Hepatology is the study of liver disease and it is an ever-changing field of medicine. Liver related problems encompass approximately 20% or more of a general gastroenterology practice. Because of the complexity of certain liver diseases, an entire sub-specialty within the realm of gastroenterology is devoted to diagnosing and treating patients with acute and chronic liver related problems. The GI department is staffed with well qualified physicians who are specifically trained to treat your liver related issues.
We treat all forms of liver disease to include hepatitis C and hepatitis B, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, primary biliary cholangitis , primary sclerosing cholangitis, drug-related liver injury, cirrhosis and all of the complications related to advanced chronic liver disease. We also treat patients who have had liver transplants and medically manage post-liver transplant care. Although NMCSD is not a transplant center, we have very close working relationships with both liver transplant centers in San Diego and work together to ensure that liver transplant patients are properly managed.
Cirrhosis and Liver Transplantation
Cirrhosis is the end result of chronic liver disease and is caused by many different factors. The most common causes of cirrhosis in the United States are from hepatitis C, chronic alcohol use and non-alcoholic fatty liver disease Many other diseases can lead to cirrhosis if left untreated such as hepatits B, autoimmune liver disease and certain genetic conditions primarily affecting the liver; however, these are less common causes in this country.
Cirrhosis results from chronic inflammation of the liver cells (hepatocytes) resulting from exposure to a harmful agent, such as viral hepatitis or alcohol. Over a long period of time, scar tissue (fibrosis) can develop as a result of this inflammation. There are various stages of fibrosis, and cirrhoisis is the most advanced form. Occasionally cirrhosis can go undiagnosed for long periods of time until complications develop. Many patients who have an early form of cirrhosis continue to have normal function of the liver and may not know they have liver disease. However, as the liver disease progresses, the liver function begins to deteriorate (or decompansate) to the point where the liver is no longer able to carry out it's primary duties in the body. It is at this point where liver transplantation may be the only option for complete cure. Sometimes removing the factors causing the liver disease can improve hepatic function to the point where liver function may improve and the patient may not need a liver transplant. This is specifically true for those who stop drinking alcohol or if the viral hepatitis is successfully treated. Unfortunately despite removing the causative agent, for some people liver transplantation is still necessary if the liver function does not improve.
Complications of decompansated cirrhosis include:
- Ascites: Collection of fluid in the abdomen
- Varices: Accessory blood vessels in the stomach or esophagus that may bleed and require endoscopic intervention to help stop the bleeding
- Encephalopathy: Changes in mental status/confusion/concentration or sleeping habits that result from toxins not being cleared by the liver
- Hepatocellular Carcinoma: The most common form of liver cancer. All patients with cirrhosis are at risk of hepatocellular carcinoma and because of this, will need imaging of the liver every six months to ensure that suspicious nodules or lesions are not developing.
Please click below to get answers on FAQ regarding cirrhosis.
http://patients.gi.org/topics/liver-cirrhosis/
http://www.gastro.org/info_for_patients/2013/6/6/understanding-cirrhosis-of-the-liver
For those who require a liver transplant evaluation, patients are typically sent to one or both liver transplant centers in San Diego for evaluation. The two centers in our area are at Scripps Green and UCSD. There are other liver transplant centers in our region which you may go to (the next nearest being in Los Angeles), however most patients tend to be evaluated and listed here in San Diego. We will help you arrange appointments at the transplant center if we feel that you would benefit from an evaluation.
Hepatitis C
After alcoholic liver disease, chronic hepatitis C (HCV) has historically been the next most common cause of chronic liver injury and cirrhosis in the United States. Although it was only officially identified in 1989, the hepatitis C virus has been around for decades and has been the primary cause of liver related mortality for millions of individuals over the past 30-40 years. The vast majority of chronic hepatitis C patients are those of the "baby boomer" generation, however we most certainly continue to see new cases of HCV diagnosed in younger individuals as well.
