Fatty Liver, Hepatitis, and Liver Disease in OPD: Clinical Management Guide for Indian Doctors

Liver disease in India spans a spectrum from the ubiquitous (fatty liver on ultrasound in every second urban patient) to the treatable (hepatitis C, now curable in 8 weeks) to the urgent (decompensated cirrhosis). As a clinic doctor, you are the primary detector and manager of early liver disease.

Approach to Deranged Liver Function Tests

Abnormal LFTs are a common incidental finding. The pattern points to the cause:

Isolated raised ALT (<3× ULN): Repeat in 3 months. If persistent, investigate: HBsAg, anti-HCV, fasting lipids, glucose (NAFLD workup), iron studies, caeruloplasmin in young patients (Wilson's disease). Review all medications and supplements — statins, antitubercular drugs, herbal medicines are common culprits.

NAFLD/MAFLD: India's Silent Epidemic

Non-alcoholic fatty liver disease (NAFLD), now renamed MAFLD (Metabolic dysfunction-Associated Fatty Liver Disease), affects 38% of urban Indians — often in patients who are not obese by BMI but have central adiposity, diabetes, or dyslipidaemia.

Diagnosis

Ultrasound showing fatty liver + metabolic risk factor (diabetes, obesity, dyslipidaemia) = MAFLD. No alcohol (men <21 units/week, women <14 units/week) is required for NAFLD label.

Risk-stratify with FIB-4 score (available online calculator):

• FIB-4 <1.3: Low fibrosis risk — lifestyle modification, annual review
• FIB-4 1.3–2.67: Intermediate — referral to hepatology for FibroScan or liver biopsy
• FIB-4 >2.67: High fibrosis risk — referral to hepatology for advanced disease assessment

Management

No approved pharmacotherapy for NAFLD in India (as of 2026). Management is entirely through metabolic control:

• Weight loss: 5–7% body weight reduction reduces hepatic fat. 10% reduction may reverse fibrosis
• Diabetes control: SGLT2 inhibitors (Dapagliflozin) and GLP-1 agonists (Semaglutide) have hepatoprotective benefit beyond glucose control
• Lipids: Statins are safe in NAFLD (mild transaminase elevation is expected and acceptable — do NOT stop statins for NAFLD)
• Alcohol: Complete abstinence in any NAFLD patient with fibrosis

Hepatitis B: Screening, Vaccination, and Treatment

Screening

Screen with HBsAg: all pregnant women (at first antenatal visit), all patients starting immunosuppressants, all close contacts of HBsAg-positive patients, high-risk groups (healthcare workers, IV drug users). Incidentally found HBsAg+ patients need: HBeAg, anti-HBe, HBV DNA, LFTs, and referral to hepatology.

Vaccination

The 3-dose hepatitis B vaccine (0, 1, 6 months) is highly effective and should be offered to all non-immune adults. Check anti-HBs titre 4–8 weeks after completing series — titre >10 mIU/mL = immune. Non-responders need repeat series.

Treatment

Treatment decision for chronic HBV is based on HBV DNA, ALT, and fibrosis stage — a hepatology decision. Your role in OPD:

• Identify all HBsAg+ patients and refer to hepatology for staging
• Screen contacts and vaccinate non-immune family members
• For patients on HBV treatment (usually Tenofovir or Entecavir): monitor LFTs, creatinine, HBV DNA every 6 months
• HCC surveillance: ultrasound abdomen + AFP every 6 months for all cirrhotic HBV patients

Hepatitis C: Curable in 8–12 Weeks

Hepatitis C is now effectively cured with direct-acting antivirals (DAAs). India has generic versions available at very low cost (₹10,000–20,000 for a full course under government schemes).

Screen with anti-HCV antibody: People who ever injected drugs, recipients of blood transfusions before 1992, healthcare workers with needlestick injuries, partners of HCV-positive patients, unexplained liver disease.

Treatment (Sofosbuvir-based): Sofosbuvir 400mg + Velpatasvir 100mg (SOF/VEL) OD for 12 weeks achieves >95% SVR (sustained virological response = cure) across all genotypes. Available free under NVHCP (National Viral Hepatitis Control Programme) at government referral sites. Refer to hepatology/gastroenterology to initiate — you can screen and counsel in OPD.

Alcoholic Liver Disease in OPD

India is among the top five countries globally for alcohol-attributable liver deaths. Alcoholic liver disease spans: fatty liver (reversible) → hepatitis → cirrhosis.

Alcoholic hepatitis — fever, jaundice, hepatomegaly, tender liver, high AST:ALT ratio (>2:1) with GGT elevation — can progress to acute liver failure. Discriminant Function (DF) = 4.6 × (PT - control PT) + bilirubin (mg/dL). DF >32 = severe disease, consider hospital admission and corticosteroids (Prednisolone 40mg OD for 28 days if no infection). Refer to hepatology.

CAGE questionnaire for alcohol screening in OPD (any 2 positive = problem drinking):

• Cut down — have you ever felt you should cut down?
• Annoyed — has anyone criticised your drinking?
• Guilty — have you felt guilty about drinking?
• Eye-opener — have you ever had a drink first thing in the morning?

Recognising Cirrhosis and Complications

Clinical signs of cirrhosis in OPD: spider angiomata, palmar erythema, Dupuytren's contracture, splenomegaly, caput medusae, gynaecomastia, leukonychia, loss of body hair. Any combination warrants investigation.

Complication recognition — refer urgently:

• Ascites: New-onset ascites in a known cirrhotic — rule out spontaneous bacterial peritonitis (SBP). Fever + abdominal pain + ascites = diagnostic paracentesis urgently (PMN >250 cells = SBP, IV cefotaxime)
• Variceal bleed: Haematemesis in cirrhotic = massive oesophageal variceal bleed until proven otherwise. IV Terlipressin, IV Ceftriaxone, transfer to hospital with endoscopy
• Hepatic encephalopathy: Confusion + asterixis (flapping tremor) in cirrhotic = encephalopathy. Lactulose 30–60ml TDS, correct precipitating cause (infection, constipation, GI bleed, sedatives)

Hepatology Referral Criteria

• Any HBsAg+ patient for staging and treatment decision
• Anti-HCV positive for DAA therapy initiation
• FIB-4 >1.3 in NAFLD
• ALT >10× ULN
• Jaundice of unknown cause
• Any suspected cirrhosis
• Unexplained ascites
• Suspected HCC (liver mass on ultrasound)
• Pre-liver transplant evaluation

Chronic liver disease patients require structured monitoring at 3–6 month intervals. CliniqFlo tracks chronic disease patients with automated recall reminders →