Fatty Liver Disease – Testing & Treatments

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 – Am I At Risk

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.

Tackling Chornic Ulcerative Colitis

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. 

Gastric Bypass and Vitamin and Micronutrient Deficiency

With the national obesity epidemic, bariatric surgery is commonly performed. Patients who have undergone bariatric surgery require lifelong vitamin and mineral supplementation. Consultation with a GI specialist regarding malabsorption of vitamins and minerals will prevent the development of these complications.

After Roux-en-Y gastric bypass (RYGB), a long portion of the proximal small bowel is bypassed. This portion of the small bowel is critical in absorbing iron, multiple vitamins, and essential minerals. Calcium, magnesium, iron, zinc, folic acid, and copper are absorbed in this portion of the small bowel. Without supplementation, vitamin and mineral deficiencies will occur. Many patients are told to take one or two multivitamins a day.

Most of these supplements do not contain enough iron nor calcium, such as selenium, zinc chromium, and copper. Nutritional supplements need to be tailored to the individual patient’s nutritional requirements. A GI MD can monitor this.

After sleeve gastrectomy, the recommendations for multivitamin and mineral supplementations are generally the same. After either type of gastric surgery, a nutritional assessment is recommended every six months for the first year. Laboratory testing will be needed annually after that. A GI specialist can manage this assessment.

Below is a summary of the recommended vitamin and mineral supplements following surgery. Also listed are the disease complications associated with the specific deficiency.

  Vitamins and Minerals

 It is crucial that, after weight loss surgery, you ensure you’re getting the necessary vitamins and minerals. Nutritional deficiencies will most likely occur as you are eating less. This means you may not be getting the necessary vitamins and minerals from your food intake. You should have your labs checked regularly.

Below you will find the recommended supplements for patients of weight loss surgery. However, make sure you always consult your doctor as your individual needs may differ.

  Multivitamin

Take a high-potency, chewable multivitamin and mineral supplement containing a minimum of 18 mg of iron, 400 mcg of folic acid. Selenium, copper, and zinc daily. Brands that contain this formula include Centrum adult chewable multivitamins. Take two tablets daily until at least three months after your surgery, and then one tablet daily for life.

  Calcium

Take 1,200 to 2,000 mg daily to prevent calcium deficiency and bone disease. To enhance absorption, take the calcium supplement as two to three divided doses throughout the day. For example, take 500 to 600 mg tablets three times a day. Calcium citrate is the preferred form of calcium.

  Vitamin D

Take 800 to 3,000 international units (IUs) of vitamin D daily. This total amount should be taken as 400 to 500 international units (IUs) twice a day with your calcium supplement. If you prefer, you can take a combination of calcium-vitamin D supplement as long as it contains the proper dosages to avoid taking multiple pills.

  Vitamin B12

Take 500 mcg of vitamin B daily. This can be taken as a tablet or a liquid under the tongue. Remember, whole pills must be crushed. You may need additional folic acid or iron supplements, particularly if you are a female and still menstruating.

You should never take non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, Advil, Motrin, Aleve, Vioxx, Naprosyn, or Celebrex. This is because these medications increase the risk of developing ulcers. 

Ulcers become increasingly difficult to diagnose and treat following bariatric surgery. Always consult with your doctor or pharmacist before starting a new medication.

Trouble with constipation is common among patients of bariatric surgery. Should this present a problem, there are a few things that might help; Benefiber being one of those things. Two teaspoons of Benefiber powder can be mixed into hot or cold drinks. You can also take Benefiber in the form of a caplet or chewable pill. Metamucil could also help. 

Diagnosing H Pylori

Helicobacter Pylori Infection (H Pylori) is the most prevalent chronic bacterial infection. This infection is associated with chronic stomach inflammation, stomach and duodenal ulceration, and stomach atrophy. Having this infection increases your risk of developing gastric cancer and gastric lymphoma (M A L T).

H pylori is often diagnosed by upper endoscopy by a GI specialist for evaluation of upper abdominal pain. H pylori can cause gastric and duodenal ulcers. The eradication of the infection will decrease the possibility of recurrent ulcers. In patients taking nonsteroidal anti-inflammatory medications, H pylori’s presence increases the chance of ulceration and intestinal bleeding. 

