A Wake-Up Call from Your Liver

The message, change your lifestyle to improve your health, is so repetitive that it easily falls into the background like white noise. But if your doctor diagnoses a fatty liver, the need to heed that call becomes much more relevant. Lifestyle changes can, in some cases, repair a damaged liver and return it to normal.

“To a certain extent the liver can repair itself,” says gastroenterologist and transplant hepatologist Beshoy Yanny, MD, UCLA Division of Digestive Diseases. “But if the liver is repeatedly injured, scar tissue forms, which may lead down the path of no return. At that point, we do everything possible to keep it from deteriorating further, but it may not go back to normal.”

Using the skin as a comparison, Dr. Yanny further explains how untreated liver problems can escalate. “The first time you get a small cut, the skin repairs itself,” he says. “But if the same area is injured over and over, scar tissue develops, and skin loses vital functions. Similarly, repeated injury to the liver also can result in tissue scarring (fibrosis), at which point liver function can begin to decline, sometimes fatally.”

What the Liver Does

The liver’s most well-known role is like that of a waste treatment plant—it removes waste products produced by the body and detoxifies the body from substances such as alcohol, drugs, and environmental toxins. But the liver does so much more than that. It manufactures essential proteins, metabolizes and stores fats and carbohydrates that provide energy, secretes bile that aids in the breakdown of fats, and promotes absorption of fat-soluble vitamins (vitamins A, D, E and K).

Without a well-functioning liver, you may not get adequate nutrition, even if your diet is healthy. In addition, your body may not produce enough energy, and you may have harmful substances circulating in your bloodstream and throughout your body because the liver was unable to filter it properly.

Fatty Liver Causes and Risk Factors

Most people recognize that excessive alcohol consumption damages the liver, but nonalcoholic fatty liver disease (NAFLD), sometimes referred to as “simple” liver disease, also does so. It is the most common type of fatty liver disease.

Excess fat/obesity is a major risk factor and deserves a bright spotlight. Consider this: The rise of obesity in United States, estimated to be at about 30 percent population-wide, tracks with the estimated incidence rate for NAFLD, which is also about 30 percent.

Of course, it’s normal for a person, and the liver, to have some fat. But as a person becomes severely overweight or obese, the liver accumulates excess fat, too. As it does, the cells start to complain and elbow each other like too many people in crowded room. In addition, fat cells release a number of inflammatory chemicals, which damage liver cells. Inflammation ensues. And left unchecked, a cascade of liver destruction commences. Other risk factors for fatty liver include chronic conditions such as high blood pressure, sleep apnea, diabetes, high cholesterol, and metabolic syndrome.

Obesity plays a supporting role in metabolic syndrome development, which also has a special relationship with NAFLD. Metabolic syndrome is the name for a collection of risk factors that raise risk for health problems, such as cardiovascular disease, diabetes, and high blood pressure. Obesity raises the risk for both NAFLD and metabolic syndrome. The two conditions often coexist. For example, two key components of metabolic syndrome, high blood glucose (sugar) and triglycerides (a type of fat), are overproduced by a fatty liver. Both disorders also may result from and be exacerbated by excessive consumption of simple sugars and lack of physical activity. This relationship is so interwoven that a panel of experts recently proposed to change NAFLD to “metabolic associated fatty liver disease” (MAFLD) as it more accurately describes the disease pathway. The rationale behind the name is interesting and informative. A short article in The Lancet describing it can be found online at http://tiny.cc/MAFLD.

The key takeaway is, regardless of which disorder occurred first, lifestyle changes (e.g., healthy diet, regular exercise, weight loss as needed) can help improve both and potentially repair liver damage.

The Disease Spectrum

NAFLD and non-alcoholic steatohepatitis (NASH) are the two main types of fatty liver disease. NASH is the more advanced disease. People with NASH not only have a fatty liver, they have an inflamed liver and are at greater risk for fibrosis (tissue scarring), cirrhosis (late-stage scarring), and liver cancer.

NAFLD progresses slowly and at an early stage can be reversed. No inflammation occurs with NAFLD, but if this warning sign is ignored, the stage is set for advancement.

Studies have shown that NAFLD is present in 80 to 90 percent of obese adults, 30 to 50 percent of people with diabetes, and 90 percent of those with high cholesterol. National Institutes of health estimates about 12 percent of adults have NASH.

Symptoms and Diagnosis

Most people with NAFLD/NASH have no symptoms, but some may complain of fatigue, thirst, bloating, and sleep problems. Some people also may report discomfort or achiness in the right upper abdominal area, where the liver is located. Symptoms of more advanced cases of NASH/liver fibrosis include nausea, vomiting, jaundice, easy bleeding, loss of appetite, and memory impairment. All these symptoms could have multiple causes. That’s why most people become aware of having a fatty liver when routine blood tests reveal elevated liver enzyme levels or when liver inflammation is detected incidentally on abdominal imaging (e.g., ultrasounds, CT scans, or MRIs). Typically, enzyme levels are only mildly elevated, and this is such a common finding that it may sometimes be overlooked. However, if liver tests are persistently abnormal, it’s wise to consult with a gastroenterologist who specializes in liver diseases or a hepatologist (liver specialist).

At UCLA and other major medical centers specializing in liver treatments, Fibroscan, an ultrasound machine for the liver, is a noninvasive test that can be used alone or with other tests to determine liver status. The results indicate stage of fibrosis and fatty infiltration. It also can be used to monitor effectiveness of treatment, including lifestyle changes. Biopsy, considered the gold standard in testing, is invasive but may be recommended to further determine severity of liver damage or diagnose a liver problem that can’t otherwise be identified.

Before declaring the diagnosis of NAFLD or NASH, physicians will want to rule out other causes of liver damage, such as from excessive alcohol, infections, drugs or supplements, or hepatitis A, B, or C, as these have specific treatment protocols.

“There are many reasons an individual may have the appearance of fatty liver,” says Dr. Yanny. “For example, some medications and herbal supplements can result in drug-induced liver injury that resembles fatty liver. Discuss herbal and non-prescribed medications with your physician.”

Treatment/Prevention

The recommendation is to lose 10 percent of body weight. Even that small amount helps reduce inflammation and decreases risk of fibrosis.

“We have had many individuals come in with high liver test levels,” says Dr. Yanny.  “They work hard to lose the weight and their numbers do normalize after six months to a year.”

A fatty liver also can be treated with vitamin E, though it’s not for everyone. It’s inappropriate for people who have diabetes, issues with the prostate, or bleeding disorders. If vitamin E is recommended, Dr. Yanny recommends that it be prescribed and monitored by a liver doctor.

A healthy diet, regular exercise, and normal body weight treat NAFLD/NASH, and also can help prevent other diseases. But it’s not a one and done deal cautions Dr. Yanny. “Lifestyle modification must be implemented for the long term,” he says. “If the liver improves and goes back to normal but the person goes back to poor eating habits and a sedentary lifestyle, damage can recur.”

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