2/13/08

Question : I have a patient who was put on a daily 500 milligram sodium diet. She is asking for recipes or ideas of what she can eat. Can you suggest some options? Warm Regards, Suzanna Masartis, Executive Director American Liver Foundation.

Answer: The body requires about 50 to 400 milligrams of sodium per day. Yet the average American consumes about 25 to 35 times that amount! While this overconsumption of salt is not necessarily dangerous for most healthy people, it can create problems for a person with advanced liver disease who are required to mainain a low sodium diet. For every gram of sodium consumed, the accumulation of 200 milliliters of fluid results. The lower the consumption of sodium in the diet, the better controlled this excessive fluid accumulation is. For people with ascites, sodium intake should be restricted to less than 1,000 milligrams per day and preferably under 500 milligrams. This goal is difficult, yet attainable. In order to successfully adhere to a salt-restricted diet, it is necessary to become a knowledgeable food shopper and to diligently read all food labels. It is fortunate that many foods on the market  have been specifically manufactured as low sodium products. Furthermore, as of 1986, the FDA has required that the sodium content of all processed foods be listed on the package label. This regulation has been a boon to the consumer.

10 general guidelines regarding sodium consumption are as follows:

1. The amount of sodium in fresh foods is significantly less than that in the same foods after they have been processed, cured, canned, or frozen; therefore, choose fresh foods whenever possible.

2. Table salt and salt used for cooking should be totally eliminated from the diet. One teaspoon of table salt contains 2,325 milligrams of sodium!

3. All canned foods and food from fast food restaurants should be avoided.

4. Some over-the-counter medications have high sodium contents. For example, one tablet of Rolaids contains 53 milligrams of sodium, two tablets of Alka-Seltzer contains 567 milligrams of sodium, and one serving of Bromo-Seltzer contains 717 milligrams of sodium. These medications should be substituted with products that have a lower sodium content. If the label on a medication or other product does not clearly state the sodium content, a pharmacist should be able to supply this information or offer a way to obtain it.

5. Meats, especially red meats, have a high sodium content. Consequently, adherence to a vegetarian diet may become necessary for people who develop severe ascites.

6. Spices, such as basil, dill pepper, and vinegar, to name a few, may be used in place of salt as a food seasoning. Salt substitutes containing potassium chloride should be avoided. These substitutes tend to raise potassium levels in the body. This can be especially dangerous to people taking spironolactone (Aldactone), a potassium-sparing diuretic (water pill) used in the management of ascites.

7. Avoid boxed cold cereals with milk for breakfast. For example, 1 cup of Cornflakes has 351 mg of sodium, Rice Krispies has 320 mg and Raisin Bran 350 mg and one cup of milk is an additional 120 mg of sodium. A healthly substitute to consider is hot cereal with water such as Wheatena or Quacker Oats oatmeal, which have 0 mg sodium.

8. Avoid all sauces and dressing. Substitute lemon or lime when applicable such as on vegetables or salads.

9. Order chinese food steamed with any sauce. Ginger and garlic may be substituted.

10. Make sure you purchase low sodium breads. For example, an English Muffin has 378mg of sodium.

Question: Can a Hepatitis B infected husband transfer Hep B virus to hepatitis B immunized wife (one who has developed antibodies after immunization ) when they are trying to conceive? Can the baby be Hepatitis B positive at birth in such a case?
Thank you very much. Best regards, D.

Answer:

No. If your wife has succesfully made hepatitis B surface antibody titers > 10 IU/mL after vaccination, then she is protected. There is no risk of transmission during pregnancy or childbirth. However, your newborn will none-the-less need to be immunized as he or she will have household contact with you.

2/2/08

Dear Dr. Palmer,

My 13 year old daughter was diagnosed in November with PSC. Her pediatric GI prescribed Creon 10 3Xday, and Urso Forte 2xday. Shortly thereafter, she began to complain of pain around her eye socket. We took her to the pediatrician and an ophthalmologist, who said there was nothing wrong. We got a second opinion on the PSC at Columbia Presbyterian, and that doctor increased her dosage to Creon 20 3xday. Her facial pain continues to worsen and now affects her entire face. We took her back to the pediatrician this week, who said it was a sinus infection (no symptoms of congestion) and put her on an antibiotic 4 days ago. She has cramping and diarrhea from the antibiotic, but no relief from the facial pain. Is it possible that this pain is a side effect of the Creon? Or the Urso? She is also on Rifampin, Doxepin and Atavan. She is very miserable. Please answer as soon as possible.

Thanks,Nancy River Vale, NJ

Answer:

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease that results in damage to the intrahepatic and the extrahepatic bile ducts. Most people with PSC are male, and approximately two-thirds of people with PSC have an inflammatory disease of the colon (the large intestine) known as ulcerative colitis.

Urso Forte [Ursodeoxycholic acid (also known as UDCA or ursodiol)] is a drug commonly used to treat PSC. URSO is taken with food in oral pill form at a dosage of 13 to 15 milligrams per kilograms of body weight each day. Urso is a naturally occurring bile acid, but unlike many other bile acids in the body, it is not toxic to the liver. It is found in humans in small quantities, but is found in large quantities in bears. However, it has been established that increasing the amount of Urso in the body will generally decrease the amount of liver-toxic bile acids in the body. This, in turn, should diminish or prevent destruction of bile duct cells. Side effects of UDCA are minimal. Most studies have indicated that less than 3 percent of people develop adverse side effects from UDCA. When side effects are experienced, they include diarrhea, decreased white blood cell count, elevated glucose levels, elevated creatinine levels, peptic ulcers, and skin rashes.

Creon adds in the digestion of food by replacing digestive enzymes that are made by the pancreas. It is given to individuals with pancreatic insufficiency such as cystic fibrosis or chronic pancreatitis. It is sometimes used to aid in general digestion.Side effects of Creon include mouth irritation, diarrhea, nausea, vomiting, boating, constipation, and stomach cramps. If kept in the mouth or if chewed mouth sores may occur.

While facial pain are not typical side effects of either of these drugs it is best to discontinue one at a time under advisement of your physician. In this manner, a possible culprit may be determined.

Lastly, I would like to make you aware of the FINDLING FOUNDATION, a non-profit charity formed to create an awareness of PSC. You can contact them at (973) 535-5629 or visit at www.psccure.org.

11/30/07

Question: I have been on a transplant list for 4 yrs. now. I was then diagnosed with end-stage Cirrohosis of the liver. And, it was labeled "Cryptogenic". What is this caused from. (Never have been a alcohol drinker; and, or drug user.) I am 62 yrs. old and wondering if I will get too old to receive a transplant. Is there an age limit? Thank you for caring and answering so many requests. Sincerely, Alva

Answer: Cryptogenic liver disease was a term most frequently utilized prior to the discovery of the hepatitis C virus in 1989. Now-a-days, most cases of cryptogenic cirrhosis are due to nonalcoholic steatohepatitis (NASH).

Age (approximately 65 years old or older) is known as a "relative contraindication" to liver transplantation. This means that while less than optimal for a liver transplant, but do not rule out the possibility.

Question: Can you recommend a physician in the Los Angeles area that treats HCV along the same lines as Dr. Palmer. One that shares the same views on the way she treats HepC.? Thanks, Sara

Answer: For a person with liver disease, finding the right doctor is no simple task. It may require both time and effort. In most instances, someone with chronic liver disease will be under the care of the same doctor for many years or possibly for his/her entire life. There are many excellent hepatologists in the LA area. For starters, you may want to contact your local chapter of American Liver Foundation (ALF) or the American Association for the Study of Liver Disdease (AASLD).

Question: I am a 51 year woman, who has been found to have 12 hemangiomas on my liver. I had a hysterectomy about five years ago. In your book you state that people with liver disorders or abnormalities should not take amino acid supplements. I am currently taking "Sweet Wheat", an amino acid supplement, because I've found that it gives me energy, but I would like to know whether it is helping or adversely affecting my liver. Claire, from Rhode Island

Answer:

Hemangiomas are the most common benign tumors of the liver, and are not considered to be a "liver Disease" per se. They have no malignant potential and may occur in a person with or without underlying liver disease. About 10 percent of people with a hemangioma will have more than one of them.  Hemangiomas are more common in women, but can also be found in men, and can occur at any age. Amino acid supplementation is potentially dangerous for people with liver disease. Although amino acids are indeed natural, it doesn’t mean that they’re always safe, especially for people with liver disease. Most of the amino acid supplements that are available over- the- counter come in quantities that are far greater than the amount the body needs. Consumption of excessive amounts of amino acids may cause serious side effects. As always, it is important to check with your personal doctor.

