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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 Thanks for reading!

Q&A with Dr. Todd Sheer from Centura Health Physician Group Southwest Gastroenterology in Durango, Colorado.

Dr. Sheer is a member of our Medical Advisory Committee

What is the scope of the problem?

Excess alcohol use (or alcohol use disorder) is one of the most common causes of liver disease and is responsible for almost half of the cases of liver-related death in the United States and worldwide. One in 12 adults abuses alcohol and 88,000 Americans die from alcohol-related causes per year, including deaths from liver disease, motor vehicle accidents, and violence.

How much alcohol is too much?

At risk drinking is usually defined as two drink equivalents for women and three drink equivalents for men per day. The definition of a drink equivalent is 1.5 ounces of liquor, 5 ounces of wine, or 12 ounces of beer. In reality, most “drinks” are even greater than these volumes.

Binge consumption of alcohol is also a form of alcohol abuse. Binge consumption consists of > 4 drinks for women and > 5 drinks for men, consumed over a 2-hour period.

The widely purported health benefits of alcohol are far from certain and very variable from person to person. It is not advisable abstinent person to start consuming alcohol for “health benefits.”

What are the effects of alcohol on the liver (and beyond)?

Alcohol ingestion initially results in accumulation of fat droplets in the liver cells, known as steatosis. This leads to cell injury and death with a resultant immune response and scarring. Eventually, scarring can lead to cirrhosis and despite the liver’s excellent ability to regenerate, the damage at this point is irreversible. From cirrhosis as host of complications can ensure including development of abdominal distention from fluid (ascites), confusion (encephalopathy), jaundice, gastrointestinal bleeding, liver cancer, and frank liver failure. These complications are more likely if one continues to drink alcohol. A significant additional entity worth mentioning is that of alcoholic hepatitis, a particularly devastating immune attack on the liver with minimal to no effective treatment options and a high rate of mortality.

Outside of the liver, alcohol abuse can cause additional injuries of which a few are listed below:

1. Pancreatitis – a painful inflammation of the pancreas with significant chance of death and permanent loss of function

2. Cardiomyopathy – heart muscle damage with heart failure

3. Neuropathy – damage to peripheral nerves with chronic pain and balance difficulties

4. Encephalopathy – atrophy of the brain with loss of cognitive function

5. Cancer – besides liver cancer as mentioned above, rates of breast, colon, mouth/throat, and esophagus cancers are higher

6. Depression and suicide

7. Accidents such as falls, motor vehicle accidents, and those related to other poor choices often made while intoxicated

Who is at most risk?

The amount of alcohol ingested is the most important risk factor for the development of liver disease. However, only 10-20% of chronic heavy drinkers develop cirrhosis or alcoholic hepatitis and therefore there must be additional variables involved. These are not fully known but as hinted above, women are at greater risk than men for equal amounts consumed. Possible causes for this discrepancy include sex differences in stomach and liver metabolism of alcohol as well as the liver’s inflammatory reaction to alcohol, a greater proportion of body fat in women, and menstrual cycle-induced variations in alcohol absorption. Genetics and race are other variables to be considered. There appears to be an inherited predisposition to alcoholism and the amount of damage alcohol has on the liver. The frequency of alcohol-induced cirrhosis is higher in African-American and Hispanic males compared to Caucasian males and the mortality rates are highest in Hispanic males. Coexisting liver diseases (which are often undiagnosed) such as hepatitis B and C and fatty liver from being overweight or obese also increase the risk of progression to chronic liver disease. Cigarette smoking is not uncommon in individuals consuming alcohol and likely exacerbates the effects of alcohol on the liver, including increasing the risk of liver cancer once cirrhosis is established.

The type of alcohol (wine, beer, or liquor) does not appear to be a determinant in the chance of liver disease, despite the common misconception to the contrary. In other words, keeping in mind the equivalents defined above, your liver is no safer with the consumption of wine or beer over liquor. Exercise and drinking black coffee may be protective but should not be relied upon as an alternative to reducing alcohol use or abstinence.

What can be done?

Minimization of alcohol intake or abstinence is the cornerstone of decreasing the risk of alcohol related liver disease. The good news is that even if advanced liver disease, including cirrhosis, is already established, significant improvements in liver function and survival can be achieved with abstinence. This improvement is often rapid, with two-thirds of individuals seeing a clinical difference within 3-6 months of alcohol cessation. Societal studies have shown a decline in liver disease during times of alcohol rationing, prohibition, and price increases. Recidivism, or a return to drinking, is a major problem, with rates ranging from 67%-81% within a year. Ways to maintain sobriety include consultation with addiction specialists, community-based support networks (e.g., Alcoholics Anonymous), and even medications. If you suspect you have an alcohol use disorder, it is encouraged to discuss with your physician. Testing can be relatively easily performed to determine the status of your liver and assistance with quitting and maintaining sobriety can be provided.

