Tag Archives: CIRRHOSIS

Three Complications of Cirrhosis: Dr. Rashid Khan Explains Further

Cirrhosis is a slowly progressing disease in which healthy liver tissue is replaced with scar tissue, thereby preventing the liver from functioning properly. This scar tissue blocks the flow of blood through the liver and slows the processing of nutrients, drugs, hormones and naturally produced toxins.

According to the National Institutes of Health, cirrhosis is the 12th leading cause of death by disease, Fatty liver, Hepatitis C and alcohol abuse are the most common causes of cirrhosis of the liver in the U.S. Patients need to be aware of the complications of cirrhosis. The top three ones are:

  1. Variceal bleeding. Variceal bleeding is caused by portal hypertension. This is an increase in the pressure within the portal vein (the blood vessel that carries blood from the digestive organs to the liver). This increase in pressure is caused by resistance to blood flow through the liver as a result of cirrhosis. Increased pressure in the portal vein causes other veins in the body to enlarge (varices), such as those in the esophagus and stomach, to bypass the blockage. These varices can bleed easily, causing patients to present to hospitals either vomitting blood or dark stools. Portal hypertension also leads to extra fluid buildup in a person’s abdomen ( ascites) and( or) lower legs/feet( pedal edema). Prompt medical attention should be sought from a liver specialist for both variceal bleeding and fluid accumulation.
  1. Hepatic encephalopathy (confused thinking). Toxins produced in our intestines are normally detoxified by the liver, but once cirrhosis occurs, the liver cannot detoxify as well. Toxins get into the bloodstream and can cause confusion, changes in behavior, and even coma. Laxatives such as lactulose are used to speed their removal from the intestines.

  1. Liver cancer. There is about a 5-6% annual incidence of liver cancer in patients with cirrhosis from any cause. Usually it occurs without any symptoms at all. Liver cancer is picked up by periodic surveillance typically using ultrasound. Various modalities can be used to treat these cancers, including evaluation for liver transplantation.

 

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Top Five Symptoms of Hepatic Encephalopathy

Top Five Symptoms of Hepatic Encephalopathy

Hepatic Encephalopathy

Hepatic Encephalopathy

Hepatic encephalopathy, seen in advanced liver disease and cirrhosis, results in a number of neuro-psychiatric symptoms, that cover a wide spectrum of manifestations. Being aware of the clinical presentations are important for both the patient and their caretaker, as well as healthcare professionals involved in their care. These include:

 

 

  1. Personality changes.
  2. Changes in sleep-wake cycles, associated with excessive daytime somnolence and nighttime insomnia.
  3. Disorientation to person, place and time.
  4. Development of inappropriate behavior, associated with confusion.
  5. Coma.

Individuals with hepatic encephalopathy have serious live problems, and should be considered for liver transplant evaluation.  All of us at Liver Specialists of Texas are experienced to care for these complex patient needs.

 

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Top Five Reasons to Evaluate Nonalcoholic Fatty Liver Disease (NAFLD)

Dr. Rashid Khan adds this blog entry further reviewing important issues related to nonalcoholic fatty liver disease (NAFLD)

I few weeks ago I wrote on this topic as guest editor on Dr Joe Galati’s blog. We talked about some basic concepts surrounding Nonalcoholic Fatty Liver Disease (NAFLD). To recap, this condition involves fat accumulation in the liver of non drinkers. I mentioned the importance of prompt evaluation, necessary investigations and potential therapies. Here I once again write about this common condition, afflicting close to 100 million Americans, highlighting five reasons why NAFLD needs to be taken seriously.

  1. The most relevant reason from a liver doctor’s perspective is the potential transformation of fatty liver disease to liver cirrhosis. Fatty liver is generally benign, but the development of cirrhosis becomes a game changer.
  2. Along with the potential risk of cirrhosis, comes the added risk of developing liver cancer. Studies have shown that this risk is even present in the absence of cirrhosis, though small.
  3. Cardiovascular disease( CVD) is one of the most common medical conditions in the US and globally. NAFLD and CVD go hand in hand. Usually both exist in many patients. Fatty liver is known to be an independent predictor of CVD.
  4. Type II diabetes is another very common medical condition . Numerous studies have shown the propensity of diabetic patients to develop fatty liver . This association is bi directional, meaning some patients with fatty liver will go on to develope diabetes.
  5. Finally, I will mention chronic kidney disease( CKD), another disease afflicting millions of Americans in this day and age. While the association of NAFLD and CKD may not be as robust as with CVD and diabetes, nevertheless it all comes back to the metabolic syndrome entity, which involves dangerous plaque build up in the blood vessels throughout the body.

 

Here at Liver Specialists of Texas, it is our sincere hope that fatty liver disease is recognized and evaluated in its earliest stages. Our practice is specifically geared towards the management of these patients, as well as other liver diseases, and we will be more than happy to see you in our offices.

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AASLD Liver Meeting 2015

AASLD Liver Meeting 2015

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For the next several days, liver disease experts from around the world will be in San Francisco learning and sharing the latest developments in liver disease at the annual Liver Meeting.