Question: Can you have normal liver function tests with a positive AMA (1:160) and still have the disease or do the LFT have to be elevated as well? Kim Christ

Answer: PBC is most often diagnosed when abnormalities are found on blood tests. Usually, an isolated elevated alkaline phosphatase (AP) level is initially discovered. This typically leads to additional blood work testing for a specific autoantibody, the antimitochondrial antibody (AMA), that is associated with PBC. The finding of an AMA of a titer greater than 1:40 in a person almost always confirms the presence of PBC, whether or not LFTs are abnormal.

Question:I have Hepatitis B, I obtained this disease back in the early 1950's when my parents were getting ready to go to Germany, I had gall bladder removal earlier this year. Now I am experiencing pain that radiates from my back to the front on my right upper abdomen area...it is almost as if I have my gall bladder back. What is going on? Nancy Bright

Answer:

Most people with liver disease expect to feel pain over their liver.  This type of pain is known as right upper quadrant pain or tenderness (RUQT). However, RUQT is rarely due to chronic liver disease. RUQT may indicate gallstones, But if your gallbladder has already been removed a stone remaining in the duct ( passageway) from the liver to the old gallbladder site should be considered. This is known as choledocholithiasis. A test to examine this area must be done, known as an MRCP or ERCP. Anyone with chronic hepatitis B must be evaluated for liver cancer—also known as hepatoma or hepatocellular carcinoma (HCC) on a regular basis. Scar tissue from prior abdominal surgery- known as adhesions, is also a cause of abdominal pain. Intestinal pain must also be considered, as the right side of the large intestine lies in close vicinity to the liver. Other causes of abdominal pain include those related to the stomach, such as peptic ulcer disease and gastritis, which are not necessarily indicative of liver disease and are readily treatable when -discovered.

Question: What is the likely significance, if any, of persistently elevated bilirubin for someone who has NASH? It's been about 2.5 years since diagnosis, within six months of diagnosis all other makers had returned to normal (AST, ALT, GGT, AKP, ferritin, etc), but the bilirubin remains consistently elevated to date? Thanks, Erin

Answer:

First, worsening of your liver disease must be evaluated, however, if all else has really normalized your doctor has to consider Gilbert’s syndrome. This is a very common, albeit benign, inherited disorder of bilirubin breakdown (metabolism).  It occurs in approximately 4-9 percent of the population. It is characterized by intermittently elevated  bilirubin levels.  The presence of Gilbert’s syndrome is usually discovered when blood tests are routinely performed, or when they are performed for the evaluation of an unrelated problem, or for preemployment or preinsurance screening.  Bilirubin levels usually rise to about 3 mg/dl, but rarely do they  go any higher than 5 mg/dl.  Levels typically increase during periods of fasting, stress, menstruation, or during the course of an unrelated illness or infection.  All other LFTs are normal.  No long-term complications arise from this harmless syndrome, and no therapy is required.

Question: My name is Elizabeth and I work in a drug and alcohol treatment facility. I am wondering if there is a list of foods for a patient who has severe liver disease. I am the Kitchen Supervisor and it would be helpful. Thank you for your time.

Answer:

Unfortunately, there is no “diet for liver disease.” Such an across-the-board diet simply does not exist. Many factors account for the unfeasibility of a standardized liver diet, including variations among the different types of liver disease (for example, alcoholic liver disease versus primary biliary cirrhosis) and the stage of the liver disease (for example, stable liver disease without much damage versus unstable decompensated cirrhosis). One’s other medical disorders even if unrelated to their liver disease, such as diabetes or heart disease, must also be factored into any diet. Each person has her own individual nutritional requirements, and these requirements may change over time.

Notwithstanding the above information, an optimal diet for a person with stable liver disease (modifications to be made as per individualized needs) might contain all of the factors listed below.

• 60- to 70-percent carbohydrates—primarily complex carbohydrates, such as pasta and whole-grain breads.

• 20- to 30-percent protein—only lean animal protein and/or vegetable protein If encephalopathy ( brain fog ) is present vegetable protein is preferred.

• 10- to 20-percent polyunsaturated fat.

• 8- to 12 eight-ounce glasses of water per day.

• 1,000 to 1,500 milligrams of sodium per day If ascites is present, 500mg or less is preferable.

• Avoidance of excessive amounts of vitamins and minerals, especially vitamin A, vitamin B₃, and iron.

• No alcohol.

• Avoidance of processed food.

• Liberal consumption of fresh organic fruits and vegetables.

• Vitamin D and calcium supplement.

- Vitamin C

-  an antioxidant such as vitamin E or CoQ 10

-  Glucosamine chondroitin

09/21/07

Question:

Both my wife and I had our first shot (of three) for Hepatitis B this week, and the doctor gave up some conflicting information. What we would like to know is whether it is advisable for us to try and conceive during the period of us having the shots. The next injection is in one month and the last is in six months after the second. We are concerned that the vaccine might affect the baby. Please tell us if this would be the case.

Answer: Always weigh risks versus benefits. If a person needs to be protected against HBV due to possible exposure risk, then the benefits outweigh the risks. In this situation one can still get pregnant, as it is safe to be vaccinated during pregnancy. However, in general, I would not advocate vaccination during pregnancy if it can be avoided.

Question: A person with advance liver disease that has strong gas pain, what can safely take to relief the pain? Safely that will no create an addiction to the medicine. Ximena

Answer:

Some people with liver disease complain of increased gas production (flatulence), abdominal bloating, and abdominal distention. These symptoms may stem from malabsorption (impaired absorption) and/or maldigestion (impaired digestion) of certain nutrients by the body. These symptoms are especially likely to occur in people with alcoholic liver disease and cholestatic liver diseases, such as primary biliary cirrhosis. Such symptoms may also be caused by the medications used in the treatment of liver disease. Cholestyramine (Questran) is one example of a medication that is likely to cause increased gas production. Alternatively, flatulence may not be related to a liver disorder at all, but instead may stem from increased consumption of foods that have a tendency to cause gas (see the list on page xx) or from the development of a food intolerance, such as lactose intolerance.

To remedy these symptoms, people can try decreasing their consumption of gas-containing foods and of foods that they are having difficulty digesting. Often, elimination diets are helpful. An elimination diet involves eliminating one food at a time from the diet to determine whether that food is solely responsible for the gas production. It is usually best to begin by eliminating milk and milk products, as they are the foods most commonly not tolerated. One approach that will cut down on the gas-producing potential of fruits is to peel off the skins. Another is to cook fruits and vegetables until they are soft and soggy. Unfortunately, these methods of preparation also significantly reduce the nutritional value of these foods. Finally, taking an anti-gas remedy (typically containing simethicone) can sometimes help.

Foods that can cause gas include:

• Dairy products, such as milk (including skim and low-fat), yogurt, milk chocolate, cheese, and cheese pizza.

• Raw vegetables, especially onions, carrots, cabbage, lettuce, broccoli, cauliflower.

• Beans.

• Bagels.

• Pretzels.

• Soups.

• Fruits with skins.

• Dried fruits, such as raisins and prunes.

• Fatty foods.

• Artificial sweeteners, such as sorbitol.

• Carbonated beverages, such as soda.

• Chewing gum.

Question: My wife is pregnant after two and half year of my first child's birth. She is HCV positive. please tell me how it can affect the baby and what should we do.

T. Hussain/Doha, State of Qatar

Answer:

Of great concern to pregnant women infected with HCV and to women with chronic hepatitis C who are contemplating pregnancy is the likelihood of transmitting the virus to their babies. If this occurs during pregnancy, it is known as vertical transmission, and if it occurs around the time of birth, it is known as perinatal transmission. However, the risk for either of these types of transmission is very low—occurring only approximately 3 to 5 percent of the time. Transmission to the newborn has been found to occur only in HCV-infected women who had high viral loads (the amount of HCV viral particles per milliliter of blood) of at least 1 million. It has also been noted that women who are doubly infected with HIV and HCV appear to have a higher probability of transmitting HCV to their children than women who are not infected with HIV.

Breast-feeding is not considered a means of transmitting HCV. Therefore, it is believed that an HCV-infected mother may safely breast-feed her child. In fact, studies comparing the incidence of HCV in breast-fed versus bottle-fed infants whose mothers were infected with HCV showed a fairly equal incidence of HCV in each group of infants—approximately 4 percent.

