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Doctor Notes

Liver Health and Wellness

Doctor’s Notes are written by members of the Rocky Mountain Division Medical Advisory Committee and our partners in the liver community. They are updated when new information is available. If you have any suggestions for future topics please email the Rocky Mountain Division at rminfo@liverfoundation.org. Thanks for reading!

Q & A with Dr. John Goff

Author: Dr. John Goff, Rocky Mountain Gastroenterology Associates
Published: January 3rd, 2016


Dr. John Goff, a member of both our Board of Directors and Medical Advisory Committee, wrote this month’s article on the topic of Fatty Liver Disease.

Fatty Liver Disease

Q: What is it?
A: Fatty liver disease is when there is excess fat in the liver. This fat can be associated with inflammation or can just be isolated fat in the liver. The fat associated with inflammation will eventually lead to scarring (fibrosis). When the fibrosis becomes extensive the liver is severely damaged and we call that situation cirrhosis.

Q: How common is it?
A: Up to 30% of adults in the US have fat in their livers. We call this non-alcoholic fatty liver disease (NAFLD). About 5% of adults will have fat and inflammation, which is called non-alcoholic steatohepatitis (NASH). Fat in the liver is the most common reason for a person to have abnormal liver blood tests (abnormal liver enzymes).

Q: What is the cause?
A: The cause(s) of NAFLD/NASH are not fully known and there are likely factors involved that we do not yet understand. However, we do know that insulin resistance (insulin not working as well as it should) and oxidative stress in the liver are significant factors in causing this problem.

Q: How do I know if I am at risk for NAFLD/NASH?
A: Clinical conditions that are associated with fatty liver are: diabetes, being overweight (especially increase abdominal girth or truncal obesity), high blood pressure, and elevated triglycerides (lipids) in the blood. Other conditions with a less strong association include: gout, poly cystic ovary syndrome, obstructive sleep apnea, cardiovascular disease, hypothyroidism and the use of tamoxifen.

Q: How do we diagnosis NAFLD/NASH?
A: The usual inial finding is elevated liver enzymes, but these are not specific so other tests need to be done some of which would be to exclude other causes of liver problems. An ultrasound, CT scan or MR scan of the liver can sometimes tell if there is fat in the liver. Measuring a fasting insulin and glucose level in the blood can help determine if there is good or bad fat in the liver (NAFLD vs NASH). However, the gold standard for determining exactly what is going on in the liver and determining the severity (stage) of the problem is a liver biopsy. However, now we can use FibroScan (a noninvasive device) or one of several composite blood tests on the market (FibroSure, FibroSpect, APRI, etc) to assess liver fibrosis and thus avoid a liver biopsy in many patients.

Q: What can I do about it, if I have NASH?

  1. A: Exercise vigorously 30-60 minutes daily. This improves insulin resistance.
  2. A: Weight loss through a diet of reduced calories, reduced intake of trans fats (unsaturated fat) with more intake of fish oil (omega 3), olives, and peanut or canola oil, and reduced carbohydrate intake (do not eat white foods) to achieve ideal body weight.
  3. A: Vitamin E at about 800 IU daily since it is an antioxidant but be aware that too much vitamin E can increase heart disease and cause prostate cancer.
  4. A: Lipoic acid may also be useful since it is an antioxidant and improves insulin resistance. It needs to be used with caution when taking hypoglycemic agents as it may cause low blood sugar levels.
  5. A: The drug with the most data supporting it as beneficial for NASH is the oral blood sugar lowing agent pioglitazone (Actos). Unfortunately, it has many potential side-effects, which include: weight gain, worsening of congestive heart failure, osteoporosis, and recently reported, a small but definite risk for bladder cancer. However, if the NASH is severe and not responding to other measures, the risks are outweighed by the benefits of this medication.
  6. A: There are some experimental agents being looked at for NASH and hopefully they will prove to be useful. These include drugs that prevent the development of fibrosis and others that will combat the metabolic abnormalities in the liver that lead to NASH.
  7. A: Bariatric surgery is not indicated to treat NASH, but would be considered if there are other associated conditions.

Q: What are my chances?
A: There is an increased mortality compared to normal people in those with NASH that is due to liver disease. About 20% of patients with NASH will develop cirrhosis if not treated. The risk of developing liver cancer is quite low, but is increased over normal in those who develop cirrhosis. The goal is to normalize the liver enzyme levels by maintaining ideal body weight through the above mentioned life style changes and with medication as needed.

Author: Shikha S. Sundaram, MD MSCI

Shikha S. Sundaram, MD MSCI is the Assistant Professor of Pediatrics at the University of Colorado School of Medicine and Children’s Hospital Colorado. She is interested in childhood liver disease, Non-alcoholic fatty liver disease and Pediatric liver transplant. She wrote this month’s article on Pediatric Non-Alcoholic Fatty Liver Disease.


What is Pediatric Non-Alcoholic Fatty Liver Disease (NAFLD)?

NAFLD is a spectrum of diseases that all begin with excess fat deposition in the liver. As the disease becomes more severe, inflammation or irritation of the liver occurs and then scar tissue (fibrosis) accumulates. The disease is then referred to as NASH (Non-Alcoholic Steatohepatitis). If the fibrosis is extensive, cirrhosis develops and the liver may function poorly.


