#568 - Focal Liver Lesions, Steatotic Liver Disease, FOPO

From the American College of Gastroenterology (ACG)

1)  Guidelines for the Management of Focal Liver Lesions (FLL)

We are all familiar with how this goes…We order CT of the abdomen, and it comes back with a liver finding, most often when we were not suspecting the liver. The ACG has put together a helpful guideline trying to address the management of the spectrum of the common focal liver lesions (FLLs). A big problem with this guideline is that there is VERY little good evidence. The guideline committee used the GRADE methodology, which is a good standard for quickly communicating the evidence-base of the recommendation as well as the actual recommendation. Unfortunately, this guideline has only one of nineteen evidence-based recommendations that is graded above Low or Very Low strength of evidence. Despite that, there are some strong recommendations made by the committee based on the options available and their assessment of the likelihood of patients making that particular choice. There is a table (larger than the evidence-based recommendation table) in the report called “Key Concepts” – which is a list of recommendations (largely derived from “best practice” and “committee consensus”) that purport to fill in the gaps in the evidence.

I will list the primary-care focused, evidence-based recommendations below first. Strength of recommendations are graded strong (S), and conditional (C). Evidence ratings are noted as high (H), moderate (M), low (L), very low (VL).

The guideline details management of six major types of FLL. There is an overall recommendation that evaluation of any focal liver lesion include multi-phase contrast imaging with either CT or MRI. [S, L]

Hepatic adenomas: These are usually due to exogenous hormone use (oral contraceptives, hormonal IUDs). MRI is the preferred imaging modality to assess them. [C, VL] If < 5 cm, these can be followed, after discontinuing hormones [S, L] and working on weight loss [C, VL], with contrast imaging every 6 months for at least 2 years, then annually.[C, L]

Focal nodular hyperplasia: MRI is also recommended if these are suspected, with hepatobiliary-specific contrast. [C, L] There is no need to discontinue hormones for this condition. [C, VL]

Hemangioma: If there is cirrhosis or chronic hepatitis B who otherwise need hepatic carcinoma surveillance, these should be imaged every 3 to 6 months for one year. [S, L]

Simple hepatic cysts: If simple and asymptomatic, no follow up is needed. [S, L] If there are high-risk features (septation, fenestration, calcification, thickening, nodularity, etc.) seen on ultrasound then CT or MRI is warranted. [S, L] If symptomatic, there are procedures to drain the cysts.

Polycystic liver disease: Discontinue exogenous estrogen. [C, VL] If there are too many cysts to deal with procedurally, consider treatment with somatostatin analogs. [S, M]

Hydatid/echinococcal cysts: Surgical management is preferred [C, VL] over percutaneous treatment followed by anthelminthics, which may be necessary if surgery is not appropriate. [C, L]

Highlights of the key concepts include:

• Use history, physical and basic labs to assess the patient’s risk status. Most low-risk people will have benign causes for their FLLs.
• Biopsy is still indicated if there is an atypical or concerning appearance to any of these lesions.
• Hepatic adenomas in men should be resected. Hepatic adenomas > 5 cm in either sex can be observed for 6-12 months with risk factor modification, followed by resection if persistently large.
• Focal nodular hyperplasia is generally benign and does not need to be followed if confirmed by advanced imaging.

John’s Comments:

Many of these recommendations are common sense, but it is really surprising to see how little good evidence there is to guide our decisions in this area. There are other, less common, FLLs discussed in the Key Concepts section, and some nice flowcharts that detail the recommended workups, both of which make this guideline useful as a reference to consult when needed.

Reference:

·         Frenette C, Mendiratta-Lala M, Salgia R, Wong RJ, Sauer BG, Pillai A. ACG Clinical Guideline: Focal Liver Lesions. Official journal of the American College of Gastroenterology | ACG. 2024;119(7):1235. Link

From the “Guidance” and the AASLD 

2)  Steatotic Liver Disease 2024

The prevalence of NAFLD in adults is estimated to be 25%–30% in the general population and varies with the clinical setting, race/ethnicity, and geographic region studied but often remains undiagnosed.  NAFLD is closely linked to and often precedes the development of metabolic abnormalities (insulin resistance, dyslipidemia, central obesity, and hypertension).  The presence and severity of obesity are associated with NAFLD and disease progression.  Visceral fat, which is more metabolically active and inflammatory than subcutaneous fat, mediates the majority of this risk.  As adipose tissue becomes more metabolically stressed, dysfunctional, and inflamed, insulin signaling is progressively impaired, promoting the inappropriate release of fatty acids leading to intrahepatic lipid accumulation and inflammation.

In 2023, the American Association for the Study of Liver Diseases (AASLD) released updated guidance (differing from a “guideline”) on the clinical assessment and management of nonalcoholic fatty liver disease (NAFLD).  According to the AASLD, a “Guidance” differs from a “Guideline” in that it is not bound by the Grading of Recommendations, Assessment Development and Evaluation (GRADE) system. Thus, actionable statements rather than formal recommendations were provided. The highest available level of evidence was used to develop these statements, and, where high-level evidence was not available, expert opinion was used to develop guidance statements to inform clinical practice.

