Online Health Chat with K.V. Narayanan Menon, MD

Wednesday, August 3, 2016


As the largest internal organ in the body, the liver performs many vital functions, from cleansing the blood of toxins to assisting with food digestion and energy storage. To date, more than 100 liver diseases have been identified. These diseases interfere with the liver’s ability to perform these essential functions, which, in turn, affects the entire body.

Join Medical Director of Liver Transplantation Dr. K.V. Narayanan Menon online for answers to your questions concerning liver diseases, symptoms to watch out for and the latest treatment options available.

About the Speaker:

K.V. Narayanan Menon, MD, is the Medical Director of Liver Transplantation in the Department of Gastroenterology and Hepatology at Cleveland Clinic. Dr. Menon has completed subspecialty training in Advanced Endoscopy and Hepatology. He is an Assistant Professor of Medicine at the Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University. Dr. Menon’s specialty interests include liver transplantation, liver and bile duct cancer, advanced endoscopy, and advanced liver disease.

Let’s Chat About Hepatitis C and Liver Disease

Hints About Hepatitis C

khelm: What is hepatitis C?

K.V._Narayanan_Menon,_MD: Hepatitis C is a viral infection of the liver that can lead to cirrhosis and liver cancer. There are good treatments available now for the treatment of hepatitis C.

jprah: How is hepatitis C spread?

K.V._Narayanan_Menon,_MD: It is usually spread through blood transfusions, sharing needles and unprotected sex.

edworznik: Who is prone to getting hepatitis C?

K.V._Narayanan_Menon,_MD: It is recommended that everyone born prior to 1965 get tested for hepatitis C. It was generally spread through blood transfusions prior to 1990, but is also spread through recreational drug use and unprotected sex.

Jessi89: Are there specific symptoms for hepatitis C? How do I get screened?

K.V._Narayanan_Menon,_MD: There are no specific symptoms for hepatitis C, unless you develop cirrhosis and liver failure. It is very easy to diagnose hepatitis C with a simple blood test that any of your primary care doctors can order.

Joyce1: What is the average size of a liver in a middle-aged male who is 5' 9' tall and 170 lbs?

K.V._Narayanan_Menon,_MD: The liver is generally 10 to 12 cm in size.

Jbennett: How often are patients checked with general blood work since symptoms are rare?

K.V._Narayanan_Menon,_MD: If your question is about hepatitis C, a single test at one time point should suffice, unless you engage in activities that could predispose you to acquiring hepatitis C again.

Other Liver Disorders

jamesofoakton: What are the main causes of liver failure: alcohol, foods, other factors?

K.V._Narayanan_Menon,_MD: The main causes of chronic liver failure are alcohol, fatty liver disease, viral hepatitis and autoimmune liver disease.

erosenb2771: I have had a 1.5 cm right liver lobe hemangioma that is benign for 10 years. It appears stable on ultrasound and has so over the years. Do small liver hemangiomas ever go away on their own? Or do you have them for the rest of your life? I cannot find an answer to this anywhere and have received different answers from different health care providers. Most have said that small liver hemangiomas don't go away. How often should it be monitored, and should I do more than ultrasound (i.e., MRI) if it is stable?

K.V._Narayanan_Menon,_MD: Hemangiomas generally do not go away on their own, but may get smaller with time. If it has been stable for 10 years, I am not sure that this needs routine monitoring. However, you should discuss this with a qualified physician before stopping monitoring of your condition.

jamesofoakton: How does one protect themselves from a fatty liver disease?

K.V._Narayanan_Menon,_MD: Avoiding alcohol and staying at a healthy weight will help prevent fatty liver disease. It is also important to ensure that your lipids are normal, and that diabetes and blood pressure are well controlled.

MLL288: In diagnosing autoimmune hepatitis, what are the criteria that most doctors use?

K.V._Narayanan_Menon,_MD: Please refer to American Association for Study of Liver Diseases (AASLD) guidelines. There are many criteria used for the diagnosis of autoimmune liver disease that are dependent on the type of autoimmune liver disease that you may have. A liver biopsy may also be needed to diagnose this condition.

MoonX: I was diagnosed by ultrasound with non-alcoholic fatty liver disease, and my liver enzymes were fairly high. My ALT was 285 and my AST was 128. Are those enzyme levels typical in early-stage fatty liver disease, or do they seem higher than normal for this disease?

K.V._Narayanan_Menon,_MD: These seem slightly higher than normal for your condition. You will need a complete workup, which may include a liver biopsy before commenting further on your condition.

MoonX: In your experience with liver disease, specifically NAFLD, when the liver is normal size and shape, and there is no splenomegaly, just a diffuse increased echogenicity in the liver combined with high liver enzymes of ALT and AST, would this typically be considered the early stage of the disease? Or, because of the enzymes being four times higher than normal, would it more likely indicate a more advanced progression such as NASH (non-alcoholic streatohepatitis)? Thank you!