How common is Pediatric NAFLD?

NAFLD is the most common liver disease in the United States. It is thought to affect approximately 30 million people, 8.6 million of whom have the more severe form of the disease, NASH. NAFLD affects almost 10% of all children in the United States. Approximately 1% of 2 to 4 year olds, and 17% of 15-19 year olds have NAFLD. In addition, 38% of obese children have NAFLD. Among adults, NAFLD has become the 3rd leading indication for liver transplant. Children, who will have the longest time course of disease, are at particular risk of complications and poor prognosis, including the need for liver transplant in adulthood.


What are the risk factors for developing pediatric NAFLD?

Most children with NAFLD are in their early adolescent years. NAFLD, however, is being increasingly observed in young children. Males are affected twice as often as females and Hispanics are more likely to develop NAFLD than non-Hispanics whites or blacks. Obese children are at the greatest risk for developing NAFLD. In addition, having type 2 diabetes or pre-diabetes, the metabolic syndrome, or hyperlipidemia increases your risk of developing NAFLD.


What are the symptoms of pediatric NAFLD and how will my doctor diagnose it?

Most commonly, children with NAFLD are asymptomatic. In such an instance, a doctor may notice abnormal blood tests during a routine well child check up. Some children experience right sided abdominal pain, fatigue, or constipation. On exam, doctors may find obesity, especially in the waist area, an enlarged liver, signs of insulin resistance called acanthosis nigricans, a dark discoloration on the back of the neck and armpits, or the exam may be completely normal.

In order to diagnose pediatric NAFLD, your doctor will start with blood tests to look for elevations of liver enzymes. They may also test for pre-diabetes and hyperlipidemia, and try to exclude other causes of liver disease, such as viral hepatitis, autoimmune hepatitis and Wilson’s disease. They may check an abdominal ultrasound to look for fat deposition in the liver. The only way to be certain that you have NAFLD, however, is a liver biopsy. This test allows your doctor to determine if you have NAFLD, and how severe the disease is.


What causes NAFLD?

The exact cause(s) of pediatric NAFLD is currently unknown. It is likely a combination of several factors, including a predisposing genetic background along with environmental triggers that allow for insulin resistance and accumulation of specific fats in the liver. Activation of immune cells and oxidative stress then likely can cause ongoing damage to the liver.


What can I do if I have NAFLD?

Currently there is no medication that treats this disease. Many research trials of medications for NAFLD are underway and may yield effective medications in the future. NAFLD must be treated by gradual weight loss, typically about 1 pound per week. Research shows that for many children, losing only 10% of their body weight can help their liver disease. This should occur through a combination of both exercise and dietary changes. A reasonable goal is to exercise 3 to 5 times per week for at least 30 minutes. Exercise not only helps to burn stored calories, but also increases the body’s metabolism. Nutrition should be balanced, including regularly eating breakfast. Sugar sweetened beverages should be limited and lean meats, poultry and fish, along with fresh fruits and vegetables and whole grains emphasized.

Author: Gregory T. Everson, M.D., F.A.C.P.


Originally published in Published by Hatherleigh Press. Distributed through Random House. Available wherever books are sold. In stores 8/21/2012.


In a breakthrough publication, leading hepatologist and hepatitis C expert Gregory Everson, M.D. provides state-of-the-science information to guide patients through the diagnosis and treatment of hepatitis C. Until recently, hepatitis C was considered incurable. “Curing Hepatitis C” outlines the new treatment protocols that offer the outcome of complete cure from this disease.

“Curing Hepatitis C” provides an indispensable and comprehensive overview for the nearly 160 million people worldwide and 4 million Americans diagnosed with hepatitis C. Perhaps most importantly, “Curing Hepatitis C” provides hope.

Author’s Statement
“Hedy Weinberg and I wrote five editions of Living with Hepatitis C: A Survivor’s Guide for the purpose of providing patients and caregivers a resource that could serve as an authoritative readily-available resource. I provided the medical information and Hedy provided the patient perspective by interviewing many patients with HCV to provide a personal connection for the reader. In this new book, I have focused on issues and questions related to the current new standard of treatment, Triple Therapy, and the exciting emerging therapies. As treatment continues to improve, eradication of HCV infection will become increasingly common – the new paradigm will be living without, not with, hepatitis C. Perhaps I am overly optimistic, but I believe that it is entirely possible that the emerging treatments will be so potent and effective that nearly every patient with chronic hepatitis C may be cured by future antiviral therapies!”


Curing Hepatitis C: Current and Future Options for Treatment
Written by Gregory T. Everson, Foreword by Gene Schiff
Published by Hatherleigh Press
ISBN: 978-1-57826-425-4
Available wherever books are sold


Dr. Everson recently wrote an article that was published in the September 2016 Journal of Hepatology. His editorial focuses on a paper that suggests that once a person on the waiting list is cured, there is a chance that the listed person could improve to the point of delisting and potentially avoiding liver transplant. His editorial discusses the PROs and CONs of the article and provides perspective on the issue. Read the article here.

Hepatitis C infection (HCV) is a chronic viral infection of the liver that affects upwards of 1-2 percent of adults. Fortunately, in children and adolescents, hepatitis C is less common, but it remains a significant health issue. In this article I will address the most common questions about hepatitis C in children and adolescents. Read the entire article here…


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