Liver disease (Hepatitis B and C, Cirrhosis, Abnormal Liver Enzymes, Fatty Liver)
This information is intended only to provide general guidance. It does not provide definitive medical advice. It is important that you consult your doctor about your specific condition.
The liver is a large, solid organ that lies in the right upper part of abdomen just under the rib cage. The liver has multiple functions including digesting and processing food, performing many chemical processes in the body, clearing toxic substances from the body, and storing many essential nutrients. The liver can be damaged by certain genetic diseases, alcohol, viral infections, medications, immune system abnormalities, and fat accumulation in the liver. Symptoms may be present, but sometimes the only evidence of injury or inflammation is abnormal blood tests (liver enzymes: ALT, AST, alkaline phosphatase). Over time, the injury can lead to scarring (cirrhosis) that interferes with the function of the liver and causes serious illness.
This web page will explain some of his specific diseases that may damage the liver.
What are these symptoms and signs of liver disease?
- Jaundice, a yellow color of the skin and eyes.
- Chronic fatigue.
- Loss of appetite.
- Abdominal pain.
- Abdominal swelling by fluid (ascites).
- Confusion and/or excessive daytime sleepiness.
- Swelling of the ankles and legs.
- Abnormal liver enzymes, blood tests that reflect injury or inflammation of the liver.
- Dark (or tea-colored) urine color.
- Itching all over the body.
- Bleeding in the gastrointestinal tract.
How is liver disease evaluated?
Once liver disease is suspected because of the above symptoms and signs or because of abnormal blood tests, Dr. Albert M. Harary, in his New York City office, will use a number of tests to define the cause and severity of the liver disease:
- Blood tests: Liver enzymes (AST or aspartate aminotransferase, ALT or alanine aminotransferase, and alkaline phosphatase) are blood chemicals whose levels become abnormally high when the liver is inflamed or injured. The pattern of enzyme elevations can suggest what type of liver disease is present. In addition, specific blood tests indicate whether there is viral hepatitis and which virus is present, autoimmune hepatitis, celiac disease, or genetic liver disease. Blood tests may also provide information as to how well the liver is functioning. An elevated bilirubin, decreased albumin and platelets, and abnormalities of blood clotting tests may indicate that the liver is not functioning well.
- Abdominal ultrasound: to assess for fat in the liver, blockage of the bile ducts that can affect the liver, possible tumors in the liver, the blood supply to and from the liver, and the presence of complications of cirrhosis such as ascites (fluid in the abdominal cavity), enlarged veins, or enlargement of the spleen. This noninvasive test, done by a radiologist, uses sound waves to visualize the liver and surrounding organs.
- Fibroscan or transient elastography: This is a noninvasive test that uses sound waves to measure the stiffness of the liver. When the liver has accumulated scar tissue as a consequence of continuing damage over the years, as it begins to develop cirrhosis, it becomes stiffer.
- CT scans and MRI scans also can image the structure of the liver, bile ducts, and blood vessels.
- Liver biopsy, in which a hollow needle is passed into the liver to obtain a thin piece of liver tissue that can be studied under the microscope. Although there is a small risk of severe bleeding, a liver biopsy may provide the most complete information about what is wrong with the liver. However, with improvements in the above imaging tests, liver biopsy is needed only infrequently.
- Changing medicines: Since medications are frequent causes of abnormal liver enzymes, switching away from suspected medications is often done, followed 6-8 weeks later by repeat blood tests to check if the liver tests have normalized. Herbal medications and non-prescription medications can cause abnormal liver enzymes and may need to be changed or stopped too.
Hepatitis A Virus Infection
The hepatitis A virus causes an acute (relatively brief) infection of the liver, which usually lasts for a few weeks and infrequently for a few months. All patients with hepatitis A eventually clear the infection and do not have long-term consequences. Hepatitis A is spread by food or water contaminated by feces (stool) from an infected person or sexual contact with an infected person. It is more common in international travelers, but outbreaks do occur in the United States too, especially among unvaccinated persons.
