Can fatty liver cause feet swelling? In most cases, fatty liver disease does not directly cause swelling of the feet or ankles during its early stages. However, when the condition progresses to advanced liver disease or cirrhosis, feet swelling can develop as a significant complication. This occurs because a severely damaged liver cannot produce enough albumin, a protein that keeps fluid within blood vessels, leading to fluid accumulation in the lower limbs. Understanding the connection between liver health and peripheral oedema is important for recognising when medical assessment is needed.

Can Fatty Liver Cause Feet Swelling?

Fatty liver disease itself does not typically cause feet swelling in its early stages. Non-alcoholic fatty liver disease (NAFLD) and alcohol-related fatty liver disease are common conditions where excess fat accumulates in liver cells. In the majority of cases, particularly with simple steatosis (fat accumulation without significant inflammation), patients remain asymptomatic and do not develop peripheral oedema. (Some literature now uses the term metabolic dysfunction-associated steatotic liver disease [MASLD]; NICE guidance continues to use NAFLD.)

However, swelling of the feet and ankles can occur when fatty liver disease progresses to more advanced stages, specifically cirrhosis. Cirrhosis represents the end stage of chronic liver disease, characterised by extensive scarring and impaired liver function. When the liver becomes severely damaged, it can no longer produce adequate amounts of albumin, a crucial protein that helps maintain fluid within blood vessels. Low albumin levels lead to fluid leaking into surrounding tissues, causing oedema in the lower extremities due to gravity.

The mechanism behind liver-related swelling involves several pathophysiological processes. Advanced liver disease causes portal hypertension (increased pressure in the portal vein system), reduced synthesis of clotting factors and albumin, and activation of hormonal systems that promote sodium and water retention. These changes collectively contribute to fluid accumulation, initially presenting as ankle and feet swelling, and potentially progressing to ascites (abdominal fluid accumulation).

It is important to note that the presence of feet swelling in someone with known fatty liver disease warrants urgent medical evaluation, as it may indicate disease progression to decompensation. New or worsening oedema should prompt urgent same-day GP assessment and baseline tests including liver function tests (with bilirubin and albumin), international normalised ratio (INR), full blood count, platelets, and urea and electrolytes. Most individuals with uncomplicated fatty liver disease will not experience peripheral oedema, and its presence should prompt investigation for alternative or additional causes.

Other Causes of Swollen Feet to Consider

Swollen feet and ankles are common symptoms with numerous potential causes beyond liver disease. Understanding these alternative explanations is essential, as they are often more prevalent than liver-related oedema in the general population. Bilateral swelling typically suggests systemic causes (heart, kidneys, thyroid) or venous insufficiency, whereas unilateral swelling suggests deep vein thrombosis (DVT) or lymphoedema.

Cardiovascular conditions represent a significant cause of lower limb swelling. Heart failure occurs when the heart cannot pump blood efficiently, leading to fluid backup in the venous system and subsequent peripheral oedema. This typically affects both legs symmetrically and worsens throughout the day. Venous insufficiency, where leg veins struggle to return blood to the heart, is another common cause, often accompanied by skin changes, varicose veins, and aching legs.

Kidney disease can cause fluid retention and swelling due to impaired sodium and water excretion. Nephrotic syndrome, characterised by significant protein loss in urine, leads to low blood albumin levels similar to advanced liver disease, resulting in generalised oedema including the feet and ankles.

Medications frequently contribute to peripheral oedema. Common culprits include:

• Calcium channel blockers (e.g., amlodipine) used for hypertension

• Non-steroidal anti-inflammatory drugs (NSAIDs)

• Corticosteroids

• Some diabetes medications (thiazolidinediones)

• Hormone therapies including oestrogen

If oedema develops after starting a medicine, discuss with your GP whether an alternative treatment is appropriate, balancing the indication for the medicine against the side effect.

Other important causes include:

• Lymphoedema – impaired lymphatic drainage, often following surgery or infection

• Deep vein thrombosis (DVT) – blood clot in leg veins, typically causing unilateral swelling with pain and warmth

• Pregnancy – hormonal changes and increased blood volume; new swelling accompanied by headache, visual disturbance, right upper quadrant or epigastric pain, or high blood pressure may indicate pre-eclampsia and requires urgent maternity or obstetric assessment

• Prolonged immobility – long flights or sedentary lifestyle

• Obesity – increased pressure on leg veins

• Thyroid disorders – particularly hypothyroidism

Identifying the underlying cause requires careful clinical assessment, including medical history, medication review, examination, and appropriate investigations to guide management.

When to Seek Medical Advice for Swollen Feet

Certain features of feet swelling require prompt medical evaluation to exclude serious underlying conditions. Understanding when to contact your GP or seek urgent care is crucial for patient safety.

