Evaluation and Management of Incidental Hepatic Steatosis

Initial Hepatic Evaluation

The American College of Gastroenterology recommends obtaining a complete hepatic panel, including transaminases (AST and ALT), to differentiate the cause of hepatic steatosis, with a ratio of AST/ALT >2 suggesting an alcoholic origin and a ratio <1 suggesting non-alcoholic fatty liver disease (NAFLD) 1, 3
A complete hepatic panel, including alkaline phosphatase, bilirubin, albumin, and prothrombin time (INR), is necessary to evaluate overall hepatic function 2, 1

The American Association for the Study of Liver Diseases recommends screening for hemochromatosis with serum ferritin and transferrin saturation, as elevated ferritin is common in NAFLD but may indicate iron overload 1
Viral serologies, including hepatitis B (HBsAg, anti-HBc) and hepatitis C (anti-HCV), should be performed to exclude chronic viral hepatitis 1, 2
Screening for Wilson's disease with serum ceruloplasmin should be considered, especially in patients under 40 years old 1
Autoantibodies, including antinuclear antibodies (ANA) and anti-smooth muscle antibodies (SMA), should be tested to exclude autoimmune hepatitis, although their elevation is often an epiphenomenon in NAFLD 1

Fasting glucose and HbA1c should be measured, as NAFLD is present in 90% of diabetic patients 3
A complete lipid profile, including total cholesterol, LDL, HDL, and triglycerides, should be performed to evaluate metabolic syndrome 1, 2
A complete blood count (CBC) and creatinine should be measured for overall evaluation 2

The NAFLD fibrosis score or FIB-4 score should be calculated to stratify the risk of advanced fibrosis, using age, transaminases, platelets, and albumin 2
If the score is intermediate or high, consideration should be given to elastography (FibroScan with CAP measurement) to quantify hepatic stiffness and fat content 2

A detailed questionnaire on alcohol consumption should be administered, with ≥21 drinks/week in men defining significant consumption that would suggest alcoholic steatosis rather than NAFLD 1
Confirmation with a close contact should be sought if there is clinical discordance 1

An isolated elevated ferritin does not necessarily indicate hemochromatosis, as it is common in NAFLD 1
Normal transaminases do not exclude significant liver disease, including NAFLD or NASH 1, 2
Ultrasound detects moderate to severe steatosis (>30% fat) with 84.8% sensitivity and 93.6% specificity, but this patient already has an established diagnosis 3, 2
Calculation of fibrosis scores should not be neglected, as they identify patients requiring referral to hepatology 2