K.V._Narayanan_Menon,_MD: The key issue in fatty liver disease is to determine how much scaring there is in the liver irrespective of the degree of elevation of your liver enzymes and the size of the liver. This can only be determined by a specific blood test, imaging such as a Fibroscan or a liver biopsy. The degree of scaring will tell you how severely your liver is affected by the disease.

PBC MTFHR: Is PBC related to our liver toxicity and sensitivity to many medications, or is it the MTHFR gene that my daughters and I are heterogeneous positive for? If so, how do we treat rheumatic diseases when we've had steroid episodes, too?

K.V._Narayanan_Menon,_MD: PBC is an autoimmune condition and is more common in patients with other autoimmune diseases. PBC generally does not cause other autoimmune diseases. Symptoms from PBC are generally related to lack of bile flow and can result in itching and jaundice. Other late-stage manifestations of PBC include osteoporosis and symptoms related to cirrhosis of the liver. These could include fluid accumulation in the abdomen, bleeding from your gut and confusion.

PBC MTFHR: Is there a difference in fatty liver and fatty liver disease?

K.V._Narayanan_Menon,_MD: Fatty liver is the earliest stage of fatty liver disease, which can range from simple fatty liver to nonalcoholic steatohepatitis and cirrhosis. They generally fall under the umbrella of nonalcoholic fatty liver disease.

Personal Stories

govols123: I’m a 55-year-old male who was diagnosed with congestive hepatopathy in 2014. Severe tricuspid regurgitation (4+) was the cause and was corrected by tricuspid valve repair at Cleveland Clinic in late 2014. Current regurgitation is in the trace-to-mild range based on echocardiograms since surgery. Note that I had a Doppler ultrasound of the liver/spleen, an abdominal MRI and a CT scan of the abdomen at Cleveland Clinic in 2014 leading up to the diagnosis. All three showed a normal liver (except for the congestion from heart valve). A hepatologist redid all liver blood work and did an ultrasound a month ago, and everything is completely normal (borderline AST), but he still recommends a transjugular biopsy. My questions are:

  1. What is the likelihood of significant liver damage based on all the previous testing, and what is a possible benefit of having the biopsy (I drink minimal alcohol, no drugs, etc.)?
  2. Do probiotic supplements for the gut potentially protect from liver inflammation?
  3. Do milk thistle and coffee protect the liver?

K.V._Narayanan_Menon,_MD: 1) It is difficult to predict the degree of liver damage, and a liver biopsy may help clarify the situation. There is a newer test called a Fibroscan that may help. 2) We have no evidence to show that probiotic supplements for the gut protect from liver inflammation. 3) There is ongoing research about coffee and milk thistle in liver disease. There is no firm evidence that either protects the liver.

MLL288: Hello, doctor. My name is Michele. My liver enzymes in a recent blood test were normal. However, my ASMA came up positive at a recent visit to my primary care doctor. She took the test to see if it would still be positive, as it was 14 years ago. The current results are 92 units for F-Actin. I had just had a colonoscopy screening a couple of weeks before that and was diagnosed with lymphocytic colitis. The GI doctor wanted me to do a follow-up visit, which I did just last week. He saw the results of the positive ASMA on my chart and decided to do more antibody tests. Results are: ANA – negative, AMA -- positive. Can you please tell me a little bit about AIH and PBC, as that is what I was told this could signify? I have an appointment for an ultrasound next week that my GI ordered. Also, in 2002 I was told my liver was slightly enlarged, 16 cm, I believe.

K.V._Narayanan_Menon,_MD: AIH and PBC both fall under the broad umbrella of autoimmune liver disease. It is possible that you have an overlap condition. Your case is fairly complicated; you should consider scheduling an appointment at Cleveland Clinic for a complete examination.

Mdsmith9: I have cirrhosis from NAFLD and PCOS. I was misdiagnosed and got a second opinion and had a second review of my liver biopsy, where it was found I had cirrhosis at 36. I'm now 42. I made a lot of lifestyle changes and dramatically slowed the progression, but have not been successful in managing the symptoms of splenomegaly, pancreatitis, SOD or cirrhosis with hepatic encephalopathy. It’s been seven years since my diagnosis, and my enzymes look great, but my blood platelets and blood counts are all off. I have low B12, anemia, pain, HE and chronic issues from side effects that really affect my quality of life. So while I slowed the progression I’m not eligible for transplant as my Meld is a 9-10, but I feel worse than ever. How can we better cope with the symptoms? I wonder if I would have gotten a new liver by now and feeling so much better had I not made the lifestyle changes. I did know the risks of transplantation. I question if there is medical benefit to milk thistle and its risk with being approved for transplantation. Thanks.

K.V._Narayanan_Menon,_MD: There is no evidence that milk thistle will help with liver disease at your stage. Your case is complicated, and it is difficult for me to give an opinion without reviewing the details of your medical history. Please consider making an appointment. To find a specialist for your needs, please call 216.444.7000.

cbone: My liver is fatty, enlarged and inflamed. It measured just over 20cm on the ultrasound. My liver enzymes were elevated, but my triglycerides were normal. During the mitochondrial AB test, it came with a weak positive. Should I be concerned about this?

