The symptoms of NAFLD and NASH are identical. They are very bland (not dramatic) and nonspecific (can also be observed in other diseases). They can occur at any adult age and, in children, usually appear after 10 years of age. Actually, most patients have no symptoms. They may, however, experience occasional, vague right upper-quadrant abdominal pain (below the ribcage on the right side). This pain characteristically is dull and aching, without a predictable pattern of occurrence. It is not an intense, sudden, and severe pain, as might occur with, for example, gallstones. The abdominal pain in NAFLD and NASH is thought to be due to the stretching of the liver covering (capsule) when the liver enlarges and/or when there is inflammation in the liver.
Symptoms of severe, acute (rapid onset) liver failure (due to intense hepatitis) are not observed in NAFLD or NASH. The symptoms and signs of liver failure include yellowing of the skin (jaundice), intense fatigue, loss of appetite, nausea, vomiting, and confusion.
The classic signs of insulin resistance dominate the physical exam in NAFLD and NASH. Obesity (especially abdominal obesity) is the most frequent finding. In addition, patients with long-standing diabetes mellitus type 2 (DM2) may have complications from the diabetes, such as retinopathy (abnormal blood vessels in the eye), kidney (renal) failure, and coronary artery disease. Elevated blood pressure (hypertension) is frequent.
Acanthosis nigricans, a dark pigmentation of the skin of the armpits and neck, can be a sign of insulin resistance and is frequently seen in children with NASH. When the liver is palpated (felt by the doctor), it usually feels normal. However, when very large amounts of fat accumulate in the liver, it can become quite large with a soft, rounded edge that can be easily felt by the doctor.
The cirrhosis stage of NAFLD usually occurs later in life (age 50 to 60 years), presumably after many years of NASH. Frequently at this stage, patients have insulin dependent DM2. NASH patients with cirrhosis can be without symptoms (asymptomatic) if diagnosed early. However, they can have typical signs of compensated or decompensated cirrhosis.
The signs of compensated cirrhosis include a large hardened liver, small star-shaped vessels (spider angiomata) on the skin of the upper torso, blotchy redness on the palms (palmar erythema), whitened nails, thin silky hair, loss of body hair, prominent veins on the abdomen (abdominal collateral veins), irregular or absent menstruation in premenopausal women, and small testes and enlarged (sometimes painful) breasts (gynecomastia) in men. The signs of decompensated cirrhosis include all the above except that the liver may be shrunken and there may be swelling of the legs (edema), accumulation of fluid in the abdomen (ascites), bleeding from veins in the esophagus (varices), and mental confusion (hepatic encephalopathy).
Fatty liver has also been described in several medical syndromes (groupings of abnormalities). For example, fatty liver occurs in polycystic ovarian syndrome, in which polycystic ovaries are associated with obesity, excessive hair (hirsutism), and insulin resistance. Congenital lipodystrophy syndromes, which are rare disorders in which the fat in the torso and extremities shifts to the abdomen, are also associated with an enlarged fatty liver.
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