Patients are usually asymptomatic, and "fatty liver" is usually an incidental finding on imaging done for other purposes. When patients do have symptoms, they are usually nonspecific, constitutional or right upper quadrant discomfort. 

It is important to obtain detailed alcohol use, review past medical history, family history, current and past prescription medications, and use of over-the-counter drugs or supplements. The history should include diet, physical activity, change in weight ( weight gain more than 18 kg in 2-3 years) and evaluation for associated conditions like obesity, hyperlipidemia, and diabetes ).[13]

Laboratory studies lack specificity and cannot distinguish NASH from NAFLD; however, initial evaluation should include an assessment of a complete hepatic panel, lipid panel, and iron. Lab tests may be used to evaluate insuline resistane which include Homeostasis Model Assessment (normal value<3.99)[14] and The Quantitative Insulin Sensitivity Check Index [15]. labtests to rule out viral hepatitis and Hemochromatosis should be ordered. If the patient has elevated liver enzymes chronically or has family history of cirrohsis, additional tests should be considered like antinuclear antibody, smooth muscle antibody,a1-antitrypsin, ceruloplasmin and thyroid-stimulating hormone levels.[16][13]

patients with alcoholic-liver disease may have or have not elevated serum aminotransferase levels. The absolute level of liver enzyme elevation does not related to the severity of alcohol liver disease but the pattern of elevation in liver enzymes is helpful in making a diagnosis alcoholic liver disease. AST level is typically two to three times greater than ALT in alcoholic liver injury. Also, these patients have an elevated serum gamma-glutamyltranspeptidase (GGT).[17]

Imaging studies play a key role in the diagnosis of NAFLD. The mainstay is ultrasonography; it is least invasive, and relatively inexpensive. The sensitivity for an ultrasound to detect NAFLD is in the range of 60% to 90% with a specificity around 90%. Unenhanced abdominal computed tomography and magnetic resonance are alternatives but are more costly and are not significantly superior to ultrasonography.[18][3][19]

Diagnosis of NASH requires a liver biopsy; however, not all patients with NAFLD require a liver biopsy. The decision to proceed with histological examination depends on risk factors, laboratory workup, and disease severity. According to the 2012 guidelines from American Association for the Study of Liver Disease (AASLD), liver biopsy should be reserved for subjects who will 'benefit,' for subjects with potentially competing diagnosis, and for children with either an unclear diagnosis or in whom consideration is being given for medication.

Liver biopsy has moderate risk of complicationsand is invasive, subject to sampling error and is expensive.[20]

Lifestyle modifications and weight loss are the mainstays of the treatment. Treatment also involves glycemic and lipid control. For patients with significant obesity, gastric bypass or other weight loss surgical modalities should be considered. Weight loss is proven to reduce hepatic steatosis. Evidence available suggests that loss of 3% to 5% of body weight is necessary to notice an improvement in steatosis, but a greater loss (up to 10%) is necessary to improve necroinflammation. [21][22][23]

Patients should abstain from alcohol or hepatotoxic drugs.

Pharmacological options include Metformin, Vitamin E, fish oil, Orlistat (an inhibitor of gastric and pancreatic lipase), and Sibutramine. It is important to notice that the evidence behind these pharmacological modalities is weak. Three Cochrane reviews found insufficient evidence to support the use of bile acids (ursodeoxycholic acid) antioxidant supplements, metformin or thiazolidinedione in the absence of diabetes in patients with non alcoholic fatty liver disease. [24][25]Studies have shown that metformin has no significant effect on liver histology; therefore, its use is only recommended if there is another indication for it. Vitamin E is currently only recommended for non-diabetic patients with biopsy-proven NASH. Pioglitazone can be used to treat patients with biopsy-proven steatohepatitis, but its long-term effects are not known. A randomized controlled trial of 247 adults with nonalcoholic steatohepatitis found improvement in AST and ALT levels with the use of vitamin E and pioglitazone but no improvement in fibrosis.[26]

For patients with advanced disease and cirrhosis, liver transplantation might have to be considered.

• Viral Hepatitis
• Alcoholic hepatitis
• Alpha1 Antitrypsin Deficiency
• Primary sclerosing cholangitis
• Wilson disease
• Primary biliary cholangitis
• Cirrhosis

patients with NAFL (Non-alcoholic fatty liver disease )have 26 %  higher health care cost in five year follow up.[27]

• Cirrhosis
• Ascites
• Esophageal varices
• Liver failure
• Liver cancer
• Type 2 diabetes

• Patients should be tested for other causes of liver injury like hepatitis B and offer vaccination
• All drugs that affect the liver must be discontinued
• The disease progression should be monitored for signs of liver dysfunction like ascites, palmar erythema, decreasing levels of albumin and elevated levels of INR.
• Levels of blood alcohol should be checked regularly to check for abstinence from alcohol.
• Patients with end-stage liver disease should be screened for liver cancer and gastroesophageal varices.

• General and bariatric surgeon
• Radiologist for TIPS
• Gastroenterologist

• The patient should refrain from alcohol
• Malnutrition is common in these patients and a dietary consult should be obtained. A low-fat diet and weight loss is recommended. 
• Participating in a regular exercise program is highly recommended.

Although the overall risk of cirrhosis due to NAFLD is modest, certain groups are at particular risk. Important risk factors for NASH are obesity, diabetes, and advanced age. 

Fatty liver is on the rise in the US primarily because of an increase in obesity, type 2 diabetes, and consumption of alcohol. The condition can be reversed if detected early but it requires an interprofessional approach.

Education of the patient is vital to ensure that there is complete abstinence from alcohol. For those who do not remain compliant, end-stage liver disease can develop which carries a high morbidity and mortality.

The nurse should also emphasize the importance of lifestyle changes and a healthy diet. Exercise and a healthy weight can help reverse the disorder and markedly improve the quality of life.

The pharmacist must be closely involved in the management of these patients because several studies show that the use of oral hypoglycemics and lipid-lowering agents may be helpful by lowering the risk of heart disease.

For patients who are not able to lose weight with conservative measures, a bariatric surgery consult may be helpful. There is evidence showing that appropriate weight loss surgery can significantly lower the risk of diabetes and heart disease.[21][28] (Level II)

Outcomes

Several studies show that if there is early intervention before the onset of fibrosis, the prognosis is excellent. However, if the treatment is delayed, and end-stage liver disease develops, the prognosis is poor. In order to reduce the morbidity of fatty liver, evidence suggests that one should adopt an aggressive an interprofessional strategy for managing obesity, diabetes, and the metabolic syndrome.[29][12][30] (Level V)