especially if the pain is severe.