Dr. Lee was born in Shanghai, China, and received his college and medical training in the United States. He is fluent in English and three Chinese dialects. He graduated with chemistry departmental honors from Harvey Mudd College. He was appointed president of AOA society at UCLA School of Medicine. He underwent internal medicine residency and gastroenterology fellowship training at Cedars Sinai Medical Center.
Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Alcohol is a very common
cause of cirrhosis, particularly in the Western world. The development of
cirrhosis depends upon the amount and regularity of alcohol intake. Chronic,
high levels of alcohol consumption injure liver cells. Thirty percent of
individuals who drink daily at least eight to sixteen ounces of hard liquor or
the equivalent for fifteen or more years will develop cirrhosis. Alcohol
causes a range of liver diseases; from simple and
uncomplicated fatty liver
(steatosis), to the more serious fatty liver with
inflammation (steatohepatitis or
alcoholic hepatitis), to cirrhosis.
Nonalcoholic fatty liver disease (NAFLD) refers to a wide spectrum of liver diseases that, like
alcoholic liver disease, ranges from simple steatosis, to nonalcoholic
steatohepatitis (NASH), to cirrhosis. All stages of NAFLD
have in common the
accumulation of fat in liver cells. The term nonalcoholic is used because
NAFLD occurs in individuals who do not consume excessive amounts of alcohol,
yet, in many respects, the microscopic picture of NAFLD is similar to what can
be seen in liver disease that is due to excessive alcohol. NAFLD is associated
with a condition called insulin resistance, which, in turn, is associated with
the metabolic syndrome and diabetes mellitus type 2. Obesity is the most
important cause of insulin resistance, metabolic syndrome, and type 2
diabetes. NAFLD is the most common liver disease in the United States and is
responsible for 24% of all liver disease. In fact, the number of livers that are
transplanted for NAFLD-related cirrhosis is on the rise. Public health officials
are worried that the current epidemic of obesity will
dramatically increase the development of NAFLD and cirrhosis in the
population.
Cryptogenic cirrhosis(cirrhosis due to unidentified causes) is a common
reason for liver transplantation. It is termed cryptogenic cirrhosis because
for many years doctors have been unable to explain why a proportion of
patients developed cirrhosis. Doctors now believe that cryptogenic cirrhosis
is due to NASH (nonalcoholic steatohepatitis) caused by long standing obesity,
type 2 diabetes, and insulin resistance. The fat in the liver of patients with
NASH is believed to disappear with the onset of cirrhosis, and this has made it
difficult for doctors to make the connection between NASH and cryptogenic
cirrhosis for a long time. One important clue that NASH leads to cryptogenic
cirrhosis is the finding of a high occurrence of NASH in the new livers of
patients undergoing liver transplant for
cryptogenic cirrhosis. Finally, a study from France suggests that patients
with NASH have a similar risk of developing cirrhosis as patients with long
standing infection with hepatitis C virus. (See discussion that follows.)
However, the progression to cirrhosis from NASH is thought to be slow and the
diagnosis of cirrhosis typically is made in patients
in their sixties.
Chronic viral hepatitis
is a condition where hepatitis B or hepatitis C virus infects the liver for
years. Most patients with viral hepatitis will
not develop chronic hepatitis and cirrhosis. For example, the majority of
patients infected with hepatitis A recover completely within weeks, without
developing chronic infection. In contrast, some patients infected with
hepatitis B virus and most
patients infected with hepatitis C virus develop chronic hepatitis, which, in
turn, causes progressive liver damage and leads to cirrhosis, and, sometimes,
liver cancers.
Inherited (genetic) disorders result in the accumulation of toxic substances in the liver
which lead to tissue damage and cirrhosis. Examples include the abnormal
accumulation of iron (hemochromatosis) or copper (Wilson's disease). In
hemochromatosis, patients inherit a tendency to absorb an excessive amount of
iron from food. Over time, iron accumulation in different organs throughout
the body causes cirrhosis, arthritis, heart muscle damage leading to heart failure, and
testicular dysfunction causing loss of sexual drive. Treatment is aimed at
preventing damage to organs by removing iron from the body through bloodletting
(removing blood). In Wilson disease, there is an inherited abnormality in one of
the proteins that controls copper in the body. Over time, copper accumulates in
the liver, eyes, and brain. Cirrhosis, tremor, psychiatric disturbances and
other neurological
difficulties occur if the condition is not treated early. Treatment is with
oral medication that increases the amount of copper that is
eliminated from the body in the urine.
