Fatty Liver Grades And Severity: Grade 1, 2 And 3 Explained

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Fatty liver (Yakrit Roga) affects about 1 in 10 people. Fat build-up in the liver is normal up to a certain extent, but more than 5% fat in the liver can cause organ damage. Fatty liver occurs when lipids, mostly triglycerides, accumulate in hepatocytes. Treatment for fatty liver can vary. It mainly focuses on managing underlying conditions, which are categorised into different grades on the basis of severity.  

What Ultrasound Grades Mean

Ultrasound can be used to examine the amount of fatty liver visually. How much fat has built up in your liver can be measured by US (ultrasound); B-mode imaging allows you to create real-time pictures and videos of the organ without any radiation. Ultrasound focuses on how bright the liver appears on the scan and how the structure appears.

Different types of images appear on different grades:

• In Grade 1, the image of the liver appears slightly brighter than the kidney. In this grade, the blood vessel walls remain clearly visible. 
• In Grade 2, the image of the liver shows a moderate increase in brightness levels. In this grade, the blood vessel walls start to get blurry.
• In Grade 3, the image of the liver gets completely bright. In this grade, the blood vessel walls get blocked, which means- completely invisible. 

Grade 1, 2 and 3 At A Glance

The grading helps in understanding the amount of fat infiltrated in liver tissue. Fatty liver is graded on a scale from Grade 1 to Grade 3. These grades are based on the percentage of fat accumulated in the liver cells. These grades help in gaining better knowledge of the disease and are directly responsible for better treatment. Let's get deep into the topic and understand these grades:

Grade 1: 

It indicates between 5%-33% of fat accumulated in the liver cells. In this grade, the liver gets slightly bigger in size. This condition can be diagnosed with an abdominal ultrasound and regular health checkups. Mostly in this stage, liver function tests remain normal or show only a borderline elevation in ALT (alanine aminotransferase) and AST (aspartate aminotransferase). This grade is highly reversible through diet and exercise.

You can diagnose this stage by these symptoms:

• Mild fatigue 
• Tiredness
• Mild abdominal discomfort
• Bloating after eating.

Grade 2: 

It indicates between 33%-66% of fat accumulated in the liver cells. In this grade, the liver may appear enlarged (hepatomegaly). This stage can affect the liver’s functional ability. Liver enzymes (ALT and AST) get elevated in this stage, but liver function tests (LFTs) are often within the normal range in most of the cases. This stage is also reversible but requires a lot of effort and time. 

You can diagnose this (grade 2) stage by these symptoms:

• Fatigue
• Low energy levels
• Nausea
• Weight changes
• Feeling of fullness in the right upper quadrant
• Cognitive effects such as difficulty concentrating.

Grade 3: 

This stage is severe. It indicates that more than 66% of the fat is accumulated in the liver cells. In this grade, the liver may appear enlarged (hepatomegaly) and inflamed. This stage can affect the liver’s functional ability and, in extreme cases, cause liver damage. Liver enzymes (ALT and AST) get elevated in this stage. This stage is harder to treat and needs strict medical treatment. 

You can diagnose this (grade 2) stage by these symptoms:

• Scarring (fibrosis) 
• Cirrhosis.

Grade Versus Inflammation And Fibrosis

Grade measures the amount of fat in the liver (steatosis). That means Grades 1 to 3 (mild to severe) measure the amount of fat trapped in the liver through ultrasound. Inflammation occurs when fat accumulates in the liver and irritates the cells, causing swelling and cell damage. Fibrosis is permanent scarring that happens when inflammation activates cells that lay down collagen fibers. To measure actual scar tissue and see beyond the fat grade, certain tests such as a FibroScan or blood markers are required.

Symptoms Are Not A Reliable Severity Measure

The symptoms of fatty liver disease are not associated with the actual damage within the liver; it is frequently referred to as a silent disorder. These symptoms can also happen naturally; that's why it is difficult to diagnose the exact symptoms. 

The reason why it does not seem severe:

• No early signs 
• Vague signals 
• It happens over years; that's why the body gets used to it. 

But it can be correctly measured through:

• Blood tests
• Ultrasound
• Fibroscan
• Staging (severe fibrosis and cirrhosis)

Tests That Diagnose Fatty Liver 

Test diagnosis helps in better understanding the disease. In the case of fatty liver, the test helps to measure different stages of actual fat accumulation, tissue stiffness, and abdominal health.

Fatty liver can be assessed using tests such as:

• LFTs (liver function tests): They can measure levels of ALT, AST, bilirubin, and albumin to spot liver stress, inflammation, or damage.
• Ultrasound: This test uses sound waves to create pictures of the liver and detect general fat accumulation (steatosis), but it cannot measure the exact amount of scar.
• FIB-4 Index: It combines ALT and AST tests to estimate the risk of advanced liver scarring (fibrosis).
• FibroScan: It can measure liver stiffness (hardness indicating scarring or fibrosis in kilopascals) and fat content, CAP (Controlled Attenuation Parameter) score in decibels per meter, without any pain. 
• Liver biopsy: This procedure is used in complex cases; they remove a tiny piece of liver tissue to diagnose the exact damage in the liver.

What Changes By Grade

The different grades measure different percentages of fat accumulation and stiffness in the liver cells. Fat accumulation, symptoms, and outlook of the disease vary from grade-1 to grade-3. 

Difference between grade-1 to grade-3:

Red Flags and Next Steps

Many people do not feel any symptoms for many years in the case of Yakrit Roga. But this disease can cause severe harm to the body in the later stages. Here are some red flags people commonly ignore that can even cause permanent organ damage:

• Chronic fatigue (Glani)
• Constant weakness (Daurbalya)
• Mild pain in the upper abdomen
• Bloating 
• Dark urine 
• Swelling in the abdomen 
• Weak digestion (Mandagni)
• Indigestion (Ajeerna)
• Heaviness (Gaurava)
• Loss of appetite (Anannabhilasha)
• Jaundice (Kamala), commonly known as yellow skin
• Itching without rashes
• Easy bruising and bleeding 
• Brain fog or focus loss 
• Sudden weight changes 

What Should I Do Next?

If you have any of these red flags, you need to take some practical actions: 

• Talk to a specialist: Schedule an appointment with Jiva’s specialised Ayurvedic doctors.
• Get blood tests done: Tests may include LFTs, ultrasound, FibroScan, and blood glucose tests.
• Cut out alcohol: Alcohol can worsen liver damage.
• Focus on a healthy diet: Avoid eating oily, heavy, and processed food, as well as reduce sugar intake.

Conclusion

Fatty liver can range from mild fat accumulation in Grade 1 to more severe accumulation in Grade 2 and 3. The grades give an idea of how much fat is present in the liver, but they cannot tell whether the liver has been damaged. Early attention to these grades and regular follow-ups can help manage the condition and lower the chances of further liver damage. For better understanding, explore our guides on Grade 1, Grade 2, and Grade 3 fatty liver.

References 

Non-alcoholic fatty liver disease: Definition and subtypes - PMC

Fatty Liver - StatPearls - NCBI Bookshelf

Fatty Liver Grading Using Computed Tomography Hounsfield Unit Values and Correlating With Ultrasonography Grading - PMC

Effect of Ayurveda interventions in non-alcoholic grade II fatty liver associated with obesity – A case report - PMC