Sunday, March 15, 2009

Fatty liver disease

"As the nation gets heavier, our livers will get fatter."
---Chin Hee Kim, MD

Nonalcoholic fatty liver disease (NAFLD) is the most common form of liver disease AND it affects 20-30% of the US population per Drs. Kim and Younossi writing in the Cleveland Clinic Journal of Medicine(1). NAFLD can range from no big deal fat in liver through inflammation and liver cell damage (nonalcoholic steatohepatosis or NASH) to cirrhosis, liver cancer, or liver failure.

The standard, automated laboratory blood profile includes a panel of liver enzymes. These transaminases(2) which are involved in the production of amino acids are part of the biochemical equipment within liver cells. They are normally present in the bloodstream in small amounts, but disruption of liver cells causes their blood levels to rise. A case of hepatitis skyrockets transaminase levels into the 1,000s and beyond, but even very low level elevations found on lab screening are worthy of follow-up because they may indicate an ongoing, asymptomatic inflammatory liver process that can ultimately lead to cirrhosis and liver failure.

Often, elevated liver enzymes or liver function tests (LFTs) in overweight persons demonstrating signs of metabolic troubles (fat concentrated around the waistline, elevated blood pressure, elevated triglycerides, low HDL, or high blood sugar) are the first sign of NAFLD. This fatty liver business is usually asymptomatic and only noted on lab testing. In order to chase down the cause of abnormal LFTs, we next order tests to check for chronic hepatitis B or C infections, auto-immune liver disease, or metabolic diseases such as abnormally stored copper or iron in the liver. An ultrasound of the liver is fairly accurate in assessing the presence of fat in the liver.

Liver biopsy is the best way to determine if the fatty liver troubles are benign or carry a risk of progression from nonalcoholic steatohepatosis to scarring and permanent liver damage or failure. Once diagnosed, the best approach to treating fatty livers is the same strategy that improves overall health in overweight persons on the road to diabetes or heart disease. These include weight loss (including use of bariatric or gastric bypass procedures), trials of various drugs that promote insulin sensitivity such as metformin, Actos, or Avandia or drugs that lower triglycerides and raise HDL levels such as statins and gemfibrozil. Fatty livers are more sensitive to damage from regular alcohol intake.

If you tend to pack the pounds around your waistline, be sure to ask your doctor to test your liver enzymes.
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1) Kim, HK and Younossi, ZM. Nonalcoholic fatty liver disease: A manifestation of the metabolic syndrome. Cleveland Clinic Journal of Medicine. October, 2008, Vol 75, pp 721-728.
2) Aspartate transaminase (AST) and alanine transaminase (ALT) levels generally range up to 40 or so. In mild NAFLD, AST <> ALT.

12 comments:

Ruth said...

In the past year I have seen three non-drinkers with NASH who have died in our program with liver failure and ascites. At first I couldn't believe that they had no history of alcoholism as I had never heard of NASH before. All had been obese and diabetic.

judycolby said...

A lot of patients with Cushing's Syndrome/Disease also have fatty liver, even the very young.

Anonymous said...

I was never overweight until i began treatment for graves disease. PTU is known to cause this problem ,but i was not told of that. I now have fatty liver disease and extra weight, and I dont know what to do... losing weight is impossible on the antithyroids...and all they want to do is irradiate, which I believe causes cancer risk to go up, but they dont admit that either. I dont know what to do... my doctors suck.

Anonymous said...

I would also like to know from a doctor why it is when something goes wrong, like fatty liver disease on PTU,or other problems, when and why patients get dumped by doctors....
that isnt fair, it seems.... are doctors just cruel in protecting their 'liability'.... or what?
How does a patient feel who has been dumped when they need their doctor the most? Comment?

Anonymous said...

I want to know how to keep doctors from dumping me because I have a lot of potential problems with illness,meds etc
My attitude has really turned bad now, and I dont even want to have to see a doctor.... and I can barely hide my feelings...
What do you recommend?

femail doc said...

Ruth: I always appreciate your clinical experience; scary to have a silent liver disease and end up dead from it!

Judy: Thanks for commenting. I didn't know about that association, but it makes sense.

Anon: I'm sorry you've had such a time of it with your thyroid AND your doctors. So much of the doctor/patient relationship rests on trust, and your experiences haven't done much to foster trust, have they? I think anger creates defensiveness in the person at whom the ire is directed. I hope you can start afresh with a new physician soon.

Anonymous said...

thanks
I hope you realize that as much as you are programmed to 'give', that the people you know and even strangers give back to you all the time, even if it is just in spirit......and that you may not always know what is helping you at any given moment... so you 'receive' also... just a reminder thought.

sangeeta said...

first time here, found it very informative.......want to read more of it.

Amanda T said...

I am looking for an internal med doctor in Denver that has experience with Non-alcoholic Steatohepatitis (sp?). My mom has had this disease for about 14 years (diagnosed 14 years ago that is), and she will be moving in with me in a month. I am tired of bringing her to doctors that do not know much about it. Do any of you have a recommendation for a doctor in the Denver area that has experience with the disease? Thank you in advance. I look forward to hearing back.

femail doc said...

Hi Amanda,

I always refer my liver patients to one of the local GI docs. I don't know that any one of them 'specializes' in NASH, but I have to call one tomorrow to ask another question so I'll ask him. I'd prefer to convey this info to you by e-mail, so please send an e-mail to my AOL address femailhealthnews@aol.com.

Naveen said...

hello doc
My dad's GGT levels are so high -131u/L( normal:-0-50u/L).Is this an indication of any kind of liver disease.he is rite now taking a medicine that contain carbamazepine(300 mg) for the treatment of trigeminal neuralgia ... Is this causing the elevated GGT Level..?Should he take medicine for this..?

femail doc said...

Actually, Naveen, 131 is not that high for GGT levels. Such elevations are extremely common with carbamazepine. If not associated with elevations in other liver tests, this is generally not a problem and not a reason to discontinue the drug. His doctor who knows his overall health picture best will be his best guide as to how best to proceed.