Question: Viral load and HCV

1.Five years ago my viral count was 850,000. Results a few days ago showed a count of 22,500,000. Is this alot? Do you reccomend another test? I feel fine, What is the highest level attainable without symptoms? Steve

2. Does a viral load go up when a person is sick and then return to what is was before the infection? My immune system as been really low and I have contracted several sinus infections this summer. My viral load has elevated since May. Will it return with the infection gone? Janet

Answer: It is important to understand that the viral load does not correlate with the severity of liver disease. Therefore, a very high viral load i.e.: > 1 million IU/mL, does not automatically indicate that a person has more liver inflammation and damage than a person with a viral load of 5000 IU/mL for example. Furthermore, the viral load typically fluctuates and does not correlate with the degree of elevation of the transaminases (AST and ALT). Finally, viral load does not appear to correlate with symptoms. HCV viral loads do correlate with response to interferon therapy, however. A person with consistently high viral loads typically have a harder time clearing the virus compared with people whose viral loads run low. Also, the tecnique by which viral loads were determined years ago is different now, so make sure that IU are not being compared to copies.

04/27/07

Q : Any time I have an alcoholic beverage with dinner or with friends, my eyes with start to hurt and very quickly I get to the point to where I cannot stand to open my eyes. My left eye is effected far more than my right. Could this be because of liver disease?

Sheryl Sprenger

A: Possibly. While alcoholism is more common among men, it has been demonstrated that women are more susceptible to the adverse consequences of alcohol on the liver. In fact, women who develop ALD and cirrhosis due to alcohol do so at a younger age than men, and they have consumed a less alcohol in total. It has been noted that women with cirrhosis due to alcohol have a shorter life expectancy than men with cirrhosis due to alcohol. So why are women so much more susceptible to the toxicity of alcohol than men? Well, the most obvious explanation is that women generally weigh less and are smaller than men. Women on average have a smaller total body area throughout which any ingested alcohol can be distributed. But neither this fact, nor the total amount of alcohol ingested, completely accounts for why women are at a much greater risk of developing ALD. Hormonal differences between men and women have been suggested as a factor.  It has been demonstrated experimentally that female rats are more susceptible to alcohol – induced liver damage than male rats, at least in part because of the higher levels of estrogen- the female sex hormone,  in their bodies. However, this theory has not been proven in humans.   

     Probably the factor that most significantly differentiates the genders is that, as compared with men, many women (not all) have less of the enzyme alcohol dehydrogenase in the lining of their stomachs. This enzyme is the same one that is found in the liver that breaks down alcohol into the byproducts that are less toxic to the liver. Thus, the reduced amount of alcohol dehydrogenase enzyme in women increases the likelihood that they will absorb nonmetabolized alcohol from their stomach linings directly into their bloodstreams. Hypothetically, if a man and a woman of equal size and weight each consumes an equivalent amount of alcohol over the same span of time, the woman will have a much higher blood-alcohol level than the man. Once in their bloodstreams, high blood-alcohol levels circulate in their bodies, placing women at increased risk for the toxic effects of alcohol on their livers and other organs.

Q From: UpMayo

My brother has Liver cancer, Hep C, Cirrhosis, Gallstones, enlarged spleen, encephalopathy, etc..... How will I know when his liver has failed. How will I know when he needs the hospital. Is it coma? He is so fatigued. Please answer. By the way, your book is his bible. Thank you

A Signs of a failed liver include an enlarged spleen—a condition known as splenomegaly, which occurs to compensate for the decreased functional abilities of the damaged liver. Encephalopathy is an altered or impaired mental status, typically leading to coma, that can occur in people with liver failure. Encephalopathy is often associated with poor coordination, fetor hepaticus (foul-smelling breath), and asterixis (uncontrollable flapping of the hands). A person experiencing such a condition should bring it to his doctor’s immediate attention, as this may require emergency treatment.

Q From: Patricia Husband

Dear Dr. Palmer,

Thank you for your website....it has been my main resource for information since being diagnosed last May.

I'm still confused as to which pain medications can be used: Motrin vs. Tylenol For Pain Relief Which is safest to take and in what amounts?

A Acetaminophen (Tylenol) is a medication used to control pain (known as an analgesic) and fever (known as antipyretic). In small doses (less than 4 grams per day, or eight pills taken over a twenty-four hour period of time) acetaminophen is quite safe for the liver—unless combined with alcoholic beverages. (Note: each acetaminophen tablet or pill typically contains 500 milligrams of acetaminophen.) In fact, acetaminophen is the recommended medication for relieving minor aches, pains, and headaches in people with liver disease. However, when taken in excessive quantities or when combined with alcohol, acetaminophen may cause death due to liver failure.

The consumption of alcohol in conjunction with acetaminophen significantly increases the likelihood that a person will incur severe liver damage. Therefore, people who consume alcohol on a regular basis should probably limit acetaminophen intake to a maximum of 1 to 2 grams per day (that is, two to four pills within a twenty-four hour period). Still, the best advice for people with liver disease is to totally abstain from alcohol.

People should take special note that acetaminophen is also an active ingredient in more than 200 other medications, including Nyquil and Anacin 3. Therefore, it is essential to read the labels of all over-the-counter medications carefully. Other commonly used medications, such as omeprazole (Prilosec), phenytoin (Dilantin), and isoniazid (INH), may increase the risk of liver injury caused by acetaminophen. It is always in the liver patient’s best interest to consult with a liver specialist prior to taking any medication.

Acetylsalicylic acid (aspirin) and other NSAIDs such as Motrin are drugs that are widely used for their anti-inflammatory and analgesic effects. They also have the potential to cause drug-induced liver disease. In fact, many NSAIDs have been withdrawn from the market due to their hepatotoxicity. All NSAIDs have the potential to cause liver injury. However, some NSAIDs are more hepatotoxic than others. NSAIDs presently on the market that have been frequently associated with liver injury are aspirin (ASA), diclofenac (Voltaren), and sulindac (Clinoril). Ibuprofen (Motrin) has been reported to cause severe liver injury in people with hepatitis C.

     It is recommended that people with advanced liver disease avoid using all NSAIDs. If NSAIDs are medically required for the treatment of another medical disorder, a reduced dose should be used for a limited period of time and only by people with stable liver disease. Older women with liver disease seem to be particularly susceptible to the hepatotoxicity of NSAIDs and are advised to avoid NSAIDs altogether.  Since NSAIDs may cause salt and water retention people with fluid retention problems such as ascites or leg swelling may suffer worsening of these conditions.  People with decompensated cirrhosis are at increased risk kidney damage stemming from the use of NSAIDs. Since this may lead to hepatorenal syndrome, people with advanced liver disease are advised to totally avoid all NSAIDs.  Furthermore, people with ascites (fluid accumulation) may not respond to treatment with water pills (diuretics), while on NSAIDs, as they counteract their actions. People with liver disease who have had internal bleeding, - from an ulcer or esophageal varices, for example, may be at risk for recurrent bleeding induced by NSAIDs, and should totally avoid this class of medications. People who are also taking corticosteroids (such as prednisone), or anticoagulants (such as coumadin) may have and increased risk of complications from NSAIDs.  Finally, people with liver disease who smoke cigarettes or drink alcohol should avoid NSAIDs as they are also at increased risk for its complications.

Q I recently had a liver biopsy and was diagnosed with Autoimune hepatitis, Grade -III Stage IV, with early cirrhosis. My doctor has never mentioned what a grade or stage is. What does this mean to me? Is this an indicator of how advanced the disease is? If so how serious am I?

Debbie Primmer

A. . The classification system for liver biopsies takes into account the cause (autoimmune hepatitis, for example), the grade - the amount of liver inflammation (mild grade 1, moderate grade 2, severe grade 3), and the stage (degree of scarring from none - stage 0 to cirrhosis stage 4). Therefore, grade III stage IV is an advanced stage of disease.

Q : From: "LuJay" I love your book! When is a Levine shunt or a TIPS procedure indicated or not indicated for a cirrhosis patient with ascites?

Ascites is characterized by massive accumulation of fluid in the abdominal cavity. This results in abdominal swelling and distention. Treatment of ascites includes a low-sodium (low-salt) diet and fluid restriction to about one liter of fluid per day. Treatment through sodium and fluid restriction alone adequately decreases ascites in only about 20 percent of people. Therefore, diuretics (water pills) are often added to dietary restrictions in an effort to maximize results. The most commonly used diuretics are furosemide (Lasix) and spironolactone (Aldactone). This type of therapy works well in approximately 90 percent of people. When medical therapy fails, a person is known as having refractory ascites. Refractory ascites can be managed by physically removing the fluid by a process known as a paracentesis. A paracentesis involves the removal of large amounts of fluid through a needle inserted into the abdomen. A paracentesis should also be performed on all patients with ascites at the time when ascites first develops in order to examine the fluid for possible infection—a condition known as spontaneous bacterial peritonitis (SBP)—or for liver cancer or other cancers, such as ovarian. People with SBP commonly have a fever and abdominal pain, although these symptoms are sometimes absent. SBP requires hospitalization and treatment with intravenous antibiotics.