Symptoms of Hepatitis A:
- Jaundice (yellow color of eyes and skin).
- Loss of appetite.
- Abdominal pain.
- Severe itching.
- Dark urine.
- Low-grade fever.
Diagnosis of Hepatitis A: Dr. Albert Harary, in his New York City office, makes the diagnosis of hepatitis A by blood tests that identify the specific antibody to the virus and exclude other causes of hepatitis.
Treatment of Hepatitis A: Acute hepatitis A is not treated with antiviral medications. If necessary, symptoms can be controlled with medications for nausea and vomiting or for itching. Symptoms usually resolve within a few weeks but may last months.
Prevention of Hepatitis A: Persons infected with hepatitis A virus should wash their hands frequently and practice careful bathroom hygiene and sanitation. People exposed to the virus can be treated with immune globulin and vaccination. Young children should be vaccinated, as well as adults planning to travel to areas where hepatitis A is common; they should avoid drinking tap water in those areas and practice careful hygiene.
Hepatitis B Virus Infection
The hepatitis B virus initially causes acute hepatitis, which usually lasts a few weeks or months and ends when the body’s immune system removes all the virus from the body. However, in about 5% of patients with acute hepatitis B, the immune system is unable to completely eliminate the virus, resulting in chronic hepatitis, which may last many years and slowly damage the liver, sometimes leading to scarring/cirrhosis or even liver cancer. Hepatitis B can be caused by sexual contact with an infected person, intravenous drug abuse, blood transfusion before 1987, exposure of healthcare workers or hemodialysis patients to infected blood, living in areas were hepatitis B is very common (East Asia and parts of Africa) or in infants born to infected mothers. Vaccination with 3 injections can prevent hepatitis B.
Symptoms of hepatitis B: Acute hepatitis B may cause nausea, vomiting, loss of appetite, fatigue, or jaundice (yellow color of eyes and skin). Some patients have no symptoms. Chronic hepatitis may also cause these symptoms but usually does not cause symptoms unless cirrhosis (scarring) develops. Chronic hepatitis B may be found after abnormal blood tests are discovered when blood tests are performed during a routine checkup.
Treatment of hepatitis B: Acute viral hepatitis B usually does not require specific treatment. Chronic hepatitis B can be treated with antiviral drugs such as interferon, entecavir, tenofovir, lamivudine, adefovir, and telbivudine, although such treatment is not necessary in some patients with low blood levels of the virus.
Prevention of hepatitis B: Dr. Albert Harary advises all patients who are actively infected with hepatitis B to practice safe sex (condoms, etc.) and avoid sharing toothbrushes, razors, and nail clippers. All pregnant women should be screened for hepatitis B so that their newborn babies can be treated immediately. Vaccination for hepatitis B (3 shots) should be given to all children, adolescents, and adults at risk.
Hepatitis C Virus Infection
The hepatitis C virus usually causes chronic hepatitis C infection lasting many years, and this may cause damage to the liver leading to cirrhosis (scarring) and failure of the liver (in over 20% of untreated patients) or even liver cancer. In most people infected with hepatitis C, the immune system is unable to eliminate the virus, and chronic hepatitis C results. Most people do not feel sick when they are initially infected, so they are not aware that they have the hepatitis C infection. Chronic hepatitis C infection is discovered when abnormal liver blood tests are discovered on routine blood testing or by screening people born between 1945 and 1964 (“baby boomers”) with a blood test for the hepatitis C virus.
Who is at risk for hepatitis C?
- Injection drug abuse abusers.
- People with multiple sexual partners.
- Sexual partners of an infected person.
- Healthcare workers.
- Patients infected with HIV.
- Hemodialysis patients.
- Infants born to women infected with hepatitis C.
- Immigrants from countries where hepatitis C is common.
- Anyone who received a transfusion of blood or blood products or clotting factors before July 1992, when blood donors began to be tested for hepatitis C in the USA.