Today, the one-day postgraduate course covered common clinical conditions, including non-alcoholic fatty liver disease, hepatitis C, liver cancer/hepatocellular carcinoma, and complications of cirrhosis, including volume overload/ascites, malnutrition, and hepatic encephalopathy.

More updates will be posted through the meeting.

Dr. Joe Galati

Liver Meeting 2015

 

 

 

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Nonalcoholic Fatty Liver Disease: What You Need to Know? Dr. Rashid Khan Explains

Nonalcoholic Fatty Liver Disease: What You Need to Know? Dr. Rashid Khan Explains

Dr. Rashid Khan, Hepatologist at Liver Specialists of Texas, guest edited this blog entry on Fatty Liver Disease.


Obesity and Fatty Liver Disease

Obesity and Fatty Liver

In my 9 years of medical practice, it still does not cease to amaze me, that the public as well as the general physician’s perspective on fatty liver disease could be so wrong.

Every day of the week I see at least 10 patients with fatty liver, who have been told by their family physician that fatty liver is “no big deal”, and it is nothing to worry about. I tell them it is “ absolutely something to worry about”. Let me explain why.

Nonalcoholic fatty liver disease is a condition where there is fat accumulation in the liver of people who drink little or no alcohol.This condition is very common and generally causes no signs or symptoms, and generally no complications. Most people feel “OK” with this condition.

A wide range of diseases and conditions can increase your risk of nonalcoholic fatty liver disease, including: gastric bypass surgery, high cholesterol, high levels of triglycerides in the blood, metabolic syndrome, polycystic ovary syndrome, sleep apnea, diabetes, hypothyroidism, and of course, obesity.

In some people with fatty liver, the fat that accumulates can cause inflammation and scarring in the liver. This form of nonalcoholic fatty liver disease is called nonalcoholic steatohepatitis, commonly called NASH. In its most severe form, fatty liver can progress to liver cirrhosis (scarring), liver failure, and even liver cancer. About 20% of patients with fatty liver disease related steatohepatitis can progress to liver cirrhosis, so the risk is not trivial. In these such cases, liver transplant is discussed, and may be the only option to survive.

Evaluation of fatty liver begins with simple blood tests to assess liver function. These blood tests are the ALT, AST, bilirubin, and possibly alkaline phosphatase.

Unfortunately, many times these liver tests are elevated, and ignored by both physician and patient. These elevated (and abnormal) liver tests may be the first indication that trouble is brewing in the liver. This is almost always followed by some sort of liver imaging test, such as an ultrasound, CT scan or MRI of the liver and abdomen. If I suspect a more advanced stage of fatty liver disease, I will recommend we perform a liver biopsy, a procedure that involves removing a small sample of tissue from the liver, and examining it under a microscope to look for signs of inflammation and scarring.

Unfortunately, despite extensive research in this field, no single standard and targeted therapy exists for fatty liver disease in 2015. In other words , no medication is currently the perfectly effective treatment for fatty liver disease. Almost always my patient will ask me , “Hey Doc, what pill can I take to fix this problem? And I reply there is none.

So we typically work to reduce the risk factors that have caused the fatty liver disease which are well known as I have eluded to above. If the patient is obese, we ask them to lose weight. Weight loss can be tough in the modern day lifestyle, but a committed approach involving caloric reduction and increasing physical activity usually works. Patients with diabetes and or high cholesterol are placed on medications to better control these disorders of their metabolism.

No alternative medicine treatments are proven to cure nonalcoholic fatty liver disease. The use of herbs, and many other widely available over the counter supplements not only don’t work, but can be dangerous. Some studies have shown that natural substances such as Vitamin E and coffee may help to reduce the damage caused by inflammation. However, more research is needed, and patients should discuss the use of these substances with their liver specialist.

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Latest News on Hepatitis C Cures

For tonight’s broadcast of Your Health First, Dr. Rashid Khan joins me to discuss the latest news on fatty liver disease, and the new therapies for hepatitis C, which results in a cure rate of over 95% of the cases. You can listed to the audio from the three segments here.

 

Dr. Rashid Khan and Dr. Joe Galati Discuss Liver Disease: Part 1 by Your Health First Radio on Mixcloud

Dr. Rashid Khan and Dr. Galati Discuss Fatty Liver Disease: Your Health First Part II by Your Health First Radio on Mixcloud

Hepatitis C: Dr. Rashid Khan and Dr. Joe Galati Discuss-Your Health First Interview Part III by Your Health First Radio on Mixcloud

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New Hepatitis C Cure FDA Approved: Daclatasvir for Genotype 3 Patients

This past week, the FDA gave approval to Bristol-Myers Squibb and their first drug in the hepatitis C market. Daclatasvir was given FDA approval for patients with the genotype 3 variety of chronic hepatitis C. Daclatasvir, commercially available as Daklinza, is approved to be taken with previously approved sofosbuvir (Sovaldi)-manufactured by Gilead-in this two-drug combination. Of note, Ribavirin nor interferon are required in the combination.

