Treatment Pathway
Treatment of Non-Alcoholic Fatty Liver Disease
NAFLD is excessive fat buildup in the liver of people who drink little or no alcohol. It ranges from simple steatosis to non-alcoholic steatohepatitis (NASH) with inflammation and fibrosis.
ACG (American College of Gastroenterology)BSG (British Society of Gastroenterology)ESGEAASLD (liver)ECCO (IBD)Maastricht Consensus (H. pylori)NICE
NAFLD is excessive fat buildup in the liver of people who drink little or no alcohol. It ranges from simple steatosis to non-alcoholic steatohepatitis (NASH) with inflammation and fibrosis.
First-Line Treatment Principles
- ✓PPI as cornerstone for acid-related disorders (GERD, peptic ulcer, H. pylori eradication regimens)
- ✓H. pylori eradication: PPI + clarithromycin + amoxicillin (7–14 days); bismuth quadruple if resistance suspected
- ✓IBD: 5-ASA for mild UC; corticosteroids for induction; biologics (anti-TNF, anti-integrin) for moderate-severe
- ✓Hepatitis B/C: antiviral therapy (tenofovir/entecavir for HBV; DAAs for HCV with >95% SVR rate)
- ✓Cirrhosis: treat underlying cause + complications (ascites, varices, HE) systematically
Non-Pharmacological Management
- •Dietary modification: low-FODMAP for IBS; gluten-free diet for coeliac disease; low-fat for pancreatitis
- •Alcohol cessation: critical in alcoholic liver disease, pancreatitis, GERD
- •Weight loss: reduces GERD symptoms and improves NAFLD (5–10% weight loss reduces hepatic steatosis)
- •Elevate bed head; avoid late meals; avoid trigger foods in GERD
- •Regular meals; avoid NSAIDs and aspirin (gastric mucosal damage); no smoking
- •Endoscopic surveillance: Barrett's oesophagus, IBD colon cancer screening, cirrhosis for HCC
- •Vaccination: hepatitis A and B for unvaccinated at-risk patients
Treatment Goals
🎯Symptom remission and maintained quality of life in IBD/IBS/GERD
🎯Mucosal healing in IBD (endoscopic remission)
🎯H. pylori eradication confirmed
🎯Prevention of cirrhosis complications: hepatic decompensation, variceal bleeding, HCC
🎯Sustained virological response (SVR) in hepatitis C
Monitoring Parameters
- ◆LFTs, bilirubin, albumin, INR: liver function — monthly in acute liver disease, every 3–6 months in chronic
- ◆FBC: anaemia (GI bleeding, malabsorption), leucopenia (azathioprine toxicity)
- ◆Faecal calprotectin: non-invasive IBD disease activity monitoring
- ◆Colonoscopy: IBD dysplasia surveillance every 1–5 years depending on duration and extent
- ◆H. pylori test of cure: UBT or stool antigen 4 weeks after eradication therapy
- ◆Hepatic elastography (FibroScan): assess fibrosis progression in chronic liver disease
- ◆Alpha-fetoprotein + ultrasound: HCC surveillance in cirrhosis every 6 months
Escalation Criteria
- →Acute GI bleeding: upper GI endoscopy within 24h; resuscitation, IV PPI, haemostatic therapy
- →Acute severe UC (Truelove-Witts criteria) → hospitalisation, IV steroids; escalate to biologics/surgery if no response at 72h
- →Hepatic encephalopathy: lactulose, rifaximin; identify precipitant; assess for transplant listing
- →Acute-on-chronic liver failure: specialist gastroenterology/transplant centre referral
Special Populations
Pregnancy: many IBD biologics continue through pregnancy (anti-TNF switch to certolizumab if needed); avoid methotrexate
Elderly: NSAIDs major GI risk — prescribe PPI; vigilance for GI bleeding on anticoagulants
Paediatric IBD: growth and development monitoring; early biological therapy consideration
Immunocompromised: lower threshold for investigation; atypical pathogens (CMV colitis, Cryptosporidium)
Clinical Insights
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