Primary biliary cirrhosis
(PBC) is a liver disease caused by an abnormality of the immune system
that is found predominantly in women. The abnormal immunity in PBC causes
chronic inflammation and destruction of the small bile ducts within the liver.
The bile ducts are passages within the liver through which bile travels to the
intestine. Bile is a fluid produced by the liver that contains substances
required for digestion and absorption of fat in the intestine, as well as
other compounds that are waste products, such as the pigment bilirubin.
(Bilirubin is produced by the breakdown of hemoglobin from old red blood
cells.). Along with the gallbladder, the bile ducts make up the biliary tract. In PBC, the destruction of the
small bile ducts blocks the normal flow of bile into the intestine. As the
inflammation continues to destroy more of the bile ducts, it also spreads to
destroy nearby liver cells. As the destruction of the hepatocytes proceeds,
scar tissue (fibrosis) forms and spreads throughout the areas of destruction.
The combined effects of progressive inflammation, scarring, and the toxic
effects of accumulating waste products culminates in
cirrhosis.
Primary sclerosing
cholangitis (PSC) is an uncommon disease found frequently in patients with
ulcerative colitis . In PSC, the large bile ducts
outside of the liver become inflamed, narrowed, and obstructed. Obstruction to
the flow of bile leads to infections of the bile ducts and jaundice and
eventually causes cirrhosis. In some patients, injury to the bile ducts
(usually as a result of surgery) also can cause obstruction and cirrhosis
of the liver.
Autoimmune hepatitis is a liver disease caused by an abnormality of the immune
system that is found more commonly in women. The abnormal immune activity in
autoimmune hepatitis causes progressive inflammation and destruction of liver
cells (hepatocytes), leading ultimately to cirrhosis.
Infants can be born without bile ducts (biliary atresia)
and ultimately develop cirrhosis. Other infants are born lacking vital enzymes
for controlling sugars that leads to the accumulation of sugars and cirrhosis.
On rare occasions, the absence of a specific enzyme can cause cirrhosis and scarring of
the lung (alpha 1 antitrypsin deficiency).
Less common causes of
cirrhosis include unusual reactions to some drugs and prolonged exposure to
toxins, as well as chronic heart failure (cardiac
cirrhosis). In certain parts of the world (particularly Northern
Africa), infection of the liver with a parasite (schistosomiasis) is the most common
cause of liver disease and cirrhosis.
Cirrhosis of The Liver - Symptoms at Onset of DiseaseQuestion: The symptoms of cirrhosis of the liver can vary greatly from patient to patient. What were your symptoms at the onset of your disease?
Gallstones are stones that form when substances in the bile harden. Gallstones (formed in the gallbladder) can be as small as a grain of sand or as large as a golf ball. There can be just one large stone, hundreds of tiny stones, or any combination. The majority of gallstones do not cause symptoms.
Liver cancer is the fifth most common cancer in the world and the majority of patients with liver cancer will die within one year as a result. Patients with associated cirrhosis caused by chronic hepatitis B or C infections, alcohol, and hemochromatosis are at the greatest risk of developing liver cancer. Many patients with liver cancer do not develop symptoms until the advanced stages of the tumor which usually makes prognosis poor. The combination of an imaging study (ultrasound, CT, or MRI scans) and an elevated blood level of alpha-fetoprotein will most effectively diagnose liver cancer, while a liver biopsy can make a definitive diagnosis. Medical treatments, including chemotherapy, chemoembolization, ablation, and proton beam therapy, are not very effective. Surgical removal of the tumor or a liver transplant may be most effective in certain cases.
Liver disease can be cause by a variety of things including infection (hepatitis), diseases such as gallstones, high cholesterol or triglycerides, blood flow obstruction to the liver, and toxins (medications and chemicals). Symptoms of liver disease depends upon the cause; however, common symptoms may include nausea, vomiting, upper right abdominal pain, and jaundice. Treatment depends upon the cause of the liver disease.
Hepatitis C is an inflammation of the liver due to the hepatitis C virus (HCV), which is usually spread by
blood transfusion, hemodialysis, and needle sticks, especially with intravenous
drug abuse. Chronic hepatitis C may be treated with interferon, usually in combination with anti-virals.
