What it is, and why it is no longer considered harmless
Fatty liver is the accumulation of fat within liver cells. For years it was treated as an incidental finding, something noted on an ultrasound report and left at that. We now know better.
In a proportion of patients the fat is accompanied by inflammation — steatohepatitis — and sustained inflammation gradually leaves scarring in the liver. That scarring is fibrosis, and it is what actually determines the outlook. It is now among the leading causes of advanced liver disease in Spain and across the West.
The figure that really matters
Two people can have identical fatty liver on ultrasound and completely different prognoses. What separates them is not the amount of fat but the degree of fibrosis. And fibrosis is not visible on a standard ultrasound or in blood tests.
Consultation, ultrasound and FibroScan in a single visit
The clinic has both an ultrasound scanner and liver elastography (FibroScan). That allows something usually split across three separate appointments and several weeks of waiting: assessment, abdominal ultrasound and measurement of liver stiffness in one sitting.
You leave knowing three things: whether there is fat in your liver, how much, and above all whether there is fibrosis and to what degree. That is enough to decide on a plan, rather than booking you again in order to begin deciding.
Elastography is painless, needs no sedation and no preparation beyond fasting, and takes a few minutes.
When it is worth investigating
- Fatty liver found on any ultrasound, even if you were told it did not matter
- Persistently raised transaminases, or even normal ones where risk factors exist
- Type 2 diabetes or insulin resistance, where prevalence is very high
- Obesity, hypertension or abnormal cholesterol and triglycerides
- Raised ferritin with no clear cause
- Family history of cirrhosis or advanced liver disease
One point bears repeating: advanced fibrosis can be present with entirely normal transaminases. Clean blood tests rule nothing out.
Treatment
There is no single pill that resolves fatty liver on its own, and you should be wary of anyone who says otherwise. What does exist is a set of measures with demonstrated effect on inflammation and on fibrosis.
- Sustained weight loss. The single most effective measure. Modest reductions improve the fat, and larger ones can reverse inflammation and even part of the fibrosis
- A Mediterranean eating pattern, with particular attention to sugary drinks and added fructose, which are among the most directly implicated factors
- Regular exercise, which improves the liver even when weight barely changes
- Tight control of diabetes, cholesterol and blood pressure, alongside your usual doctor
- Alcohol: its role is reassessed case by case, as it compounds metabolic damage
- Review of medication and supplements, which sometimes contribute unsuspected
On GLP-1 receptor agonists
GLP-1 receptor agonists have changed the picture. In patients who meet medical criteria — type 2 diabetes, obesity or particular metabolic risk situations — they help achieve sustained weight loss and improve the metabolic profile, and with it the liver.
That said, it is worth placing this properly. They are not a shortcut or a consumer product: they are drugs with specific indications and adverse effects that need monitoring, requiring prior medical assessment and follow-up. And they do not replace changes in diet and physical activity; they work by building on them.
How I approach it in clinic
I assess whether they are indicated in your particular case, coordinate with your endocrinologist or GP where appropriate, and follow the liver with elastography to check whether it is genuinely improving. What gets measured is what can be treated properly.
Follow-up
Fatty liver is a chronic condition that evolves slowly, so follow-up matters as much as the initial diagnosis. Repeating elastography at defined intervals shows whether fibrosis is stable, improving or progressing, and allows the plan to be adjusted accordingly.
If advanced fibrosis appears, follow-up changes and includes screening for complications. Catching that in time is precisely what prevents arriving too late.