Treatment of hepatitis C: Dr. Albert Harary, in his New York City office, treats his hepatitis C patients with pills containing combinations of antiviral drugs such as Harvoni (sofosbuvir and ledispavir), Zepatier (grazoprevir plus elbasvir), Epclusa (sofosbuvir plus velpatasvir), and ViekeraPak (paritaprevir, ritonavir, ombitasvir, and dasobuvir). These medications are fairly safe and are usually very well tolerated. There are usually taken for 8-12 weeks. Other antiviral medications that are useful include ribavirin, which sometimes needs to be added to one of the above combination pills, simeprevir (Olysio), and daclatasvir. The various combination pills can eradicate chronic hepatitis C in over 90% of infected patient's (up to 99%). Patients with cirrhosis and/or certain subtypes (genotypes) of hepatitis C are more difficult to treat but usually can be effectively treated. Herbal medications do not appear to be helpful and can sometimes harm the liver. All patients with hepatitis C should be vaccinated for the hepatitis A and B viruses if they are not already immune.
After treatment of hepatitis C: Treating hepatitis C will reduce the risk of developing cirrhosis, liver failure, and liver cancer. However, many patients who have been successfully treated still require periodic testing to screen for the development of liver cancer. This is done by abdominal ultrasound, a noninvasive test done by radiologists that uses sound waves to visualize the liver, and a blood test called alpha-fetoprotein (AFP), which becomes elevated when liver cancer is present. Early detection of liver cancer may allow it to be cured. These tests should be done as frequently as every 6 months and often need to be continued for many years or permanently.
Alcoholic Liver Disease
Excessive alcohol use could lead to inflammation of the liver (alcoholic hepatitis) and cirrhosis (scarring of the liver that interferes with the functioning of the liver). An earlier stage of injury to the liver is alcoholic fatty liver (steatosis), which is often without symptoms. With alcoholic hepatitis, fat deposits in liver cells, and there is inflammation of the liver tissue. There is often nausea, loss of appetite, abdominal pain, fatigue, and signs and symptoms of cirrhosis (see below). Many patients with alcoholic hepatitis will progress to cirrhosis, but stopping alcohol intake leads to improvement. Severe alcoholic hepatitis can lead rapidly to cirrhosis, liver failure, and death. Some patients develop alcoholic cirrhosis without having first had alcoholic hepatitis. Alcohol abuse is particularly dangerous when combined with other liver diseases such as viral hepatitis B or C.
Who is at risk for alcoholic liver disease? Anyone who uses alcohol heavily can get alcoholic liver disease. Heavy alcohol use is defined as follows: for men, more than 4 drinks per day or more than 14 drinks per week. For women, more than 3 drinks per day or more than 7 drinks per week. Each drink is defined as one shot (1-1/2 ounces) of hard liquor (whiskey, gin, vodka), 1 glass of wine, or one can of beer. If you have any other liver disease, such as viral hepatitis or autoimmune hepatitis or fatty liver (NAFLD or NASH) you should drastically limit alcohol intake (no more than 2 drinks per week). Anyone who drinks enough to get alcoholic liver disease is an alcoholic and needs vigorous treatment for alcoholism.
Diagnosis of alcoholic liver disease: Alcoholic hepatitis is diagnosed by abnormal liver blood tests in patients with a history of heavy alcohol use and no other explanations for the liver disease. There are certain patterns of liver enzyme abnormalities that are very suggestive of alcoholic hepatitis.
Treatment of alcoholic liver disease: Complete abstinence from alcohol use is necessary. Anyone who drinks enough to get alcoholic liver disease is an alcoholic and needs specific treatment for alcoholism. These treatments include Alcoholics Anonymous, inpatient detoxification programs, medications, and individual psychotherapy. The most important ingredient in successful treatment is the recognition by the patient that he or she has a drinking problem and is motivated and desires to stop drinking and be healthy. Nutritional support will help heal alcoholic hepatitis. Severe alcoholic hepatitis needs to be treated in the hospital; corticosteroids (cortisone, prednisone, etc.) are sometimes necessary, as well as other medications.