Hepatitis C is a blood-born pathogen and is primariy transmitted through direct contact of infected bodily fluid. Major risk factors for HCV transmission are in persons who have ever used IV or intra-nasal drugs, high risk sexual behavior, incarceration in prisions, patients on hemodialysis, transfusion of blood products prior to 1992, co-infection with HIV, tattoos obtained in an unregulated setting and inadvertent needles sticks.
All persons with a history of the above risk factors should be screened for hepatitis C. Additionally, in 2012 the CDC made a strong recommendation that any patients born between 1945 - 1965 be screened at least once, regardless of risk factors. This recommendation was made because this the most prevalent population where HCV is diagnosed. Also, this specific group was often under reporting their risk factors and thus many were going undiagnosed.
HCV Treatment
In the past, treatment for HCV was very difficult and unsuccessful for many patients, especially those with genotype 1 and for those who had cirrhosis. Up until 2013, treatment of all HCV genotypes required the use of interferon with other oral medications. Many people could not tolerate the interferon due to the side effects of the medication, and for those who could tolerate the therapy, there was a very good chance that the virus would come back after the therapy was stopped.
However, since 2014, multiple oral medications have been approved for the treatment of hepatitis C and the results are astounding! No interferon is needed with any of these medications! With these new direct-acting oral agents, we can now cure hepatitis C in 90-100% of patients, regardless of genotype. Several agents are currently on the market, and depending on your specific genotype and previous exposure to other HCV treatments, different agents have specific treatment length and indications. Listed below are the agents which are currently on the market for treating hepatitis C. Please keep in mind that this is a very fast changing field and more regimens are sure to come over the next few years. We can talk in more detail about your treatment options at your clinic visit.
Patient information regarding HCV:
http://www.niddk.nih.gov/health-information/health-topics/liver-disease/hepatitis-c/Pages/ez.aspx
http://patients.gi.org/topics/hepatitis-c/
Hepatitis B
Hepatitis B is also a blood-borne pathogen, and the most common means of transmission in the United States is via sexual transmission or exposure to contaminated needles. However, HBV can also be spread from the mother to fetus during childbirth. Maternal-fetal transmission is the most common means of transmission in other countries, specifically in Asia or sub-saharran Africa. In fact, chronic hepatitis B is the most common cause of liver disease and liver cancer in these regions of the world.
Adults who become infected with acute hepatitis B will clear the infection in approximately 95% of cases. However, if patients are exposed to hepatitis B at the time of birth or as an infant, it is much more likely that the body will not be able to fight the infection and will go on to develop chronic hepatitis B. Chronic hepatitis B goes through various different stages during it's natural course, and many times, patients are asymptomatic throughout most of their lives if left undiagnosed until they develop cirrhosis or liver cancer. There is no cure for hepatitis B at this time, and the best we can do is suppress the virus to very low and sometimes undetectable levels with the medications we have on the market today. Patients who have active inflammation of the liver from chronic hepatitis B are candidates for medical therapy.
Patients who should be screened for hepatitis B include:
- Persons born in areas of the world where hepatitis B is highly endemic (such as Asia, Africa or Eastern Europe), or have parents from endemic areas and are unaware of their hepatitis B exposure status.
- Infants born to hepatitis B positive mothers
- Persons with chronically elevated liver enzymes for an unexplained reason
- People who are HIV +, on hemodialysis or have had a high risk transmission such as needle stick/drug use/exposure to bodily fluids from patients with known hepatitis B or from a person with an unknown hepatitis B status
- All pregnant women
- Certain patients needing medications that may suppress the immune system, such as certain chemotherapy agents or other drugs that may cause immune suppression.
Please click on the following link to learn more about chronic hepatitis B and speak with your doctor about testing for HBV if you meet one of the above risk factors or have other questions about testing and treatment.
