Fatty Liver Disease Non-Alcoholic Dr. Peter MacKercher, II, MD No conflicts of interest

Objectives Risk Factors Symptoms Proper Treatment NASH: by 2020 will surpass Hepatitis C for reason for liver transplant

Dr. Peter MacKercher II, MD Undergraduate Education Westminster College, Fulton, MO BA 168 Medical Education Medical School University of Missouri-Columbia MD 1972 Internship Straight Medicine 1972-1973 Residency Internal Medicine 1973-1777 Fellowship Gastroenterology 1975-1977 Military Service Great Lakes Naval Hospital 1977-1979 Lt. Commander Employment Mountain Home, AR 1979-Present Board Certifications National Board of Examiners 1973 American Board of Internal Medicine 1977 Advanced Achievement in Internal Medicine 1987 State Licensure Arkansas Missouri Current Hospital Affiliation Baxter Regional Medical Center Mountain Home, AR 72653

Peter MacKercher II, MD Positions Held: Acting Assistant Chief of Medicine Great Lakes Naval Hospital 1978-1979 Chief of Medicine Baxter County Regional Hospital 1981-1982 Baxter County Regional Hospital 185-1986 Chief of Staff Baxter County Regional Hospital January 1988 to January 1990 Director, Alcoholism Treatment Unit Baxter County Regional Hospital 1984-1986 Society Memberships: American Society of Gastrointestinal Endoscopy Arkansas-Oklahoma Endoscopy Society American Society of Internal Medicine Arkansas Medical Society Baxter County Medical Society American Association for the Advancement of Science

Peter MacKercher II, MD Papers Published: 1. Krause, W. J., Ivey, J. K., Baskin, W. N., and MacKercher, P. A. Ultrastructure of the Human Pyloric Glands with Emphasis on the Mucus Cell Component Part I Acta Anat 99:1-10 (1977) 2. MacKercher, P. A., Ivey, K. J., Baskin, W. N., and Krause, W. J. Protective Effect of Cimetidine on Aspirin-Induced Gastric Mucosal Damage Ann Int Med 87:676-679 (1977) 3. MacKercher, P. A., Ivey, J. H., Baskin, W.N., and Krause, W. J. A Scanning Electron Microscopic Study of Normal Human Oxyntic Mucosa Using Blunt Dissection and Freeze Fracture Am J Dig Discomfort 23:449-459 (1978) 4. Ivey, K. J., and MacKercher, P.A. Effect of Cimetidine on Ion Fluxes and Potential Difference Across the Human Stomach. Gut 19:414-418 (1978) 5. Krause, W. J., Ivey, K. J., Baskin, W.N., and MacKercher, P.A. Morphological Observations on the Normal Human Cardiac Glands Anat Rec 192:59-72 (n1978) 6. Silvoso, G. R., Ivey, K.J., Butt, J. H., Lockard, O. O., Hold, S. D., Sisk, C., Baskin, W. J., MacKercher, P.A., and Hewett, J. Incidence of Gastric Lesions in Patients with Rheumatic Disease on Chronic Aspirin Therapy Ann Int Med 91:517-20 (1979)

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Liver Diseases There are many different types of liver diseases and a few of them are: Hepatitis A Hepatitis B Hepatitis C Nonalcoholic Fatty Liver Disease (NAFLD) and Nonalcoholic Steatohepatitis (NASH) Cirrhosis We will be discussing Nonalcoholic Fatty Liver Disease, Nonalcoholic Steatohepatitis, and Cirrhosis.

The most common form of liver disease in the United States is now infiltration fatty liver disease. The occurrence of nonalcoholic fatty liver disease is growing around the world but in the United States the occurrence is suggestive that this disease is affecting approximately 75 to 100 million people. While this disease can occur at any age, persons in their 40’s and 50’s who are obese and have type 2 diabetes are most at risk.

