Dr. Schoenfield served as associate professor of medicine and consultant in gastroenterology on the faculty of the Mayo Clinic for seven years. He became a professor of medicine in residence at UCLA from 1972 to 1999 (now emeritus). He was the director of gastroenterology at Cedars-Sinai Medical Center in Los Angeles for 25 years, where he received the chief resident's teaching award, the president's award, and the pioneer of medicine award.
NAFLD is probably the single most
common liver abnormality in the United States. It appears to be linked directly
to the growing epidemic of obesity in adults as well as in children. Thus, in a
sense, NAFLD is a sell-inflicted liver disease, much like alcoholic liver
disease. But only a minority of patients who are obese or diabetic will develop
severe liver disease and this is most likely determined genetically. In
addition, increasing evidence suggests that obesity and diabetes can worsen
alcoholic liver disease and liver disease due to HCV.
For these reasons, basic science researchers, liver specialists
(hepatologists), nutritionists, and hormone specialists (endocrinologists) are
combining their efforts to better understand and contain this process that has
been recognized for only the past 30 years.
Research into the genetics of this process will reveal the pathways that lead
to severe disease and help to recognize those patients most at risk. Clinical
research will help us understand the natural clinical history of this process
and perhaps identify predictors of outcome. Basic science research will be aimed
at understanding how the disease comes about and the processes involved. This
knowledge then may lead to the development of specific treatments. Currently,
small trials are ongoing that involve insulin-sensitizing agents, such as
metformin (Glucophage), rosiglitazone (Avandia), and pioglitazone (Actos). Other
treatments with anti-oxidant effects may prove of value.
The bottom line, however, is that the single most effective treatment for
obese people with NASH is to simply lose weight through diet and exercise.
Unfortunately, this is no easy task in our present society, which is dominated
by a sedentary lifestyle and high-calorie, high-carbohydrate, high-fat diets.
With great effort, however, weight loss is achievable. Furthermore, in view of
the likely role of fatty infiltration in other liver diseases, weight loss might
be added on to the treatment of these other liver diseases, such as anti-viral
therapy for HCV. Ultimately, NASH can probably be largely prevented and
eliminated by promoting healthy eating habits and active lifestyles in children,
where it all begins.
Accumulation of fat in the liver (fatty liver) is
common to all stages of nonalcoholic fatty liver disease (NAFLD). The initial
stage in the spectrum of NAFLD is simple fatty liver (steatosis).
The basic cause of NAFLD is insulin resistance, which
is a biochemical state that diminishes the effects of insulin. The most
frequent risk factor for insulin resistance is obesity, especially abdominal
obesity.
Simple fatty liver is in itself quite harmless,
disappears rapidly with weight loss, and only a minority of those affected
progress to NASH, which is the next stage of NAFLD,
Along with the accumulation of liver fat, NASH
involves inflammation of the liver (hepatitis), destruction (necrosis) of
liver cells, and scarring (fibrosis) of the liver. It can progress to severe
liver disease, including cirrhosis, which is the last stage of NAFLD.
The risk factors, the time-line, and the processes
(mechanisms) responsible for progression through the stages of NAFLD are still
unknown.
Estimates of the number of cases of NAFLD among the
obese and patients with diabetes mellitus type 2 (DM2) suggest that 90% have
simple fatty liver, 20% have NASH, and 10% have cirrhosis. Among those with
cirrhosis, primary liver cancer develops at a rate of approximately 1% to 2%
per year.
The presumptive diagnosis of NAFLD or NASH is made in
individuals who are insulin resistant, have mildly elevated liver enzymes
(transaminases) in the blood, and have signs of fatty liver on an ultrasound.
These patients will have no other known cause for these enzyme elevations or
for the fatty liver, particularly no significant alcohol use.
If weight loss results in a decrease or normalization
of the liver enzymes, the diagnosis of NAFLD is practically assured. Only a
liver biopsy, however, can confirm the diagnosis of NAFLD and NASH and
determine the severity of the disease.
Whether or not it is vital to perform a liver biopsy
in suspected NAFLD or NASH is still debated among liver specialists since no
specific treatments are available. A liver biopsy can exclude other liver
diseases and provide information about the outcome (prognosis) of the
condition.
A liver biopsy may also provide an incentive for the patient to adopt a
healthy lifestyle (diet and exercise) with the aim of losing weight. Weight
loss, if overweight, and correcting elevated cholesterol, triglycerides, and
blood sugar should be beneficial in NAFLD.
Fatty Liver - How Was Diagnosis EstablishedQuestion: The symptoms of fatty liver can vary greatly from patient to patient. What were your symptoms at the onset of your disease?
Abdominal pain is pain in the belly and can be acute or chronic. Causes include inflammation, distention of an organ, and loss of the blood supply to an organ. Abdominal pain can reflect a major problem with one of the organs in the abdomen such as the appendix, gallbladder, large and small intestine, pancreas, liver, colon, duodenum, and spleen.
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.
Cirrhosis of the liver refers to a disease in which normal liver cells are replaced by scar tissue caused by alcohol and viral hepatitis B and C. This disease leads to abnormalities in the liver's ability to handle toxins and blood flow, causing internal bleeding, kidney failure, mental confusion, coma, body fluid accumulation, and frequent infections. Symptoms include yellowing of the skin, itching, and fatigue.
Diabetes mellitus is a chronic condition characterized by high levels of sugar (glucose) in the blood. The two types of diabetes are referred to as type 1 (insulin dependent) and type 2 (non-insulin dependent). Symptoms of diabetes include increased urine output, thirst, hunger, and fatigue. Treatment of diabetes depends on the type.
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.
Cholesterol is naturally produced by the body, and is a building block for cell membranes and hormones. Low-density lipoprotein (LDL) cholesterol is the "bad" cholesterol, conversely, high-density lipoprotein (HDL) cholesterol is the "good" cholesterol. High cholesterol treatment includes lifestyle changes (diet and exercise), and medications such as statins, bile acid resins, and fibric acid derivatives.
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.
Polycystic ovarian syndrome (PCOS), also known by the name Stein-Leventhal syndrome, is a hormonal problem that causes women to have a variety of symptoms including irregular or no menstrual periods, acne, obesity, and excess hair growth. Treatment of PCOS depends partially on the woman's stage of life and the symptoms of PCOS.
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.
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.
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.
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.
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.
Reye's syndrome (RS, or Reye syndrome) is a sudden, sometimes fatal, disease of the brain with degeneration of the liver. Reye syndrome occurs in children and comes after the chickenpox or an influenza-type illness, is also associated with taking medications containing aspirin. Symptoms include vomiting, listlessness, irritability or combativeness, confusion, delirium, delusions, convulsions, and loss of consciousness. Treatment depends on early diagnosis and focuses on protecting the brain against irreversible damage by reducing brain swelling, reversing the metabolic injury, preventing complications in the lungs, and anticipating cardiac arrest.
Fast food consumption and lack of exercise are just a couple of causes of childhood obesity. Health effects of childhood obesity include type 2 diabetes, heart attack, stroke, high cholesterol, asthma, sleep apnea, gallstones, fatty liver disease, GERD, depression, and eating disorders.
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