Additional patinet information regarding HBV:
http://www.niddk.nih.gov/health-information/health-topics/liver-disease/hepatitis-b/Pages/ez.aspx
http://patients.gi.org/topics/viral-hepatitis/
Fatty liver disease and NASH
Fatty liver can develop from a number of different things, however the most common reasons for patients to have a fat in the liver are either from alcohol use or those with what is known at non-alcoholic fatty liver disease. Fat cells that accumulate in the liver can sometimes cause inflammation of the surrounding liver cells, which in turn, can lead to scar tissue formation (fibrosis) and may progress to cirrhosis . Approximately 70-75% of patients with fatty liver will have what is defined as "simple steatosis", which although not completely benign, based on our current knowledge, it is not frequently assoicated with the development of advanced liver disease. The remaining 25-30% of patients will devleop "steatohepatitis", which means that there is inflammation in the liver related to the presence of the fat cells, and this inflammation may be causing damage to the liver. Of the groups of patients with steatohepatitis, approximately 10-15% will progress to advanced liver disease and cirrhosis.
Non-alcoholic steatohepatis (NASH) is quickly becoming a leading cause of chronic liver disease in the US, and will overtake hepatitis C as the leading agent responsible for cirrhosis and liver cancer within the next 10-20 years. Patients who are at risk for developing NASH are those with the "metabolic syndrome". These patients often have one or more risk factors that are traditionally thought to be associated with cardiovascular disease, such as heart attack or stroke. Risk factors for NASH include presence of diabetes, high blood pressure, high cholesterol (specifically high triglycerides and a low HDL), and obesity. Obstructive sleep apnea and gout are also common associations with NASH.
The diagnosis of NASH is supported when patients present with traditional risk factors combined with a fatty appearing liver on imaging, elevated liver enzymes and when there are no other competing diagnoses for the elevated liver enzymes, such as chronic viral, autoimmune or drug induced hepatitis. Sometimes a liver biopsy is required to make the diagnosis and also to evaluate the degree of inflammation and fibrosis in the liver.
We do not have good medical therapy to reduce the inflammation in the liver from steatohepatitis. Some things have been studied, such as vitamin E and pioglitazone. These medications may be indicated for a subset of patients with NASH, however not all patients will be good candidates for these agents.
The best way to manage fatty liver disease is to alter your lifestyle. If you are drinking alcohol, then cessation of all alcohol use if of paramount importance. Weight loss through diet and exercise is the best means of reversing the inflammation and fibrosis. In order to lose the weight, patients will have to adjust to a more calorie restricted, healthy diet and perform cardiovascular exercise on a regular basis. Data has shown that losing as little at 7-10% of body weight can reverse the inflammation and fibrosis from NASH. We can further discuss a more detailed treatment plans for NASH in clinic, and will offer our nutrition services to you so that you can formulate a weight loss program.
Please click the link below to learn more about non-alcoholic fatty liver disease and NASH.
http://www.niddk.nih.gov/health-information/health-topics/liver-disease/nonalcoholic-steatohepatitis/Pages/facts.aspx
http://patients.gi.org/topics/fatty-liver-disease-nafld/
Autoimmune liver disease
Autoimmune liver disease is less common than other liver diseases such as NASH and viral hepatitis. However, many patients are still diagnosed with autoimmune liver disease every year. The most common types of autoimmune liver diseases are:
Liver Biopsy
A liver biopsy is a procedure wher we obtain a piece of liver tisse and examine it under a microscope. A liver biopsy may be needed in cases where whe are unsure as to the cause of your liver injury, and sometimes we perform it to confirm our suspicions so that we may be certin to treat you correctly. In other instances, a liver biopsy may be required to evaluate the degree of scar tissue (fibrosis) that is in your liver.
Liver biopsies can be done one of two ways. The first (and more common) way is obtaining a biopsy via a biopsy needle that is postioned over the liver, and with the assistance of an ultrasound to locate the site, inserting the needle through the skin into the liver tissue. The other way that a biopsy is obtained is having the radiologist get the sample. In some instances, depending on the type of data that is needed, the radiologist may chose to obtain the biopsy by placing a catheter in one of the neck veins, and with x-ray guidance, advancing the catheter down to the liver and obtaining the biopsy that way.
Please click the link to find out more about the liver biopsy procedure
http://www.niddk.nih.gov/health-information/health-topics/diagnostic-tests/liver-biopsy/Pages/diagnostic-test.aspx