However, if multiple paracentesis procedures are repeatedly required over time in order to prevent fluid reaccumulation, a transjugular intrahepatic portosystemic shunt (TIPS) should be considered. TIPS is a procedure that creates a shunt (an alternative passageway) in the liver between the portal and hepatic veins. Creating this shunt has the effect of decreasing the portal pressure and diminishing the amount of ascitic fluid. Originally, TIPS procedures were performed strictly to control bleeding from esophageal and gastric varices (discussed below). Yet TIPS is now considered to be very useful in the control of refractory ascites. While TIPS makes ascites much more manageable, this procedure has no effect on liver function, on the progression of disease, or on the patient’s survival. Therefore, people with refractory ascites inevitably need to be evaluated for a liver transplant.

Q: Can liver disease caused by alcohol consumption (Fatty liver, alcoholic hepatitis cirrhosis etc.) be reversed if the person stops drinking alcohol? Does the liver regenerate itself?

Nichole Wolter

A :

The liver is known by its remarkable ability to regenerate itself. But this statement is somewhat misleading. The liver does not really regenerate itself the way in which a starfish re-grows a missing arm. If an individual has up to 80 percent of a healthy liver removed, the remaining portion of the liver will expand to fill the empty space until its original weight is achieved. In this scenario, the liver will be fully functioning. However, if the remaining portion of a liver is severely scarred (cirrhosis), this expansion process typically cannot occur and “regeneration” is therefore unlikely. In some cases, however, once the toxin - for example alcohol, has been removed, cases of regeneration have been reported, although not commonly.

QSubject: work incident question-Hep C
Dr. Palmer, I work in healthcare and the other day I came in contact with dried blood of a Hep C positive patient. The dried blood was in their med. chart on one of the papers. It was a large amount of dried blood. My hands brushed over it before I realized what it was. Of course, I never expected to see this in the med. chart. I had a hangnail which may have hit that area on the paper. In your expert opinion, is there a risk of transmission of Hep C in this situation? I have read that Hep C can live outside the body for days and weeks.
Any feedback would be greatly appreciated. I am a bit anxious about the whole thing. Thank you in advance.

Kara

A Anyone who works in a health-care facility, including a hospital, doctor’s office, dentist’s office, or a laboratory that handles blood specimens, and emergency medical technicians, are at risk of contracting HCV. The virus may be transmitted through a needle stick injury, a blood spill, or through pricking oneself with a contaminated sharp instrument. The larger the amount of contaminated blood that enters a person’s body, the higher the likelihood she will become infected. After a single incident of accidental exposure to HCV, the risk of contracting HCV is approximately 2 percent—although this probability has been reported to range between 0 and 16 percent. Even with the potential risk to health-care workers due to the nature of their profession, the prevalence of HCV infection among this group of professionals is actually about the same as that of the general population, which is 1 to 2 percent. Once the blood has dried the likelihood of transmission has diminished greatly, and the contaminated blood must enter a break in your skin for infection to occur.

Q From: "CHEPLOWITZ,JEFF"

What can spots on your liver indicate? What is an
Hemangioma? Is it a dangerous mass?
Is it unusual for a Hemangioma to get larger?

A. Hemangiomas are the most common benign tumors of the liver. They have no malignant potential and may occur in a person with or without underlying liver disease. The name hemangioma derives from the fact that these tumors are filled with heme (blood). They resemble the small bright red spots that people commonly get on the skin of their chests and abdomens as they age. These spots, referred to as senile hemangiomas, are also benign. Hemangiomas occur in the liver in approximately 7 percent of the population, but some studies have reported ranges of from 1 to 20 percent. About 10 percent of people with a hemangioma will have more than one of them.  Some people will also have hemangiomas in other areas of the body such as the skin, lungs or brain. Hemangiomas are more common in women, but can also be found in men, and can occur at any age.

Some researchers believe that excess estrogen can cause hemangiomas to grow. In fact, growth of hemangiomas has been observed in some women during pregnancy, and in others while taking birth control pills. Furthermore, these people may be at increased risk for rupture. Although the effect of estrogen on hemangiomas is not conclusive, it is advisable for people with hemangiomas to stay off birth control pills and all other forms of estrogen replacement.

2/24/07

Q: After being diagnosed with cirrhosis, how often should a liver biopsy be performed? FJH

A: Once cirrhosis is diagnosed a liver biopsy never needs to be repeated if no treatment was obtained for liver disease due to any cause. Recent studies have shown that with removal of the cause of the underlying liver disease –such as eliminating the hepatitis C virus (HCV) with interferon therapy, or the eliminating alcohol in people with alcoholic liver damage, cirrhosis may be reversed, - at least in its very early stages, when scarring is minimal.  In these instances, a liver biopsy may be useful to document reversal of cirrhosis. I would advise waiting at least 3-5 years after the cause of liver damage has been eleimated before having another biopsy, as changes often take time to occur. Once cirrhosis has advanced to its late stages -- when complications from extensive scaring have occurred  (known as decompensated cirrhosis - i.e. esophageal varices, ascites etc), cirrhosis can never be reversed, and repeat liver biopsy need not be repeated.

Q; What are the chances of contracting hepatitis C if infected blood is splashed in the eye? Citistars

A:There is an approximately 2% chance of becoming infected with hepatitis C after being exposed to the blood oa an HCV positive infected person. However, the likelihood of contracting HCV decreases if the infected person's viral load at the time of exposure is low - less than 500,000 IU/mL. Also, the risk of acquiring the virus is lower if there is no break in the skin such as a wound or open sore. The eye is a mucosal membrane and while the risk is low, it is never-the-less advisable to be tested.

01/28/07

Q : Are pregnant women with NASH at increased risk of developing Fatty Liver of Pregnancy? Erin

A: No. Acute fatty liver of pregnancy is a rare disease which occurs in the third trimester of pregnancy. The exact cause is unknown, but believed to have a hormonal connection. There is not an increased risk for future pregnancies, and women with NASH are not at increased risk for this disease.

Q: Should a person with NASH receive the Hepatitis B vaccine and is there an association with the vaccine and MS? Erin

A: Yes. It is also advisable for any person with chronic liver disease due to any cause including NASH, obtain the hepatitis B vaccination. These patients should receive the vaccine upon diagnosis, as the efficacy of the hepatitis B vaccine is decreased in people who have already progressed to advanced cirrhosis. There is no increase risk for MS in those receiving the vaccine.

Other people who should reive the hepatitis B vaccine includes:

- People of any age who have multiple sexual partners ( more than one sex partner within a 6 –month period).

- it is currently recommended that children receive the vaccination at age eleven or twelve if they did not receive it at birth.

-   People with a sexually transmitted disease

-   Immigrants from geographic areas in which high HBV is endemic – Asia, Sub-saharan Africa, Middle East, Amazon basin

-  Children born in the United States to a person from an  HBV endemic area

-  Adopted children from HBV- endemic areas

• Men who have sex with other men.

• People who use intravenous drugs as well as their sex partners.

• People with blood clotting factor disorders.

• Those who have intimate or household contact with a person who is a hepatitis B carrier (HBsAg positive).

• People who work in health care.

• Public safety workers who may come into contact with blood.

• People receiving hemodialysis.

• People who live or work in an institution for the developmentally disadvantaged.

• Prison inmates.

• Alaskan Natives and Pacific Islanders.

Q: Which people with chronic hepatitis B need to be treated? Vincent

A: Treatment of Hepatitis B may be divided into two categories on the basis of a positive or negative Hepatitis B e antigen ( HBeAg). Symptoms of hepatitis B or the lack thereof is not used a s a parameter for treatment decisions.

HBeAg positive individuals ahould be treated if their HBVDNA > 20,000IU/mL and their ALT is elevated. If their ALT is not elevated and they are over 35 y.o., a liver biopsy should be done, and treatment started depending upon the results.

HBeAg negative individuals should be treated is their HBVDNA > 2000 IU/mL, and their ALT is elevated. Liver biopsy findings should dictate treatment decisions if ALT is normal.

