Month: December 2020

With effective treatment of Hepatitis C and Hepatitis B, fatty liver is now the most common cause of liver disease in the US. Although it has no clear cause, fatty liver is linked to obesity, insulin resistance, hypertension, heart disease, and elevated cholesterol. Certain ethnic groups, especially Hispanics, have a higher prevalence of fatty liver. 

Most commonly, fatty liver does not cause any specific symptoms. However, it may cause mild fatigue and dull right upper abdominal pain. This is due to the stretching of Gleason’s capsule. It can also cause a mild elevation of liver enzymes. 

Since no specific blood tests are available to diagnose fatty liver, other types of liver disease will need to be ruled out. This includes testing for alcohol intake, as well as blood tests to rule out Hep B, Hep C, and Wilson’s Disease. Medication history in the patient will help rule out drug reaction. 

Usually, fatty liver is diagnosed by an imaging study. On abdominal ultrasound, the liver has increased echo patterns suggestive of increased hepatic density. More specific tests include a FibroScan, which measures liver density. Although not always necessary, liver biopsy can confirm the diagnosis and severity of the liver disease. 

Fatty liver itself does not cause any significant liver dysfunction. It does, however, indicate significant metabolic problems, including an increased risk of developing diabetes, hypertension, and heart disease. However, fatty liver can progress into nonalcoholic steatohepatitis (NASH). 

On liver biopsy, NASH looks just like an alcoholic liver disease with increased fat and fibrosis. If this occurs, consultation with a GI specialist is recommended. NASH can progress to cirrhosis, which is end-stage liver disease. Even without progression to cirrhosis, the development of liver cancer (HCC) is increased. Even with the high prevalence of fatty liver, the development of HHC will substantially increase in this country. 

Although the treatment of fatty liver is an intense research area, no drug therapy is currently available. Obeticholic acid (OCA) is in phase three trials and shows promise. It has significant side effects such as pruritis and elevation of cholesterol, which may limit its use. If the patient is obese, a limited weight loss of 10% body weight can reverse fibrosis. Although no clinical trial has been published, low-dose aspirin may be of benefit as it can decrease the development of liver cancer. 

Fatty liver is now the most common cause of liver disease in this country. Consultation with a GI specialist or liver specialist is recommended for further evaluation and treatment options.

Colorectal Cancer (CRC) is a common and lethal disease. It is estimated that 100,000 cases of CRC are diagnosed in the US annually. Approximately 53,000 Americans are expected to die of CRC every year. Although the mortality rate of CRC is decreasing, it remains the third most common cause of cancer-related death in women and the second most common in men.

Although the incidence of CRC in patients over 50 has been decreasing, CRC incidence in patients aged 40-50 has been increasing.  The US Preventative Services Task Force recommends screening for average-risk African Americans at age 45. 

The type of screening should be a shared decision between the patient and the GI specialist. Colonoscopy, which is recommended by most GI MD’s is the only screening test proven to decrease CRC mortality. Optimally, this procedure should be performed at 50 in average-risk patients, and if negative, repeated every ten years. 

Fecal Immunochemical Testing (FIT) is a stool test done annually and is recommended in patients unable or unwilling to have a colonoscopy. If the FIT result is positive, a colonoscopy must be performed by a GI specialist. FIT is comparable to colonoscopy in the detection of CRC but has a lower detection rate for advanced adenomas, which may harbor localized cancer. 

Computed Tomography Colonography (CTC) is an option for patients at risk of complications from sedation or the procedure itself. CTC requires a colonoscopy laxative preparation and is done without sedation. It is relatively sensitive in identifying large polyps, which, if seen, would require a colonoscopy. 

Stool for guaiac fecal occult blood is insensitive and requires multiple stool samples. This test has been largely replaced by more specific stool tests (FIT). Most importantly, any option is better than nothing. Many patients believe that without abdominal pain, change in bowel habits, or rectal bleeding, the risk of developing colon cancer is very low. Most patients found to have colon cancer are asymptomatic and average risk. Discussion with a GI specialist will help determine the best option.

Chronic Ulcerative Colitis (CUC) is an inflammatory disease involving the distal colon, although it may extend to involve the entire colon. CUC is characterized by diarrhea commonly associated with rectal bleeding and colicky abdominal pain. Urgency is severe and involves the entire colon; colonic dilation may occur, resulting in perforation. Any type of bloody diarrhea requires consultation with a GI specialist.

Extraintestinal manifestations (infections that occur outside of the intestine) of CUC are common. These include arthritis involving the large joints and ocular problems resulting in blurred vision. 

Evaluation of possible ulcerative colitis includes laboratory and radiologic imaging. However, the diagnosis will eventually require colonoscopy done by a GI MD who performs colonoscopies. An endoscopy will evaluate the severity and extent of the inflammation. Colon biopsies will be obtained to establish the diagnosis and exclude other causes of colon inflammation.  

In the past, treatments of ulcerative colitis were limited to oral mesalamine and corticosteroids. Although treatment of mild CUC often begins with mesalamine, treatment failures are common. Corticosteroids are often used to treat moderate to severe CUC, but again, treatment failures are common, as are side effects. 

 Even if clinical response occurs, this regimen cannot be used to maintain remission. Fortunately, multiple biologic therapies are now available with new innovative drugs on the horizon. The current goal of treatment is mucosal healing. 

If this can be achieved, then complications of this disease, such as an increased risk of colon cancer, can be avoided. A total colectomy due to perforation or toxic megacolon can also be avoided. This therapy requires monitoring by GI specialists.