Autoimmune Hepatitis
Q&A with Karin Cesario, MD

1.  What is autoimmune hepatitis?

“Hepatitis” is a general term meaning “inflammation of the liver.”  Many things can cause hepatitis including medications, viruses and alcohol.  In autoimmune hepatitis, the body’s immune system attacks liver cells leading to liver inflammation.

2.  What causes autoimmune hepatitis?

It is not yet clear what causes autoimmune hepatitis.  Scientists believe that some people have a genetic predisposition to autoimmune hepatitis (along with other autoimmune diseases).  Some environmental exposure, such as medications or infection, may trigger development of the disease. Most cases of autoimmune hepatitis occur in middle-aged or older women.

3.  What are the symptoms of autoimmune hepatitis?

Many patients with autoimmune hepatitis have no symptoms and are diagnosed after an evaluation of persistently abnormal blood tests.   When chronic symptoms are present, people may experience fatigue, joint pains or itching. With a severe bout of autoimmune hepatitis, people may experience nausea, vomiting, abdominal pain, jaundice (yellowing of the skin or eyes), dark urine or pale stools.  

4.  How is someone diagnosed with autoimmune hepatitis?

Autoimmune hepatitis is often suspected based on blood work.  A liver biopsy may be ordered to confirm the diagnosis, determine the severity and/or rule out other causes of liver disease.

5.  What is the treatment of autoimmune hepatitis?

Not everyone with autoimmune hepatitis needs treatment.   The decision to start therapy is based on the severity of the disease and if symptoms are present.    When medical therapy is pursued, autoimmune hepatitis is usually treated first with a glucocorticoid such as prednisone or budesonide.   Over time, a person with autoimmune hepatitis will often be transitioned from a glucocorticoid to a second medication such as azathioprine or 6- mercaptopurine.   Rarely, methotrexate or mycophenolate mofetil may be used. All autoimmune hepatitis medications need to be supervised closely by a physician due to potential side effects.  Regular clinic check-ups with blood work are required.

6.  If started on medication for autoimmune hepatitis, will I ever get off?

Autoimmune hepatitis medications are usually continued until the disease is in remission, the treatment fails or the person develops severe side effects.   Remission is defined as a lack of symptoms, normal liver tests and near normal liver biopsy. Ten to forty percent of people with autoimmune hepatitis can minimize or discontinue their medications.  Unfortunately, most people with autoimmune hepatitis must eventually start treatment again due to relapse.

7.  Other than medications for autoimmune hepatitis, what else can I do to keep my liver healthy?

No specific diet has been shown superior for controlling autoimmune hepatitis.  Therefore, eating a balanced diet and avoiding alcohol is recommended. No herbal medications have been proven to improve outcomes in autoimmune hepatitis either.   Some herbal medications can actually cause serious liver damage. Particularly if cirrhosis is present, all supplements and new prescription medications should be checked by a liver specialist.

8.   What is the long-term prognosis for autoimmune hepatitis?

Early identification and appropriate treatment of autoimmune hepatitis can prevent liver scarring.   Untreated autoimmune hepatitis may lead to severe scarring of the liver (cirrhosis), liver failure or liver cancer.   Some patients with severe cases of autoimmune hepatitis may require a liver transplant.

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.

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.

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…

Q&A with Drs. Elizabeth Pomfret and James Burton, University of Colorado Hospital

Drs. Pomfret and Burton are both members of our Medical Advisory Committee

What is live donor liver transplantation?

Live donor liver transplantation is when a healthy person donates a portion of their liver to another person in need of a liver transplant. About 40-60% of a healthy person’s liver is removed and transplanted into an adult recipient after their original diseased liver is removed. Infants and small children require less liver volume. The portion of liver that remains in the donor and the portion that is transplanted into the recipient then regenerate over the next several months to the size that their bodies need.

Is live donor liver transplantation right for you?

With only about half of people United States donating their organs when they die, there are more people waiting for liver transplantation and organs available. Unfortunately, the results of this is many patients die on the transplant list waiting for an organ.

Live donation offers another way to perform lifesaving transplants. Choosing the option of live donation can: 

Make a recipients wait for transplant much shorter.