Q: When a needle liver biopsy is done in such a tiny area of the liver, how ca it tell the condition of the entire liver? Kathy

A: Most liver diseases affect the entire liver uniformly. Thus, this tiny sample is usually representative of the entire liver and provides a complete story. It is unlikely that this specimen would look better or worse than the rest of the liver, but it can happen. This uncommon occurrence is known as sampling error.

Q: What are the effects of Interferon and ribavivirn on pregnancy? Deborah

A: Ribavirin is teratogenic—capable of causing birth defects. Therefore, people who are pregnant, or who are contemplating pregnancy, are not candidates for treatment. If a women is in an early stages of disease (stage 1 or 2), treatment can be safely held until at least 6 months after therapy is concluded. Furthermore, if it is decided to delay pregnancy and start treatment, it is recommended to use two forms of contraception while on therapy and for six months following the discontinuation of therapy.

12/29/06

Q: A recent study done in England found that Sulfasalazine reduced liver scarring in people with cirrhosis. Is this recommended? Lois

A: Sulfasalazine is is a prodrug - meaning that is is inactive when ingested. It is later broken down by the digestive tract to 5 aminisalicylic acid ( aspirin) and sulfapyridine ( a sulpha drug). This drug has been used to treat ulcerative colitis, Crohns disease and rheumatoid arthritis. Researchers in England have shown that in laboratory animals, sulfasalazine can block the production of proteins that help make scar tissue in the liver. Sulfasalizine is not without side effects which may include - headaches, rash, bleeding, infertility in men and rarely hepatitis. Therefore, until studies are conducted on humans, it is not recommended for patients to begin sulfasalizine.

Q: What is the relationship between diabeties mellitus (DM)and hepatitis C (HCV)? -Glenn R. California

A: People with HCV are at increased risk of developing diabetes - especially type 2 DM. The two factors that are most commonly related to the development of DM are: the degree of liver scarring ( patients with cirrhosis more commonly have DM) and family history of DM. Studies have also shown that since people with DM often have slow digestive systems, they have an increased chance of developing hepatic encephalopathy (brain fog). This may worsen on interferon treatment which may increase the chance of dehydration. Furthermore, diabetic patients with HCV also have more severe symptoms of HE than nondiabetic patients with HCV. Patients with HCV who have poorly-controlled DM have an increased chance of death. Thus, strict control of glucose levels is extremely important for all patients with HCV and DM.

12/1/06 December 1st marked the 10 year anniversary of the Primary Biliary Cirrhosis Foundation. Their website www.pbcers.org . There was a full day chat of invited liver specialists from around the world who participated in a question and answer session. Below is my Q&A.

1.
Are there any new treatments or explanations for the constant, 
unrelenting fatigue of PBC?
Fatigue is the most common symptom, occurring in approximately 65 percent of people with PBC. The cause of fatigue in people with PBC is not known, however, depression and sleep disorders may be contributing factors. The degree of fatigue does not correlate with the severity of the disease and may be just as debilitating for a person in an early stage of PBC as it is for a person in an advanced stage of PBC.
The successful treatment of fatigue can be a challenge. First, all of the potential causes of a person’s fatigue should be looked into. Some are easily managed. Some commonly occur in people with liver disease. These potential causes of, and/or contributors to, fatigue include the following:
• Thyroid disease (may be primary cause of, or contribute to, fatigue).
• Anemia (may be primary cause of, or contribute to, fatigue).
• Disorders of other organs, including the heart (for example, congestive heart failure) or the brain (for example, brain tumors).
• Nutritional deficiencies (for example, a lack of iron or a lack of protein).
• Disturbances in fluid and electrolyte balance (for example, a low sodium level).
• Depression that is not attributable to liver disease.
• Some medications and drugs (a doctor should review all medication, prescription and over-the-counter, and omit those that cause fatigue, if possible).
• Excessive use of caffeine.
• Excessive use of alcohol.
• Emotional stress.
• Lack of exercise.
• Lack of sleep.
• Overwork.
 
If fatigue continues to persist after ruling out or correcting any medical conditions, there are a few lifestyle changes that may be helpful. For example, eating a healthy, low-fat, well-balanced diet, quitting smoking, refraining from alcohol consumption, and exercising daily are all lifestyle changes that can have a beneficial effect on fatigue. Drinking plenty of water and limiting caffeine-containing beverages to one or two cups per day are also recommended. It goes without saying, but bears repeating: People with liver disease should avoid drinking alcohol, another cause of fatigue. It’s also a good idea to begin a program to eliminate excess weight by following a healthy weight-reducing diet. (Never lose more than one to two pounds per week.)
The demands of a hectic job or harried home life may need to be reduced—overwhelming stress may cause fatigue even in a person who is not suffering from liver disease. Excessive and/or emotional stress are often the cause of fatigue in people with liver disease. Therefore, friends and family should attempt to reduce any excessive or unnecessary obligations or expectations that they may normally have had of the person.
If possible, a thirty- to forty-five-minute daytime nap should be taken daily. This can help rejuvenate a person with liver disease. In some cases, it may be necessary for a person with liver disease to incorporate naps into her daily schedule. Often, a doctor’s letter to the patient’s employer or supervisor may be in order. A person with fatigue should feel free to ask her doctor for such a note.
Remember, the treatment for fatigue cannot be found in pill! Be especially wary of any product that boasts “improved energy levels” on its label. Because the liver is in charge of breaking down all supplements and medications, more harm than good may result from taking such a product. Also, be aware that taking excessive amounts of vitamins and minerals in an attempt to treat fatigue—especially vitamin A, niacin, and iron—can lead to a worsening of liver disease. It is essential that a person with liver disease consult a liver specialist prior to taking any supplements or products that promise to cure fatigue.

Finally, I have personally had a great deal of success with Provigel 200mg/day.  Oftentimes your doctor may need to write a medical necessity letter, but typically it is approved by most insurances.



2.
What do you think about the use of red rice yeast to control 
cholesterol?

My personal experience with red yeast rice has been mixed.  Some patients achieve a 20-30 point drop in LDL others no response.  I have not had or read any severe adverse reactions, but since this supplement is not regulated by the FDA it is possible that reporting is not as accurate.


3.
You mention in your book Hepatitis&Liver Disease that green tea leaf and Viscum Album (European Mistletoe) harm the liver. Please tell me why - or where I find literature on this.
Both of these herbs has been linked to "hepatitis"  meaning inflammation of the liver in isolated case reports.  Whether of not this was due to the active ingredient or a contaminant or filler is not known.  However, in general I advise patients to avoid herbals.


4.
Thank you Dr. Palmer. My father died of what was called "nutritional cirrhosis", probably
undiagnosed pbc, in 1971. After  elevated liver enzymes on routine wellness screening checkup that continued for many years and workups for hepatitis, ct's that were all normal, I was finally sent to a gastroenterologist in Northwestern in 1993 and  was diagnosed with PBC stage 2 with a positive AMA and biopsy. To allay my worries  for my children ages 16-31 and concerned about the possible hereditary factor ,I would like a  recommendation when and how often to have them checked for elevated liver enzymes. Better to catch them earlier than when symptomatic.

There is currently no standard of care or recommendation on testing of children.  I routinely advise my patients to have there first degree relatives - children, parents siblings, especially females ( I am more lenient with male family members)  tested upon my initial consultation.  After that, depending upon the findings every 10 years should be sufficient, if all is normal.  With this screening I have identified siblings, parents and children with PBC.


5.
My hepa doctor thought I was in stage 1/2 now thinks stage 3, but won't do a biopsy.When should a biopsy be done,if ever?
The liver biopsy is the only diagnostic procedure that can really take the mystery out of liver disease. A biopsy can determine exactly what’s wrong with the liver and exactly how badly the liver has been damaged. This information is crucial in order to outline a course of treatment, assess the response to treatment, and to determine a prognosis. The information obtained through a liver biopsy cannot be as accurately obtained through any other method, including imaging studies and extensive blood work. Therefore, it is important to obtain a liver biopsy upon initially diagnosis of PBC.  I  rarely repeat biopsies. 



6.
Dr. Palmer, we appreciate so much your being here today to answer our questions and concerns!My question – Does drinking plenty of water (staying very hydrated) help significantly to reduce skin itching?
 8.
I don't like water, but drink a lot of tea, juice and some soda.  I do try to drink at least 2 glasses of water.  Is this ok or do I actually need the 8 glasses of water?
Thank you.