Nonalcoholic Fatty Liver Disease (NAFLD)
Nonalcoholic fatty liver disease (NAFLD) has become the most common type of liver disease. NAFLD occurs when fat accumulates inside the liver cells. It occurs most commonly in association with obesity (overweight), but can sometimes occur even with normal body weight. Over time, the fat can damage to the liver and occasionally lead to cirrhosis. It usually does not cause any symptoms until cirrhosis has developed.
What is NASH? A sub-type of nonalcoholic fatty liver disease (NAFLD) is NASH (nonalcoholic steatohepatitis), in which inflammation and injury to the liver cells are present. Progression to cirrhosis is more likely to occur in those patients who have NASH. The only way to definitely identify NASH is by a liver biopsy. However, this test is only used in selected patients with NAFLD.
How is NAFLD diagnosed? The presence of the nonalcoholic fatty liver disease (NAFLD) is suggested by abnormal liver enzymes or a characteristic appearance (echogenic liver) on an abdominal ultrasound. When other causes of these abnormalities have been excluded by specific blood tests, then NAFLD is likely. Proof that NAFLD is present occurs when the liver blood tests normalize following weight loss.
What is the treatment of NAFLD and NASH? The best way to treat NAFLD and NASH in overweight patients is to lose weight. Loss of about 10% of body weight can often cure NAFLD and NASH. In some obese patients who have not lost sufficient weight by dieting, bariatric surgery can produce enough weight loss to cure the fatty liver. Patient who are not overweight usually do not benefit from weight loss. There is some evidence that a high dose of vitamin E (400-800 units per day) and the diabetes medicine pioglitazone (Actos) benefit NAFLD and NASH patients. Many experimental drugs are being tested in the hope that they will help fatty liver. Also, alcohol intake should be minimized.
Cirrhosis is a serious disease in which liver becomes scarred and no longer functions normally. It usually occurs as the end result of years of gradual damage by viruses (hepatitis B or C), alcohol, certain hereditary (genetic) diseases, fatty liver (NAFLD or NASH), certain parasites, or damage to the bile ducts that carry bile, a digestive liquid, out of the liver into the intestine. The loss of functioning liver cells and the disruption of blood circulation through the liver prevent the liver from performing its usual tasks for the body. In addition, portal hypertension, in which the pressure increases inside the portal vein that carries blood into the liver, eventually occurs. This can result in enlarged veins (varices) in the wall of the esophagus and stomach, which can bleed severely (variceal bleeding or hemorrhage). It also frequently leads to the accumulation of fluid and swelling in the abdomen (ascites). Other serious complications of cirrhosis include:
- Hepatic encephalopathy: Confused thinking, changes in behavior, excessive sleepiness, other mental changes, or even coma, due to the failure of the liver to remove toxins and other chemicals (especially ammonia) from the blood stream.
- Kidney failure.
- Poor nutrition and weight loss or loss of muscle mass.
- Anemia (low blood count) or low platelet count.
- Bleeding or easy bruising.
- Increased risk of infection.
- Development of liver cancer.
How is cirrhosis treated? The treatment of cirrhosis is complex. Whatever has caused the cirrhosis should be corrected if possible, for example by losing weight, stopping alcohol intake, treating viral infections, etc. Dr. Albert M. Harary, in his New York City office, will prescribe medications and dietary changes for the specific complications of cirrhosis. Variceal bleeding is treated by specialized endoscopic or vascular procedures. When the cirrhosis is advanced and medications are less effective, liver transplantation is a solution. Every patient with cirrhosis should be enrolled in a transplant program so that liver transplantation is more likely to be available when and if it becomes necessary.
To learn more about the evaluation and treatment of liver diseases, please contact our New York City office today.