Give the recipient the chance to receive a transplant.

Allow options on the timing of the transplant.

Allow transplantation before the recipient becomes too sick.

On average, live donor liver transplant recipients have outcomes as good as–and often better than–those of recipients of deceased donors. Also, live donor liver transplant recipients are 50% less likely to die waiting for transplant, compared to those waiting for deceased donor.

Who is a candidate to receive a live donor liver transplant?

To be a candidate for live donor liver transplant, the recipient must first be an acceptable candidate for deceased donor liver transplant. Sometimes recipients are too sick or have anatomical or medical problems that would prevent them from having a successful live donor liver transplant. Live donor surgery is best for patients who do not have a spot that high enough on the transplant list to receive a deceased donor liver but who are sick enough to need a liver transplant. Recipient should talk to their transplant team and ask if live donor liver transplantation is right for them.

What are the potential risks or complications?

Any time major surgeries are done there are risk. The risk are directly related to the amount of liver tissue that is removed from the donor. The risk of death or need for the donor to need a transplant as a result of a complication from this surgery is estimated to be 0.1% (1 in 1000) to 0.5% (1 in 200), depending on how much liver tissue was removed.

Some of the serious complications from the surgery include the risk of a bile leak, the need for a reoperation or blood transfusion, damage to a bile duct or blood vessel, infection and slow liver function during liver regeneration. More often (90% of the time) the complications are minor and can include wound infections or gastrointestinal upset (such as nausea, bloating, constipation and/or diarrhea). This will be discussed in extensive detail during the donor’s evaluation. Occasionally the donor evaluation will identify an incidental finding during the donors evaluation that will require further medical follow-up.

Who can be a live donor?

Typically donors are greater than 18 and less than 55 years of age. They must be in excellent medical and psychological health. It is required to have a compatible blood type with the potential recipient and be able to understand the risk of the surgery and be willing to follow the requirements for clinic visits and ongoing communication with the transplant team before and after donation. The potential donor does not need to be a relative of the recipient. Friends and even total strangers can donated part of their livers.

What are the steps to becoming a live donor?

The first steps in being evaluated includes taking a health history questionnaire. Once this is reviewed by a physician the next step would be blood testing. These blood tests can happen anywhere that is convenient for a potential donor. If the results of the blood test are normal the donor is scheduled for a formal living donor evaluation at the transplant center. The donor evaluation is a detailed process that includes a physical exam, EKG, chest x-ray, additionally laboratory testing and imaging of the liver with CT and MRI. Additional testing and consults may be required depending on certain risk factors. These are determined on a case-by-case basis. During the donor evaluation there are visits with a transplant surgeon, hepatologist, donor coordinator, social worker, independent donor advocate and dietitian.

Once all the testing has been completed, the living donor team review the results and decide if one is a suitable candidate to donate a part of their liver. Donor safety is the top priority. If approved as a donor candidate and the donor wants to move forward with donation, surgery is scheduled at the earliest and appropriate time for both the donor and the recipient.

How much does it cost to be a donor?

Donors are not responsible for any medical cost associated with donation. This includes cost associated with initial lab testing, evaluation, hospitalization, surgery and follow-up. Donors are responsible for costs of transportation and lodging for the evaluation and after transplant. There may be funds available for assistance with these cost. This can be discussed with the social worker at the time of the donor evaluation.

How is liver transplant surgery performed, and how long will it take?

Two different transplant teams will simultaneously work on both the donor and the recipient. Depending on the size of the adult recipient, 40-60% of the donor liver is removed and replaces the entire liver of the recipient. A smaller amount of liver tissue is required for pediatric recipient (about 20%). The donor surgery typically requires 4-6 hours.

How long will the donor be in the hospital?

Most donors are in the hospital for 4-6 days. It may take longer if there are complications. If donors live out of state or are traveling a long way, they will need to stay in the area an additional 2-3 weeks after discharge before returning home.

What is the average recovery time?

Average recovery time differs from donor to donor and depends on the level of discomfort and fatigue. By 6-8 weeks, donor activity level will have increased. Most donors feel “normal” by 10-12 weeks. Individuals whose jobs includes mostly administrative duties typically feel like going back to work around 4-6 weeks, while those with physically demanding jobs usually do not return to work for 10-12 weeks.

Does being a family member make you a donor?

Being a family member does not necessarily make a better donor candidate. Risk of recipient rejection does not appear to be lower with a donation from a blood relative. Also, the relationship does not affect how much immunosuppression medicine the recipient receives after transplant.

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.

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