I will answer question 6 & 8 together.
The body consists of about 70 percent water. It requires water in order to carry out its essential functions. It is important for people to drink at least six to eight 8-ounce glasses of water per day. People with liver disease often find that drinking abundant amounts of water helps give them an improved sense of well-being. Some people with PBC have found that liberal water consumption helps with some symptoms of PBC such as fatigue and itching. On the other hand, people with ascites are prone to excessive water retention. These people are advised to restrict their water intake to approximately three to four 8-ounce glasses of water per day, depending upon the degree of fluid accumulation present. When drinking bottled mineral water, it is important to take note of the water’s sodium content. In some instances, the sodium content may present a problem for people on sodium-restricted diets. Also one may consider purchasing a filtration system for the kitchen faucet for more purified water.  Tea, juice and soda do not have the same health benefits of water.

7.
Hi Dr. Palmer,
I have severe problems with my bones and now having problems walking sometime. I do have osteoporosis and neurologist said I have a neurapathy.  I just loose my balance sometimes and fall.  Does this have to do with my pbc or is it the neurapathy?  My doctors keep telling me it is a combination of things and sometimes I wonder if they even know what the problem is.
Thank you for answering my question.

I agree that this is probably due to a combination of problems, however, it is unlikely that osteoporosis would cause a balance problem. Make sure that your B12 and folate levels are normal.

9.
What does it mean when your LFT’s jump quickly?   My first . Phos. went from 124 to 298, GGT from 58 to 380, AST from 24 to 70, ALT from 20 to 82 in a three month period.  I’m newly diagnosed and went on URSO in Aug. 2006 till Sept. 2006 and then stopped taking URSO.   During my first appointment with my gastro, he said he would not put me on URSO yet because my numbers were low but he also said if I wanted to take it, it would do me no harm.  I chose to take it but questioned my family doctor in Sept. who said I probably didn't need it yet.  The low numbers I posted are the numbers BEFORE going on URSO and the high ones are my numbers after being off the URSO for one month.  The only other medication I take is synthroid, which was changed from .100 to .112 in August.  I do NOT take vitamins or any herbal medicines.  Does the jump in numbers mean I am progressing quickly now?   I have my second appoint with the gastro dr. in a weeks time - at which point I will definately start taking the URSO again.

         Urso provides significant benefits to people with PBC. Levels of liver function tests, IgM, AMA, and cholesterol typically show notable improvement. People find that urso, on occasion, relieves some of the symptoms associated with PBC, such as fatigue and itching. Most importantly, urso has been found to slow the progression of PBC, and to delay the occurrence of cirrhosis. Thus, people with PBC who are treated with urso have been found to live longer, have less liver-related complications, and need liver transplants less often when compared with those who are not treated with urso. Urso should always be started upon diagnosis of PBC independent of your liver enzyme elevations. In fact, your initial liver enzymes do appear to be high.  The "jump" may have been due to a rebound effect of coming off urso.  I suspect that they may decreased to baseline elevations again, but agree to start and stay on urso.
10.
I have PBC stage 3 and fatty liver.  Is there a special treatment for the fatty liver?  Special diet /vitamin considerations.  Also have osteorporsis and sjorgens and a gastric ulcer.  I haver just switched form URSO 251  to Ursodial.  I the four months since dx'd my LFT s have come down.   Alk from 295 to 109.  Thank you
     Weight reduction is particularly important for those overweight people who have both NAFLD - nonalcoholic fatty liver disease and an additional liver disease—for example, PBC. I have published a study specifically addressing this problem in 1991 and found that  a 10-percent weight loss will also lower elevated liver enzymes although liver enzymes, may not revert to totally normal levels - unless urso is also used. 

     A combination of aerobic and weight-bearing exercises is recommended as the most beneficial exercise regimen. It has been shown that improvement in insulin resistance correlates with the intensity of one’s exercise program.  It is well-established that substantial benefits are obtained from exercise even when there is no accompanying weight reduction.  Yet, ideally, some weight loss should be achieved as well. See Chapter 23 for more detailed guidelines regarding weight loss and exercise.

Many medications are presently being evaluated for people with NAFLD. The most promising one appears to be urso. Initial studies involving people with NASH have shown that treatment with urso can lead to improvements in liver enzymes and to a reduction in the severity of fatty deposits in the liver. UDCA may possibly decrease the risk of developing gallstones during weight reduction. Further studies are ongoing as to the effects of UDCA on NAFLD.
     Metformin (Glucophage) and rosiglitazone (Avandia) are oral glucose-lowering (also known as hypoglycemic) medications used to treat type II diabetes.  These medications work by correcting insulin resistance.  Therefore, these types of drugs may potentially benefit people with NAFLD and insulin resistance. In fact, preliminary studies have shown that treatment with metformin can improve liver enzyme elevations in people with NAFLD.  However, improvement in the amount of fat and inflammation in the liver have thus far been established only in studies involving animals. Studies on humans will be required before these medications can be recommended  for people with NAFLD.
     Clofibrate, a triglyceride-lowering drug, has been tested as a treatment but has not shown to be beneficial. Gemfibrozil, another triglyceride-lowering medication was able to improve liver enzyme elevations in a small group of people with NAFLD, but its effects on liver fat and scarring was not tested.  Further study is needed on gemfibrozil. Polymixin B is an antibiotic that can reduce the amount of bacteria in the intestines. This medication may be characterized as a form of “bowel decontaminate.” Studies have shown that administering polymixin B to people on intravenous feedings (total parenteral nutrition (TPN)) can reduce the amount of fat in their livers. This treatment option needs further study before definite conclusions can be drawn about its effectiveness in treating people with NAFLD.
     Betaine is a precursor of S-adenosyl methionine (SAMe), a derivative of the amino acid methionine.  S-AMe is purported to promote the health of the liver.  In two studies, some patients who were treated with betaine experienced decreased liver enzyme elevations and a decreased  amount of fatty deposits in their livers.  The mechanism by which betaine exerts its beneficial effect on the liver, is not clear, but it is believed that it may assist in transporting fat away from the liver. Recent studies have shown that betaine approximatley 300 mcg helped reduce liver enzymes in people with NAFLD.
      Certain nutritional deficiencies which are common among  people with NAFLD may provide a clue in the search for a successful treatment. Some people who receive intravenous feedings for prolonged periods of time develop fatty liver in addition to a choline deficiency. (Choline is a B vitamin.) Correcting the choline deficiency in these people has been shown to resolve the fatty liver as well. Choline supplementation in people with NAFLD is a promising treatment option, but is one which requires further study. Coenzyme A is a substance that is essential for the metabolism of carbohydrates, fats, and certain amino acids. It contains pantothenic acid, a B vitamin which is necessary for growth.  In some studies, people with NAFLD were supplemented with a form of coenzyme A, and this caused the extent of fat deposits in the liver to decrease. More research must be done to confirm the efficacy of this type of nutritional supplementation. 
One preliminary study has indicated that vitamin E (alpha-tocopherol) supplementation may be a beneficial adjunctive treatment for people with NAFLD, but more research is needed in this area.  Biotin, a B vitamin has been shown to decrease insulin resistance.  Studies on people with NAFLD have not been conducted at this time, but biotin supplementation would be an interesting area of exploration for people with NAFLD.
In general, I advise my partients with a fatty liver to use Vit E 800 mg, coenzyme Q 10 100 mg, betaine 300 mcg and biotin 50 mcg.


11.
I have had a 2 1/2 yr Hx elevated ALT 3X alkP 2X.  Liver
biopsy chronic portal periportal hepatitis grade 2 stage
0/1, focal bile duct proliferation and rare bile duct
inflammation. Three path's and two hep's have only been
able to identify this as an autoimmune form of liver
disease.  Would you chalk this up to sampling error or
possibly a mixed not well defined pattern of disease?  Any
thoughts you have would be greatly appreciated.
 Without accompanying blood tests, physical exam and MRCP it is difficult for me to diagnose. However, bile duct proliferation is consistent with stage 2 PBC.

12.
I take paxil for depression.  Does it hurt my liver?  Should I be on another anti-depressant instead?
Thank you.
Paxil is classified as an SSRI.  Overall, I have found t13. Buona sera dottore!
amp; A that I participated Q & Prof. Poupon mentioned  that treatment with Urso/Actigall/Ursodiol can cause weight gain. Why? Dr. Gershwin recommended to ask you about it.

Do I have to raise my Urso dosage if I am on a lower than recommended dosage – and all my liver counts are in normal range
I am not aware that urso causes any significant weight gain, however, urso has been linked to elevated glucose levels which may be associated with weight gain. The most beneficial effects of Urso have been found when it is administered in a weight-based manner.  Therefore, it is advisable to increase dose according to your weight.                