Jaundice is a yellowish staining of the skin and whites of the eyes (sclerae) with bilirubin, the pigment found in bile. Jaundice can be an indicator of liver or gallbladder disease, or it may result from the rupture of red blood cells (hemolysis).
Alcoholism is a disease that includes alcohol craving and continued drinking despite repeated alcohol-related problems, such as losing a job or getting into trouble with the law.
Internal bleeding occurs when an artery or vein is damaged and blood to escapes the circulatory system and collects inside the body. Internal bleeding can be caused by a variety of situations such as blunt trauma, deceleration trauma, medications, fractures, and spontaneous bleeding. Treatment of internal bleeding depends on the cause of the bleeding.
The hepatitis B virus is a unique, coated DNA virus belonging to the Hepadnaviridae family of viruses. The course of the virus is determined primarily by the age at which the infection is acquired and the interaction between the virus and the body's immune system. Successful treatment is associated with a reduction in liver injury and fibrosis (scarring), a decreased likelihood of developing cirrhosis and its complications, including liver cancer, and a prolonged survival.
Ascites, the accumulation of fluid in the abdominal cavity is most commonly caused by cirrhosis of the liver. Some of the other causes of ascites include portal hypertension, congestive heart failure, blood clots, and pancreatitis. The most common symptoms include increased abdominal girth and size, abdominal bloating, and abdominal pain. Treatment depends on the cause of ascites.
The spleen enlarges if it is asked to do excessive work in filtering or manufacturing blood cells, if there is abnormal blood flow to it, or if it is invaded with abnormal cells or deposits. Symptoms of an enlarged spleen may include weakness and fatigue, easy bleeding, and poor white blood cell function. Treatment of an enlarged spleen is focused toward the cause of the splenomegaly. Surgery may be required to remove the spleen.
Hyponatremia is a condition where the level of sodium in the blood is low. Causes of hyponatremia can occur from excess fluid in the body, or a loss of sodium in body fluid. Some of the symptoms of hyponatremia include headache, muscle cramps or spasm, seizures, weakness and confusion. Treatment of hyponatremia depends on the cause.
Pleurisy, an inflammation of the lining around the lungs, is associated with sharp chest pain upon breathing in. Cough, chest tenderness, and shortness of breath are other symptoms associated with pleurisy. Pleurisy pain can be managed with pain medication and by external splinting of the chest wall.
Nonalcoholic fatty liver disease (NAFLD) refers to a wide spectrum of liver disease ranging from simple fatty liver (steatosis), to nonalcoholic steatohepatitis (NASH), to cirrhosis (irreversible, advanced scarring of the liver). All of the stages of NAFLD have in common the accumulation of fat (fatty infiltration) in the liver cells (hepatocytes).
Insulin resistance is the diminished ability of cells to respond to the action of insulin in transporting glucose (sugar) from the bloodstream into muscle and other tissues. Causes of insulin can include conditions such as stress, obesity, metabolic syndrome, and steroid use. Some of the risk factors for insulin resistance include fatty liver, heart disease, strokes, peripheral vascular disease, high cholesterol, and smoking. Treatment for insulin resistance are lifestyle changes and if necessary, medication.
Thrombocytopenia refers to a decreased number of platelets in the blood. There are many causes of thrombocytopenia such as decreased platelet production (viral infections for example rubella, mumps, chickenpox, hepatitis C, and HIV); increased platelet destruction or consumption (for example sulfonamide antibiotics, heparin, blood transfusions, and lupus); or increased splenic sequestration (enlarged spleen due to conditions for example liver disease, blood cancers, and more). Treatment of thrombocytopenia depends on the cause.
Cystic fibrosis is a disease of the mucus and sweat glands. Cystic fibrosis is an inherited disease. The outcome of the disease leaves the body malnourished, bulky and fouls smelling stools, vitamin insufficiency, gas, painful or swollen abdomen, infertility, susceptible to heat emergencies, and respiratory failure. There is no cure for cystic fibrosis, treatment of symptoms is used to manage the disease.