Seek immediate medical attention (call 999 or attend A&E) if swelling is accompanied by:

• Chest pain, breathlessness, or rapid heartbeat – potential pulmonary embolism or acute heart failure

• Severe abdominal pain or distension – possible complications of liver disease or other acute conditions

• Confusion, drowsiness, or altered consciousness – may suggest hepatic encephalopathy in liver disease

• Yellowing of skin or eyes (jaundice) with new swelling – indicates significant liver dysfunction

• Haemodynamic instability or collapse – requires emergency assessment

Seek urgent same-day medical assessment (contact your GP or urgent care) if you experience:

• Sudden onset of unilateral leg swelling with pain, warmth, or redness – may indicate deep vein thrombosis (DVT); urgent same-day assessment is required using a clinical probability score (Wells score), D-dimer testing if appropriate, and proximal leg vein ultrasound as per NICE guidance

• New or worsening swelling in someone with known liver disease – may indicate decompensation requiring urgent review

Contact your GP within a few days if you experience:

• Persistent or worsening swelling lasting more than a few days

• Swelling accompanied by unexplained weight gain

• Breathlessness when lying flat or during minimal exertion

• Reduced urine output or changes in urine colour

• Swelling that leaves an indentation when pressed (pitting oedema)

• Skin changes over swollen areas, including discolouration, ulceration, or weeping

In pregnancy, seek urgent maternity or obstetric assessment if swelling is accompanied by:

• Severe headache or visual disturbance

• Right upper quadrant or epigastric pain

• High blood pressure

These features may indicate pre-eclampsia.

Your GP will conduct a thorough assessment including medical history, medication review, and physical examination. Depending on clinical findings, investigations may include blood tests (liver function, kidney function, albumin, N-terminal pro-B-type natriuretic peptide [NT-proBNP]), urine analysis, chest X-ray, echocardiogram, or abdominal ultrasound. For suspected heart failure, NICE guidance recommends NT-proBNP testing: levels ≥2000 ng/L warrant specialist assessment and echocardiography within 2 weeks; levels 400–2000 ng/L within 6 weeks; levels <400 ng/L make heart failure less likely.

Early medical review is particularly important for individuals with pre-existing conditions such as fatty liver disease, heart failure, kidney disease, or diabetes, as swelling may indicate disease progression requiring treatment adjustment.

Managing Swelling Related to Liver Problems

Management of oedema associated with liver disease requires a comprehensive approach addressing both the underlying liver condition and symptomatic fluid retention. Treatment strategies vary depending on disease severity and should be guided by specialist hepatology input.

Addressing the underlying liver disease forms the cornerstone of management. For non-alcoholic fatty liver disease (NAFLD), lifestyle modifications are paramount:

• Weight loss – gradual reduction of 7–10% body weight can significantly improve liver inflammation and fibrosis

• Dietary changes – Mediterranean-style diet, reduced refined carbohydrates and saturated fats

• Regular physical activity – at least 150 minutes of moderate-intensity exercise weekly

• Management of metabolic risk factors – optimising control of diabetes, hypertension, and dyslipidaemia

• Alcohol abstinence – essential in alcohol-related liver disease; for those with NAFLD who choose to drink, adherence to UK Chief Medical Officers' low-risk drinking guidelines (not regularly exceeding 14 units per week, spread over 3 or more days)

For symptomatic fluid retention in advanced liver disease, specific interventions include:

Dietary sodium restriction – moderate restriction to approximately 80–120 mmol sodium per day (roughly 5–6 g salt per day) helps reduce fluid accumulation. Patients should avoid processed foods, ready meals, and adding salt during cooking or at the table. Dietetic support is recommended.

Fluid restriction – generally reserved for significant hyponatraemia (low blood sodium) and should only be implemented under specialist medical guidance. Routine fluid restriction is not recommended.

Diuretic therapy – under specialist supervision, medications such as spironolactone (aldosterone antagonist) often combined with furosemide may be prescribed, typically in a ratio of 100 mg spironolactone to 40 mg furosemide. These require careful monitoring of kidney function and electrolytes, particularly potassium levels, at least weekly initially. Dosing adjustments are made based on response (aiming for weight loss of approximately 0.5 kg/day if oedema alone, or 0.5–1 kg/day if ascites is also present) and tolerability.

Large-volume paracentesis with albumin replacement – for tense or refractory ascites, drainage of ascitic fluid (paracentesis) with intravenous albumin infusion (approximately 8 g albumin per litre of fluid removed) is an evidence-based intervention. Transjugular intrahepatic portosystemic shunt (TIPS) may be considered in selected cases of refractory ascites under specialist guidance.

Avoidance of nephrotoxic and fluid-retaining medications – non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided in cirrhosis due to increased risks of renal impairment and bleeding. Review other medications that may promote fluid retention.

Supportive measures to improve comfort include:

• Elevating legs when sitting or resting

• Wearing compression stockings (only if appropriate and after excluding suspected DVT or significant peripheral arterial disease)

• Maintaining skin hygiene to prevent infection

• Avoiding prolonged standing

Regular monitoring through hepatology services is essential for patients with cirrhosis and oedema, as this indicates decompensated liver disease requiring specialist management and consideration for liver transplantation assessment in appropriate cases.

If you suspect a medicine is causing or worsening swelling, report it via the MHRA Yellow Card Scheme (available at yellowcard.mhra.gov.uk or via the Yellow Card app).

Frequently Asked Questions