Fatty liver disease is a micro and macro  vesicular hepato steatosis due to abnormal retention of lipids within liver cells. Non alcoholic fatty liver disease (NAFLD), alcoholic fatty liver disease (AFLD), and metabolic diseases like diabetes, hypertension, obesity, dyslipidemia - are the common causes.¹ Less common causes include abetalipoprotienemia, glycogen storage disorder, WC disease, acute fatty liver, lipodystrophy, nutritional, drugs and toxins. Among the various causes for Fatty liver disease, Non alcoholic fatty liver diesease is now one of the common causes for chronic fatty liver disease mainly in developed countries³.There is an increase in the incidence of NAFLD along with the rise in obesity, metabolic syndrome and Type 2 Diabetes melitus^5. NAFLD is predicted to be the leading cause of Liver transplantation in the next decade^5. NAFLD is defined as the presence of hepatic fat accumulation after the exclusion of other causes of hepatic steatosis including excessive alcohol consumption and other conditions that may lead to hepatic seatosis ⁴.

Another common cause of Fatty liver is Alcohol consumption. Alcohol is mainly metabolized in the liver with the help of ADH (Alcohol Dehydrogenase) the by products released are NADH and acetylaldehyde. The acetylaldehyde released is toxic and is oxidized into aldehyde dehydrogenase 2 which help in generating NADH molecules ^6. Chronic and excessive alcohol consumption leads to various hepatic lesions and the most characteristic is steatohepatitis. The fatty liver then progresses into chronic liver disease ,dysfunction and malignancy in the population studies.

After clinical physical examination, suspicious patients with or without biochemically altered liver enzymes are subjected  to ultrasound imaging. Increase in attenuation or hyperechoic  parenchyma is considered as fatty liver in ultrasound and graded as follows: Grade 1,2 and 3.¹

Ultrasound has a variety of advantages as it is a Non Invasive investigative tool and has accurate Specificity and Sensitivity on par with Histology (gold standard) in the case of Moderate to Severe fatty liver.¹

Fatty liver is diagnosed by taking into effect the following ultrasound findings: Parenchymal brightness, liver to kidney contrast, deep beam attenuation bright vessel walls and gallbladder wall definition. ²  Grades are labeled as Grade 1: Mild (Figure 2)

Grade 2: Moderate (Figure 3)

Grade 3: Marked (FIgure 4)