H pylori can also cause chronic gastritis, which is a surface inflammation of the stomach. Chronic gastritis can result in atrophic gastritis, which can lead to iron malabsorption and anemia. Atrophic gastritis can lead to the development of gastric cancer. If a patient has a family history of gastric cancer, screening for H Pylori infection is recommended. A low grade gastric mucosal lymphoma ( M A L T) can result from such an infection. Often the only treatment needed is the eradication of the infection. Limited evidence suggests that eradication of H pylori improves platelet count in some patients with idiopathic thrombocytopenic purpura (IT). 

If you are experiencing upper abdominal pain, see a GI MD. Depending on the circumstance, an H pylori breath test can be ordered. Treatment will be administered if the test result is positive. If the pain is accompanied by GI bleeding, anemia, or weight loss, an upper endoscopy (EGD) by a GI specialist will be necessary. It may also be needed if you have a family history of stomach cancer.

Antibiotics with a proton pump inhibitor are used to treat H pylori. Since the bacteria are now resistant to multiple antibiotics, this can be exceedingly difficult and require multiple regimens prescribed by a gastroenterologist. A new drug regimen, Talicia, which I helped research, is 90% effective in eradication. 

Confirmation of cure is essential. The conventional treatment is only 60%-70% effective. This testing is usually done by H pylori breath test at least two months after completing treatment. Once the cure is confirmed, H pylori can not reoccur. If treatment is not successful, then a continued infection can lead to an increased risk of gastric cancer. A GI specialist can monitor this process.

Acute Diarrhea- Possible Causes & Cures

Most cases of acute diarrhea are mild and in short duration. These cases are most often viral and require no specific treatment. However, diarrhea accompanied by high fever, bloody stool, and severe pain could cause a bacterial infection. Because of this, an evaluation by a GI specialist is needed. Salmonella, Shigella, and Campylobacter are the most common types of infections. If a patient has recently undergone treatment with antibiotics, they may have an increased chance of suffering from an infection by C. Difficile. This is a type of bacteria that can cause severe acute colitis

History of recent travel, antibiotic exposure, duration, food intake, and animal exposure are 

important clues in determining the possible causes of diarrhea. Laboratory evaluation to screen for dehydration and kidney dysfunction is an essential part of the evaluation. 

If severe diarrhea occurs along with dehydration, severe abdominal pain, the passage of 

bloody stool, or fever, further evaluation should be ordered. Stool multiplex molecular panel will screen for multiple different bacterial, parasitic, and viral infections. Consultation with a GI specialist can facilitate this testing.  

Regardless of the cause, management of acute diarrhea starts with fluid repletion. Diluted fruit juices with saltine crackers, broths, and soup may meet fluid requirements. The fluid should contain sugar, salt, and water. However, sports drinks that are used to replace sweat are not particularly useful.  

Since a viral infection causes most cases of acute diarrhea, antibiotics are not sufficient. 

Indications for antibiotic treatment include high fever, dehydration, blood in the stool, and 

immunocompromised patients. Consultation with a GI specialist can determine appropriate 

therapy. 

Identifying Crohn’s Disease

Chron’s Disease (CD) is a type of inflammatory bowel disease characterized by transmural inflammation of the bowel. Although CD can involve any segment of the GI tract, the ileum and cecum’s involvement is most common. If this occurs, the patient’s symptoms would include right lower abdominal pain, fever, and watery diarrhea. Fistula formation caused by abscesses often complicates CD. Crohn’s disease may also present more subtle symptoms such as mild diarrhea, crampy abdominal pain, and weight loss. 

These symptoms are often thought to be due to irritable bowel syndrome, and months may pass before the diagnosis of CD is made. Because of the variability of Crohn’s involvement, multiple symptoms such as nausea, vomiting, fatigue, and fever may occur. These symptoms should be addressed by a GI specialist with expertise in diagnosing CD.

With the introduction of multiple biologic agents, the treatment of CD has greatly improved. Prior to their introduction, treatment was limited to corticosteroids and immune modulators, which were often ineffective. The resulting clinical scenario was multiple operations with resulting complications, including malabsorption, chronic abdominal pain, anemia, and malnutrition. 

After a thorough investigation and discussion with a GI MD who treats Crohn’s disease, a treatment plan tailored to the patient’s specific needs can be started. The success rate of any biologic achieving endoscopic remission is 30% to 40%. Because of the number of biologics currently available, multiple options exist. A GI specialist can monitor this.