14.
Is AMA the definitive diagnosis for PBC?  Can you have a positive AMA and a normal biopsy and not have PBC, but AIH?
The finding of an AMA of a titer greater than 1:40 in a person almost always confirms the presence of PBC. It is unlikely that you have AIH with a normal liver biopsy.PBC overlaps with autoimmune hepatitis (AIH) approximately 8- 12 percent of the time. These people have the clinical features of AIH, such as very elevated transaminases and the autoantibodies of AIH - antinuclear antibody (ANA) and/or smooth muscle antibody (SMA). However, they also have the presence of antimitochondrial antibody (AMA) in their blood, which is diagnostic of PBC. It has been suggested by some experts that those people who test positive for AMA should not be considered to have AIH.  This is because there is such a strong association of AMA with PBC. In fact, it has been demonstrated that features of AIH in people with PBC may be transient.   


15.
What is Preclinical Hypothyroidism?  What can the patient do to improve this condition?  Thank you.
Up to 20 percent of people with PBC have some type of thyroid dysfunction. While the thyroid of a person suffering from PBC may sometimes be overactive (a condition known as hyperthyroidism), an underactive, slow-functioning thyroid (a ?condition known as hypothyroidism) is more common. I am not sure what is meant by preclinical. However,  if you are suffering from fatigue, treatment of hypothyroidism may help.

16.
Many of us complain of pain and weakness in our hands.  What causes this and what can we do to help? 
There are many rheumatologic disorders associated with PBC which can cause pain and weakness in the hands. Rheumatoid arthritis is characterized by joint aches and joint deformities Raynaud’s phenomenon typically causes the fingertips to turn blue and to become numb when exposed to cold weather or when the person is exposed to emotional stress.  Scleroderma can affect the fingers and toes, known as sclerodactyly. Treatment depends on the correct diagnosis.



17.
An article in PubMed indicates that a study showed that PBCers have 
abnormal intestinal permeability to more of a degree than the normal 
population and those with HCV. Have you as practitioners come across 
this and, if so, how do you treat it? Do you think it could be a 
cause or result of PBC?
Thank you.

I am not aware of this study, but there are numerous causes of diarrhea in people with PBC such as celiac sprue and ulcerative colitis.


18.
What does it mean when the AFP tumor marker registers above normal ranges? Are elevated AFP levels "normal" in liver disease? If so, how high is okay and at what point do the elevated levels become concerning?

I've read that elevated AFP levels, when coupled with cirrhosis, indicate a patient has a greater likelihood of developing liver cancer? Does that mean patients with primary biliary cirrhosis and elevated AFP levels are likely to advance to liver cancer?

Thank you for your time and the compassion you show donating your time to help patients with PBC.

 Normal adult levels of AFP are less than 20 nanograms per milliliter (ng/ml). If the level in a person’s blood is over 400 ng/ml, then it is pretty safe to say that liver cancer is present. Levels under 400 ng/ml are a little more confusing. This is due to the fact that AFP levels can also be elevated as a result of many other conditions (see bulleted list below), especially any conditions in which there may be liver damage, such as cirrhosis or acute hepatitis.  These other conditions rarely cause one’s levels to exceed 100 ng/ml.  
Causes of an elevated AFP, other than HCC, include:
• Hepatitis—both acute and chronic
• Cirrhosis
• Liver metastases
• Pregnancy
• Cystic fibrosis
• Gastric cancer
• Pancreatic cancer
 
A rapidly rising AFP level, say from 60 ng/ml to 230 ng/ml within a few months—even if levels do not reach 400 ng/ml—is also suggestive of HCC. This abrupt increase signals the need to commence an intensive search for the tumor. It has been shown that initial AFP levels above 100 ng/ml in a person with chronic liver disease may foreshadow the development of HCC within the next five years. These people should be closely observed for tumor development. The degree of elevation of AFP is usually related to the size of the tumor—the larger the tumor, the higher the value. Thus, with very small lesions, AFP is often barely elevated. Only about 67 percent of HCCs secrete AFP. This means that 33 percent of  HCCs occur in people whose AFP is normal. Therefore, while this marker is very useful, it does have limitations.

19.My diagnosis of PBC occurred in 1997 with an AMA positive and a liver biopsy that indicated an early stage of PBC.  I immediately started using URSO and have used it daily ever since.  This past Spring I saw a new physician in Pittsburgh, PA following our relocation to the area.  After reviewing my records and checking the results of LFTs and having a cat scan, the Doctor told me that it is questionable whether I have PBC.  I have never heard of anyone whose PBC has improved.  I do have fatigue and have been told in the past that I have a fatty liver.  I now wonder if I need to continue to take URSO.  I don't know if I should be rejoicing or continue to be cautious. 

 A: A positive AMA is virtually diagnostic of PBC, especially if your liver biopsy confirmed this diagnosis. While it has not been proven that PBC can improve with treatment, I have seen the stage of the disease reverse - but, once you have PBC it will not go away.  I would continue to take urso.
20.
I read fatty deposits under the skin which are caused by NASH.  Are these the same type PBCers get under their eyes?  What is the cause and how can they be removed?

A: Xanthalasmas are irregular fatty yellow nodules or patches on the skin around the eyes due to disturbances in cholesterol metabolism. (They also occur in some people who have markedly elevated cholesterol levels from causes other than PBC.) Xanthalasmas occur in approximately 20 percent of people with PBC. Surgical removal of is not advised as they typically recur. Improvement of xanthalasmas formation may occur with Urso.

21. I've had nail fungus on one foot for over 20 years and also get psoriasis on the same leg.  The past few years I've had horrible pain in my leg making if difficult to walk at times.  The doctor said the fungus and psoriasis has gone into the bone causing the arthritis.  I can't imagine arthritis hurting this much or causing difficulty walking.  What do you think and is it possible for fungus and psoriasis to cause bone damage.  Thanks.
A: I am unsure of what is causing so much difficulty, but it is advisable to obtain both a bone scan  - to rule out bone infections or other etiologies and bone density scan - to rule out osteoporosis. ˇ¸

11/27/06

Q: Can Interferon and ribavirin treatment for hepatitis C be given to a patient who had a kidney transplant? M. Bhatti Germany

A:

Approximately 20 to 30 percent of all individuals on hemodialysis for kidney failure are infected with chronic hepatitis C. These people are often awaiting kidney transplantation. Treating individuals with chronic hepatitis C with interferon after kidney transplantation is risky, as it may cause rejection of the newly transplanted kidney. However, in selected cases treatment can be undertaken and has been successful. For this reaseon, it is strongly recommended that people with chronic hepatitis C, who are also undergoing dialysis for the treatment of kidney failure, should be treated for hepatitis C prior to undergoing a kidney transplant. Studies have demonstrated that these people respond to interferon treatment for chronic hepatitis C similarly to people who have normally functioning kidneys. As ribavirin is excreted through the kidneys, dosages must be reduced as severe anemia can result.

11/27/06

Q: Do people with hepatitis C have high iron levels and what foods with iron should be avoided? Les Davis

A: There are three liver diseases that are associated with high iron levels. They include alcoholic liver disease, nonalcoholic fatty liver disease (NAFLD), and chronic viral hepatitis—especially chronic hepatitis C. Elevated iron studies occur in about 40 to 50 percent of people with one of these underlying liver disorders. However, since these people do not have hereditary hemochromatosis - a genetic disease of iron overload, their intestines do not absorb an overabundance of iron. Thus, excessive iron deposition in the liver occurs only about 10 percent of the time in this particular group. Furthermore, the degree of iron deposits in the liver is mild compared to that found in people with hemochromatosis.

Why people with these three liver disorders have high iron levels remains an area of speculation and debate among medical researchers.  It is believed, but not conclusively proven, that some of these people may be heterozygotes for hemochromatosis (carriers of one mutant gene). If these people are treated with phlebotomy, their LFTs may show some improvement. It has also been suggested that people with chronic hepatitis C who have elevated iron studies may respond better to interferon treatment if they undergo phlebotomy. Therefore, it makes sense for the doctor to obtain hemochromatosis genetic testing on people with these liver diseases who have elevated iron studies.

There are two types of dietary iron. Heme (animal) iron found in animal foods, such as red meat, is well absorbed from the diet. Nonheme (plant) iron found in plant foods, such as spinach, is poorly absorbed into the body. Popeye was wrong: spinach is not a good source of iron. In fact, only about 15 percent of ingested animal iron and only 3 percent of ingested plant iron is actually absorbed by the body. Foods high in iron are red meats especially liver, and foods fortified with iron such as some cereals. People with high iron levels should avoid cooking with cast-iron laden cookware and should avoid eating with cast-iron laden utensils. Some herbs commonly taken to treat liver disease (for example, milk thistle, dandelion, and licorice) may contain iron. Therefore, people with diseases associated with iron overload should avoid these herbs.