The guidance created an algorithm for management of the patient with clinical suspicion of steatotic liver disease.  This would include patients with steatosis noted on imaging or for whom there is a clinical suspicion of NAFLD, such as those with metabolic risk factors or unexplained elevation in liver chemistries.  The algorithm leans heavily on the calculation of a fibrosis-4 index (FIB-4) and further management based on this.  That further management includes an outline for a multidisciplinary approach to care, including advanced lipid management, weight management, and aggressive lifestyle interventions. 

This guidance is complemented by the American Association for Clinical Endocrinology’s 2022 guideline on the diagnosis and management of NAFLD, and in particular, their guidance regarding weight management across the spectrum of disease.  This guidance emphasizes that once someone has evidence of NAFLD, even if it is “mild”, they should be treated aggressively to prevent advancement of the hepatic damage.

In 2024, the major organizations in the US and Europe came up with a new classification system for this group of liver disorders.  The overarching term of steatotic liver disease (SLD) was chosen to classify individuals with hepatic steatosis due to various etiologies. The panel recommended the term steatosis in lieu of the term fatty because the latter was considered to be stigmatizing.  The new terminologies included the use metabolic dysfunction-associated steatotic liver disease (MASLD) in place of NAFLD and metabolic-dysfunction associated steatohepatitis (MASH) instead of nonalcoholic steatohepatitis (NASH), respectively.  A new overlap category was also introduced in the new terminology that includes individuals with cardiometabolic risk factors (CMRFs) and a spectrum of alcohol consumption (metabolic dysfunction and alcohol-associated steatotic liver disease, MetALD), while continuing to recognize other causes of hepatic steatosis including alcohol-associated liver disease (ALD) with or without metabolic risk factors, drug-induced liver injury, monogenic diseases, and other etiologies.

Mark’s Comments:

While changes in terminology can be confusing, what I took away most from my reviews was that it is easy for we who practice primary care medicine to get lulled into thinking that hepatic steatosis in its many forms is just one more manifestation of obesity rather than appreciating it’s significance as a gateway to many forms of hepatic damage and the subsequent systemic impacts of this.  As we take these changes more seriously, perhaps our patients will begin to be convinced to do so as well. 

References:

• Rinella M, et al.  AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology 77(5):1797-1835, May 2023. Link
• Kanwal F, et al.  Metabolic dysfunction–associated steatotic liver disease: Update and impact of new nomenclature on the American Association for the Study of Liver Diseases practice guidance on nonalcoholic fatty liver disease. Hepatology 79(5): 1212-1219, May 2024. Link
• Cusi K, et al.  American Association of Clinical Endocrinology Clinical Practice Guideline for the Diagnosis and Management of Nonalcoholic Fatty Liver Disease in Primary Care and Endocrinology Clinical Settings.  Endocrine Practice, May 2022: 28 (5): 528 – 562.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Breaking Free from the FOPO (Fear of People’s Opinions)

"Care about people’s approval, and you will be their prisoner." — Lao Tzu

We’ve all certainly experienced it.  Remember stepping into the exam room, or the conference room, your heart racing and mind buzzing with thoughts of what the patient or your colleagues might think?  The professional pressure to be flawless – feeling the need to continually live up to the expectations of others, can feel suffocating.  This mental burden has a name: the Fear of People’s Opinions or FOPO.  

I remember vividly a time early in my career when I was struck by what I now understand to be FOPO.  It was the first grand rounds I gave as a resident, and I was presenting a complex and potentially contentious ethical case, surrounded by peers and seasoned faculty whose opinions I highly valued.   Though well-prepared, as I spoke, I became tentative and unfocused, and a sense of uncertainty overwhelmed me.  All I could think about was whether they would agree with my conclusions.  Would they judge me for taking a then quite controversial position?  Would they think I was negligent, or naïve, or even incompetent? 

Psychologist Michael Gervais, who coined the acronym FOPO and works with some of the highest performing athletes and leaders in the world, suggests that feeling trapped in a cycle of self-doubt and overreliance on external validation is one of the greatest obstacles to reaching our full potential, particularly in high-stakes fields like medicine.  Research shows that when we’re preoccupied with what others might think, we’re less likely to take risks, make decisions confidently, or speak up with new ideas. This is particularly damaging in healthcare, where appropriate confidence and timely action is essential.     

Reflecting on that meeting years ago, and many since, I now recognize my fear wasn’t really about the presentation; it was about seeking approval.  Certainly, it is normal to want to feel validated, but when that desire leads to fear and even emotional paralysis, we can no longer show up as our best selves.  Gervais’s teachings have helped me realize that during that meeting I was giving away my power by depending on others’ opinions rather than being open to them while staying true to myself.  He indicates that the antidote is to shift our focus from primarily what others think to aligning our actions with our core values.  When we focus on what truly matters to us, we gain greater freedom to act authentically, even in high-pressure situations, and in doing so, become more effective, resilient, and fulfilled in our work – and less attached to the fear. 

This week, let’s challenge ourselves and each other to identify one area of our professional (or personal) lives where FOPO might have a grip, and to take one step toward letting go of that fear.  Sure, we can still value other’s opinions, but do not have to be dependent on them.  Instead, consider speaking up in a meeting when moved to do so, proposing a new idea you are excited about, or sharing something about yourself that is important to you, but that you may be withholding out of FOPO.  You might just find that this opens a deeper level of connection with colleagues, loved ones, and even yourself.

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org