Definition The liver normally has some fat but when 5%-10% of the liver’s weight is fat it is called fatty liver (steatosis). Non-alcoholic fatty liver disease is due to an excess amount of fat in the liver cells that is not caused by alcohol and is associated with an inflammatory response.

Non-alcoholic Steatohepatitis NASH This is very serious form fatty liver disease which is noted by liver inflammation. Liver scarring and permanent damage can result and advance to cirrhosis and liver failure. https://www.nashalliance.com/what-is-nash/

Risk Factors For NALD and NASH There are many diseases that can increase the chance of a person developing nonalcoholic fatty liver disease and among the more familiar of those are: Obesity Type 2 Diabetes Hyperlipidemia High Cholesterol The risk of developing nonalcoholic steatohepatitis (NASH) is more frequent in individuals with: Type 2 Diabetes Obesity Metabolic Syndrome Middle aged and older Increased fat around the abdomen

What causes some people to develop nonalcoholic fatty liver disease is not known. Research has shown that it is inclined to run in families as well as the other risk factors of being middle aged, being overweight or obese, having diabetes, and increased cholesterol levels. There are also other risk factors or causes of this disease that include: Medications Rapid weight loss Malnutrition Viral hepatitis Autoimmune liver disease

Signs and Symptoms The majority of people with NAFLD have no signs or otherwise very indistinct symptoms such as: Fatigue Pain in right upper quadrant Weakness Weight loss The symptoms of NASH and Cirrhosis may include the following: Red Palms Gynecomastia Splenomegaly Ascites Jaundice

Cirrhosis Cirrhosis is the main complication of NAFLD and NASH. Cirrhosis is triggered in by injury to the liver. This can be from the inflammation in the live due to NASH. When the liver tries to stop the inflammation scarring occurs. This cycle can continue to take up more liver tissue. Cirrhosis can progress to: Ascites Esophageal varices Hepatic encephalopathy Liver cancer End stage liver failure http://www.mayoclinic.org/diseases-conditions/nonalcoholic-fatty-liver-disease/symptoms-causes/dxc-20211639

The progression of NAFLD The complication of NAFLD is that it advances into NASH leading to Cirrhosis. http://www.liversupport.com/fatty-liver/

http://www.jlgh.org/Past-Issues/Volume-10---Issue-3/Non-Alcoholic-Liver-Disease.aspx

Diagnosis Physical exam Imaging Studies CBC Liver ultrasound Hemoglobin A1C Lipid profile Tests for chronic viral hepatitis Liver Biopsy Imaging Studies Liver ultrasound CT MRI Hepatic elastography Fiber Scan http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hepatology/nonalcoholic-fatty-liver-disease/

Treatment The leading treatment for NAFLD is weight loss. A healthy diet and exercise program is ideal. A 10% weight loss is preferred but even a 3 to 5 percent loss of the starting weight can show an improvement in risk factors. For the severely obese, weight loss surgery is an option. Avoiding alcohol Vaccinations against hepatitis A and hepatitis B may be recommended as a safeguard against further liver damage. Avoiding any unnecessary medications Alternative medicine treatments have not shown any evidence to cure NAFLD. There are some studies by researchers of natural compounds that could be helpful but further research is needed.

Projection As obesity rates among men, women, and children rise is this country, an unrelenting focus on a healthy lifestyle in this country and worldwide needs to be addressed due to the rise in NALFD diagnosis. Maintaining a healthy weight, eating a health diet, and exercising regularly are the best ways to prevent NAFLD. We as healthcare providers need to address this issue and provide education about this disease.

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References http://www.liverfoundation.org/abouttheliver/info/nafld/ http://www.mayoclinic.org/diseases-conditions/nonalcoholic-fatty-liver-disease/home/ovc-20211638 https://www.webmd.com/hepatitis/fatty-liver-disease#2 Rinella, M. E. (2015). Nonalcoholic fatty liver disease: a systematic review. JAMA: Journal Of The American Medical Association, 313(22), 2263-2273. doi:10.1001/jama.2015.5370 http://www.medicinenet.com/fatty_liver/article.htm