Hepatitis is most often viral, due to infection with one of the hepatitis viruses (A, B, C, D, E, F (not confirmed), and G) or another virus (such as those that cause infectious mononucleosis, cytomegalovirus disease). The main nonviral causes of hepatitis are alcohol and drugs. Many patients infected with hepatitis A, B, and C have few or no symptoms of illness. For those who do develop symptoms of viral hepatitis, the most common are flu- like symptoms including: loss of appetite, nausea, vomiting, fever, weakness, tiredness, and aching in the abdomen. Treatment of viral hepatitis is dependant on the type of hepatitis.
Hereditary hemochromatosis (iron overload) is an inherited disorder in which there is excessive accumulation of iron in the body. Individuals may have no symptoms or signs, or they can have severe symptoms and signs of iron overload. The most effective treatment for hemochromatosis is therapeutic phlebotomy.
Encephalopathy means brain disease, damage, or malfunction. Causes of encephalopathy are varied and numerous. The main symptom of encephalopathy is an altered mental state. Other symptoms include lethargy, dementia, seizures, tremors, and coma. Treatment of encephalopathy depends on the type of encephalopathy (anoxia, diabetic, Hashimoto's, hepatic, hyper - hypotensive, infectious, metabolic, infections, uremic, or Wernicke's) are examples of types of encephalopathy.
Pleural effusion is an excess fluid between the two membranes that envelop the lungs. There are two classifications of causes of pleural effusion; transudate and exudate. The treatment of pleural effusion depends on the cause.
The main features of metabolic syndrome include insulin resistance, hypertension (high blood pressure), cholesterol abnormalities, and an increased risk for clotting. Patients are most often overweight or obese. Lifestyle modification such as the Mediterranean diet, exercise, and quitting smoking are the preferred treatment of metabolic syndrome.
Primary Biliary Cirrhosis is a chronic disease characterized by progressive inflammation and destruction of small bile ducts within the liver. The bile ducts transport bile from the liver to the intestine for the absorption of fat and elimination of waste products. The causes of Primary Biliary Cirrhosis may involve autoimmunity, infection, or genetic predisposition, acting alone or in combination. There are many medications and treatment options available for those with this and other associated diseases of Primary Biliary Cirrhosis.
The liver is the largest solid organ in the body, and is actually an gland. The liver has a wide variety of critical functions such as manufacturing proteins and metabolizing fats and carbohydrates. The liver also eliminates harmful biochemical waste products from the body (alcohol, drugs, toxins). The liver secretes bile that aids in digestion. Examples of diseases of the liver include cirrhosis, hepatitis, cancer, and fatty liver. Symptoms of liver disease include bleeding, easy bruising, edema, fatigue, and jaundice.
Coma is the inability to waken or react to the surrounding environment. The Glasgow Coma Scale is frequently used to measure the depth of coma. Causes of coma include trauma, bleeding, edema, lack of oxygen, poisoning, or hypoglycemia. Prognosis for a patient in a coma depends on the cause of the coma.
Male breast cancer accounts for 1% of all breast cancers, and most cases are found in men between the ages of 60 and 70. A man's risk of developing breast cancer is one in 1,000. Signs and symptoms include a firm mass located below the nipple and skin changes around the nipple, including puckering, redness or scaling, retraction and ulceration of the nipple. Treatment depends upon staging and the health of the patient.
Gynecomastia, an enlargement of the gland tissue in the male breast is the caused by an imbalance of hormones. Certain medical conditions may also lead to gynecomastia such as cirrhosis, malnutrition, disorders of the male sex organs, kidney failure, thyroid disorders, and medications. Gynecomastia is generally treated with medication, and if necessary surgery.
Portal hypertension is most commonly caused by cirrhosis, a disease in which results from scarring of a liver injury. Other causes of portal hypertension include blood clots in the portal vein, blockages of the veins that carry the blood from teh liver to the heart, and a parasitic infection called schistosomiasis.
Primary sclerosing cholangitis (PSC) is a chronic, progressive disease of the bile ducts that channel bile from the liver into the intestines. There is an association between primary sclerosing cholangitis and ulcerative colitis and Crohn's disease. Symptoms of primary sclerosing cholangitis include abnormal liver blood tests, itching, fatigue, and jaundice. Primary sclerosing cholangitis is treated with medications and in some cases, liver transplant.
Digestion is the complex process of turning food you eat into the energy you need to survive. The digestive process also involves creating waste to be eliminated, and is made of a series of muscles that coordinate the movement of food.
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