Published cure rates, also know as sustained virologic response (SVR) range from 86-90%. If you are non-cirrhotic, and naive to therapy, one can expect a 96% SVR. Unfortunately, prior treatment failures with past combinations, plus the presence of cirrhosis, carries a poor response rate of 63% in this most difficult group of patients.

For more information on hepatitis C and current therapies available, visit our website at Liver Specialists of Texas .

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Alcoholic Liver Disease: What You Need to Know-The Basics

Our latest video covers the basic aspects of alcohol related liver disease, and the complications of excessive alcohol intake. In general, there are three areas of concern:

1. The development of alcoholic fatty liver disease

2. The development of acute alcoholic hepatitis

3. Alcoholic cirrhosis

The major point to understanding is that all alcoholic drinks (servings) have about the same amount of alcohol in them. Thus, 1-beer, 1-glass of wine, and 1-serving of spirit (i.e. vodka, rum, gin, etc) all have approximately 10-12 grams of alcohol in them. Alcohol is alcohol, regardless of the volume, color, or taste.

The other key point to remember, is that the amount of alcohol daily is different for men and women. For women, one serving/day is the limit; two for men. Period. Above this, you run the risk of complications.

View our latest video.

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New Hepatitis C Drug Approved: Janssen’s Hepatitis C Drug Simeprevir Now Available

This past week, the FDA gave approval to Janssen’s new drug to treat hepatitis C. Simeprevir, commercially know as OLYSIO, is the first new hepatitis C drug since the release of telapravir (Incevik) and boceprevir (Victrelis) in 2011. Simeprevir is a  NS3/4A protease inhibitor, used in combination with interferon and ribavirin.

The release of simeprevir marks the beginning of a new wave of direct acting antiviral agents against the hepatitis C virus. Additional drugs are set for FDA approval, including the Gilead drug sofosbuvir in early December 2013.

Most of the new hepatitis C drugs will have a number of features in common. These include:

  • Very high cure rate, in the 80-90% range – lower in null and non-responders
  • Less side effects
  • Shorter duration of treatment
  • Less pills to take each day
  • Cirrhosis reduces response rates
  • Less drug-drug interactions
  • Genotype 1 subtype differences exist

Looking at the dosing of simeprevir, I have attached the official product insert that describes how the drug will be doses. Several points to consider:

  • This is an interferon/ribavirin based therapy
  • Patients with genotype 1 need additional screening for the NS3 Q80K polymorphism
  • Those with this variant have a decreased response rate to the therapy, and should be considered for an alternative therapy
  • The initial dosing is 12 weeks of simeprevir with interferon and ribavirin, followed by an additional 12 or 36 weeks of interferon and ribavirin combination therapy.
  • There are drug-drug interaction which have to be monitored closely
  • FDA approval is for genotype 1 patients only

While the release of simeprevir is welcomed, it has not provided the proverbial “home-run” we have been looking for in our quest to cure hepatitis C. In well selected patients, achieving a better than 80% cure rate is available. The concerns I have relate to the Q80K polymorphism noted above. This will be an additional step required in screening our patients. Additionally, in patients with prior non-response or null responders, as well as those with cirrhosis, these patients will still require a full 48 week of interferon and ribavirin. One of the goals of the next generation of hepatitis C therapies is reduced interferon exposure, or complete elimination. Simeprevir does not fully meet this goal.

In the days to come, I will post additional information on sofosbuvir. For now, these are the highlights to consider (refer to this FDA document for additional details):

  • Sofosbuvir will likely receive FDA approval for Genotype 1,2,3, and 4 patients with hepatitis C
  • Interferon-free treatment in genotype 2 and 3 for 12 weeks
  • Sofosbuvir combined with interferon and ribavirin in genotype 1 and 4 for 12 to 16 weeks

This treatment strategy is far different than the simeprevir treatment noted above.

Looking further, we will eventually have all interferon-free protocols. It is anticipated that as additional new drugs are approved, they will be combined (example sofosbuvir and simeprevir), allowing us to treat a wide range of patients, safely, and with a cure rate many of us may have never envisioned 20 years ago.

For a consultation to see if you are a candidate for these new drugs, contact Lexa at our office at 713-794-0700 and visit our webpage for additional information.

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Annual Liver Meetings -AASLD- in Washington, DC This Week

Annual Liver Meetings -AASLD- in Washington, DC This Week

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The annual Liver Meetings are taking place in Washington, DC, and I will report back on the breakthroughs, specifically those related to hepatitis C, cirrhosis, fatty liver, and liver cancer and transplant.

This far, discussion regarding the new hepatitis C therapies continue to report on the impact of new therapies on the cure rates we have been seeing in clinical studies. In addition to the new Gilead drug soon to be released, the FDA is favorably evaluating Simeprevir another soon to be approved hepatitis C drug.

Another popular topic yesterday and today has been non-alcoholic fatty liver disease (NAFLD and NASH). The take home message for both patients and physicians is that those individuals with obesity, diabetes, fatty liver, plus fibrosis on their biopsy have the greatest risk for serious complications.

I will update the blog as new developments are available.

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