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.
In the absence of any specific clinical or
biochemical signs, NASH remains a diagnosis that is made after excluding other
causes of fatty liver and other causes of elevated liver enzymes.
The most frequent biochemical abnormality in the blood in NASH is persistent,
mild to moderately elevated transaminases (ALT and AST). Transaminases are the
liver enzymes that are most often elevated in the various types of hepatitis.
(Remember that hepatitis refers to inflammation of the liver.) In NASH, their
levels tend to fluctuate from month to month, and most often the ALT is greater
than the AST. This is different from alcoholic liver disease (ALD), in which the
AST is usually greater than the ALT. Indeed, this fortuitous finding often leads
to initially considering the diagnosis of NAFLD or NASH. Unfortunately, however,
no biochemical test or imaging procedure can differentiate simple fatty liver
from NASH.
Most of the other liver blood tests (e.g., bilirubin and alkaline
phosphatase) are usually normal in patients with NASH.
Gammaglutamyltranspeptidase (GGTP), however, is typically moderately elevated.
Serum ferritin (a protein involved in iron storage and inflammation) can be
significantly elevated, but transferrin saturation is usually normal. These iron
studies suggest the presence of only mild, if any, deposition of iron in the
liver (iron overload).
Abnormal biochemistry tests associated with insulin resistance include
elevated total cholesterol, low-density lipoprotein (LDL, the so-called bad
cholesterol), triglycerides, and blood sugar and decreased high-density
lipoprotein (HDL, the good cholesterol). The diagnosis of NAFLD or NASH can be
considered after excluding other causes of mild elevations of transaminases,
such as alcoholic liver disease, drug-induced hepatitis, chronic HBV or HCV,
autoimmune hepatitis, genetic hemochromatosis, alpha-1-antitrypsin deficiency,
and Wilson's disease.
Drugs than can promote fatty liver (secondary NAFLD) and even features of
NASH include prednisone, amiodarone (Cordarone), tamoxifen (Nolvadex),
methotrexate (Rheumatrex, Trexall), and
nonsteroidal anti-inflammatory drugs
(NSAIDS). A difficult diagnostic situation may be encountered in patients who
are taking cholesterol-lowering drugs of the statin
type. The reason for this
difficulty is that statins
frequently raise transaminases without producing any
significant liver injury. In this situation, NAFLD can be suspected if the ALT
remains elevated long after stopping the medication. However, if the statin drug
is responsible, the ALT will return to normal soon after stopping the drug.
Ideally, before initiating statin therapy, liver enzymes should be determined,
especially in patients at high-risk for NAFLD.
A good quality liver ultrasound can be highly sensitive (detects all fatty
livers) and specific (detects only fatty livers) in diagnosing fatty liver. The
classic ultrasound finding with a fatty liver is a hyperechoic (bright) liver.
Ultrasound, however, needs a skilled operator and its sensitivity decreases with
increased abdominal fat. Computerized tomography (CT) scan performs well in
detecting fatty liver and can even measure the degree of fat infiltration. This
technique, however, is hampered by any liver iron deposition that may be
associated with NAFLD. Magnetic resonance imaging (MRI) is the overall best
imaging exam for fatty liver, but also remains the most expensive. Nevertheless,
no imaging procedure can in itself establish the diagnosis of NASH.
Thus, a presumptive diagnosis of NAFLD can be made in an individual based on
the following criteria.
Clinical and/or biochemical signs of insulin
resistance
Chronically (long duration) elevated ALT
Signs of fatty liver on ultrasound
Exclusion of other causes of elevated ALT and fatty liver
Only a liver biopsy, however, can establish a definite diagnosis and
determine the severity of the condition.
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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