11/18/06

Q: What is Primary Sclerosing Cholangitis (PSC)? Rob P. and Clint

A: Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease that results in damage to the intrahepatic bile ducts and the extrahepatic bile ducts. Most people with PSC are male, and approximately two-thirds of people with PSC have an inflammatory disease of the colon (the large intestine) known as ulcerative colitis. Fatigue and itching are common symptoms.

         The exact cause of PSC is unknown. However, PSC is believed to be a disease of autoimmune origin occurring in people with a genetic susceptibility to the disease. Diagnosis of PSC is often difficult. There are no diagnostic autoantibodies blood tests that occur in people with PSC. People are typically found to have PSC during evaluation of elevated AP and GGTP levels found on blood tests. PSC requires a special procedure called an endoscopic retrograde cholangiopancreatography (ERCP) to be done in order for the disease to be accurately diagnosed. In an ERCP, a lighted tube (a special endoscope) is inserted into the patient’s mouth and then is snaked through the stomach and into the small intestine. There is a tiny opening in the small intestine called the ampulla of vater that leads to the extrahepatic bile ducts. A thin wire is inserted into this opening and then into the extrahepatic bile ducts. This wire allows access into the extrahepatic bile ducts so that contrast dye needed to visualize the bile ducts on an x-ray can be injected. An x-ray can then be taken of the extrahepatic bile ducts to determine if they have suffered damage, thus making a diagnosis of PSC. Complications from PSC include extrahepatic bile duct blockages, due to bile duct damage and bile duct stones.

         Medical treatment of people with PSC has been somewhat disappointing. Ursodeoxycholic acid ( Actigall, Urso) is typically started, however, this medication has not shown an ability to slow the progression of PSC or to prevent its complications. Nor have these drugs exhibited much success at prolonging the survival of people with PSC. Liver transplantation is the best option for people with advanced PSC. For these people, results have been good with approximately 80 percent of transplant recipients surviving at least five years.

11/12/06

Q: Are pickled foods bad for the liver?

Chuck

A: Pickling is the process of soaking foods in a solution in order to prevent the food from spoiling. The solution usually used contains high amounts of salt. Therefore people with liver disease who suffer from fluid retention i.e. ascites ( fluid retention in the peritoneal cavity) should avoid foods with high sodium contents. Otherwise pickled foods are not harmful to the liver.

11/12/06

Q: What does it mean if my GGT is elevated but all other liver function tests are normal? Antoinette

A: GGT is a sensitive marker of alcohol ingestion, certain hepatotoxic (liver toxic) drugs, and often fatty deposits in the liver - known as fatty liver disease. It should be noted that for unclear reasons, people who smoke cigarettes appear to have higher levels of GGT than nonsmokers. Also, levels of GGT are most accurate after a twelve-hour fast.

11/12/06

Q: I have hepatitis B and my doctor has put me on Baraclude ( entecavir), but I have no improvement in my viral load. Do you reccommend pegylated interferon?- DH

A: It has been shown that achieving hepatitis B viral suppression (nondetectable HBVDNA levels) may improve the outcome of patients with chronic hepatitis B - i.e. decrease the incidence of cirrhosis, liver cancer and other complications. Therefore, if HBVDNA levels are still detectable despite treatment with entecavir - adding or changing to another antiviral therapy is suggested. Pegylated interferon has the advantage of a finite duration of treatment and a lack of resistance. Other options include Hepsera ( adevovir) and Tyzeca ( telbivudine). Lamivudine should be limited to short-term use as the development of resistence is common with long-term use.

08/16/06

Q: Are 3 beers/day too many for females and can it cause leg swelling?- Beth

A:

While alcoholism is more common among men, it has been demonstrated that women are more susceptible to the adverse consequences of alcohol on the liver. In fact, women who develop alcoholic liver disease (ALD) and cirrhosis due to alcoho,l do so at a younger age than men, and they have consumed a less alcohol in total. It has been noted that women with cirrhosis due to alcohol have a shorter life expectancy than men with cirrhosis due to alcohol.

In general, consumption of about 80 grams of alcohol daily for a significant length of time is required for men to develop ALD. 80 grams of alcohol is roughly equivalent to a six-pack of beer or a liter of wine. (To convert grams to ounces multiply by 20 and divide by 567.) Women are much more susceptible to the toxicity of alcohol than are men It has been estimated that it takes as little as 20 grams of daily alcohol ingestion - tha's 3 beers/day over an extended period of time for women to develop ALD.

Once cirrhosis develops, leg swelling - known as pedal edema may occur. Pedal edema may resolve upon permanent discontinuation of alcohol, in addition to a low sodium diet and diuretic medication - water pills.

08/15/06

Q:Are oral estrogen contraceptives safe in women with liver disease? - Credo

A: In women with early stages of any liver disease oral estrogen supplements are generally safe and well tolerated. However, in women with advanced liver disease or cirrhosis, oral estrogen supplements should generally be avoided, as they carry a risk of causing or worsening jaundice and cholestasis.

Furthermore, “natural” soy estrogen has been linked to causing hepatitis, and therefore should also be avoided. 

Some researchers believe that excess estrogen can cause some benign tumors of the liver such as focal nodular hyperplasia, hepatic adenomas and hemangiomas to grow. In fact, growth of these tumors have been observed in some women during pregnancy, and in others while taking birth control pills. Furthermore, these people may be at increased risk for rupture. Although the effect of estrogen on women with these tumors are not conclusive, it is advisable for these women to stay off birth control pills and all other forms of estrogen replacement.

08/14/06

Q: My Father has cirrhosis due to alcohol and has high ammonia levels. Is this dangerous and how is this treated? Tracy

A. Ammonia is a product of amino acid breakdown. Increased levels of ammonia may be a sign of  encephalopathy -  an altered mental status associated with cirrhosis and liver failure from any cause- i.e. alcohol hepatitis.  

Some doctors use ammonia levels to monitor the course of people with encephalopathy.  However, since some studies have demonstrated a poor correlation between ammonia levels and degree of encephalopathy, its use for this purpose is controversial.   Measurement of the ammonia level in people with liver disease is not recommended, as mild increases may occur with any liver disease and are not diagnostic of encephalopathy.  Finally, there are multiple factors which can artificially elevate ammonia levels, thereby skewing interpretability.  Such factors include- cigarette smoking, certain medications such as valproic acid (a medication used to treat seizures), accidentally mixing the patient’s perspiration with their blood sample during the blood draw, and laboratory delay in analyzing the blood sample. 

Treatment of encephalopathy includes the discontinuation and avoidance of all sedatives, tranquilizers, and pain medications; discontinuation or reduction in the dosage of all diuretics; treatment of infection; elimination of constipation; control of gastrointestinal bleeding; and reduction in amount, or total elimination of, animal protein from the diet. Some liver experts believe that strict vegetarian diets can help improve encephalopathy.

Further management involves oral administration of an antibiotic, either xifaxin or neomycin (4-6 grams per day). Lactulose is a very sweet, synthetic sugar that acts as a powerful laxative. It acidifies the stool and thereby traps ammonia and drags it out of the body along with other fecal material. Therefore, lactulose can be quite useful in the management of encephalopathy.

08/13/06

Q: A liver biopsy was done that revealed mild steatohepatitis. What supplements can improve my condition? Alfred

A: Vitamin E, Coenzyme Q 10, Betaine, and Biotin may be useful supplements for people with NAFLD or NASH.

Betaine is a precursor of S-adenosyl methionine (SAMe), a derivative of the amino acid methionine.  S-AMe is purported to promote the health of the liver.  In two studies, some patients who were treated with betaine experienced decreased liver enzyme elevations and a decreased  amount of fatty deposits in their livers.  The mechanism by which betaine exerts its beneficial effect on the liver, is not clear, but it is believed that it may assist in transporting fat away from the liver. More research is needed in this area. One preliminary study has indicated that vitamin E (alpha-tocopherol) supplementation may be a beneficial adjunctive treatment for people with NAFLD, but more research is needed in this area.  Biotin, a B vitamin has been shown to decrease insulin resistance.  Studies on people with NAFLD have not been conducted at this time, but biotin supplementation would be an interesting area of exploration for people with NAFLD.