K.V._Narayanan_Menon,_MD: You should see a liver specialist for further evaluation of your condition. The weakly positive mitochondrial antibody test should be evaluated further. Please consider making an appointment at Cleveland Clinic.

Mdsmith9: Do you have any recommendations for when you must survive chronic pain from pancreatitis and sphincter of oddi dysfunction, splenomegaly and cirrhosis. My primary care physician prescribed me Oxy30 mg a day every six hours as needed and 75 mg of Fetanyl. The pain is from severe pancreatitis and sphincter of oddi, Type 2 diabetes, spinal stenosis and degenerative disc disease. My hepatologist wants to take me off my pain medications, but my PCP and team feel that I would be worse mentally as the pain is so intense. Have you found a way to manage pain, HE and cirrhosis without such strong narcotics?

K.V._Narayanan_Menon,_MD: Unfortunately, no. It is difficult to manage pain in patients with severe cirrhosis, and a lot of people with chronic pain may need to be on narcotics. However, your case is complicated. Please feel free to schedule an appointment.

Specific Situations

truedly: Could a bleeding duodenal ulcer that led to hemorrhagic shock and massive transfusions result in ascites near the pancreas and liver, pancreatic cysts and inflammation of the pancreas, and liver biopsy findings (nine months after the ulcer surgery) of " cholestatic changes of uncertain specific etiology, but possibly related to extrahepatic obstruction with periportal and early septal fibrosis on trichrome stain. There is no evidence of autoimmune hepatitis." Is it likely all this is related, or is it separate problems? There have been lots of tests, and they don't seem near a diagnosis. How serious is this? Does it sound treatable?

K.V._Narayanan_Menon,_MD: It is possible that inflammation of the pancreas could cause constriction of the bile duct resulting in cholestatic changes in the liver biopsy. However, this is a complicated issue. Please consider scheduling an appointment.

Joyce1: My adult son Wayne (39 years of age), had hepatitis B (detected at age 18) which was asymptomatic for many years. Later (at around 30), nodules appeared on his scarred liver and he developed cirrhosis. Two weeks ago, a 3cm cancer was detected (by MRI) on one of these nodules. It is to be removed by laparoscopy in approximately two weeks at our cancer hospital in Toronto. Two other specialists told me that a liver transplant would ultimately be necessary. Wayne is adamant that he won't go this route because of the anti-rejection drugs' side effects. Can you give me an idea what the side effects might be and how debilitating they make one feel? I was told that only five drugs have to be taken after a liver transplant, and they basically suppress the immune system. Would this possibly be correct? Most of what I've written is hearsay, so please correct me. Thanks in advance for your response Dr. Menon.

K.V._Narayanan_Menon,_MD: Patients on anti-rejection medication can live a fairly normal life. The main long-term side effects are the risk of renal failure in a small proportion of patients and the development of cancers. However, the risks of a transplant must be weighed against the risk of recurrent cancer and death. Patients are generally only on one immunosuppressive agent after a transplant; however, this is a complicated issue. Please feel free to schedule an appointment in the Liver Tumor Clinic. To reach the Liver Tumor Clinic, please call 216.445.8389 or 800.223.2273, ext. 58389.

Matters of Medication

TeresaRN: Have you heard of recommending Harvoni to women, who are pregnant and hepatitis C positive, to prevent vertical transmission?

K.V._Narayanan_Menon,_MD: No. Harvoni is a new drug, and there is not enough evidence to say that it is safe for use by pregnant women.

leonafricain1: I would like to know what is a long-term medication (glucophage and zyloric ) on the liver.

K.V._Narayanan_Menon,_MD: Glucophage is generally thought to have no effects on the liver. Zyloric can occasionally cause elevated liver enzymes. This should be monitored by your physician.

jamesofoakton: What foods and over-the-counter drugs should be avoided? What foods are good for the liver?

K.V._Narayanan_Menon,_MD: In general, leading a healthy lifestyle and avoiding alcohol are good for the liver. A number of medications can affect the liver, but it would be important to discuss these with your doctor before starting any medication. Although there are recognized side effects of certain medications, all drugs have the possibility of idiosyncratic or individualistic liver injury.

PBC MTFHR: Do PBC patients or any other have hepatic encephalopathy without any morphological cirrhosis? If not, why does Xifaxin improve cognitive issues?

K.V._Narayanan_Menon,_MD: You can rarely get hepatic encephalopathy without cirrhosis. The exact mechanism of action of Xifaxin is not known, and it may explain why it does not improve some of the cognitive issues associated with hepatic encephalopathy.

marika111: I had hepatitis C for close to 45 years. Harvoni worked for me. Does this change the probability of HCC for me, and if it does, then to what extent?

K.V._Narayanan_Menon,_MD: Your risk of developing HCC, or liver cancer, depends on the degree of scaring or fibrosis in your liver. This should be determined before making an assumption about your risk of developing HCC. The degree of fibrosis or scaring can be determined by either a liver biopsy or a Fibroscan test.

Diagnosis and Treatment

MLL288: Why are autoimmune diseases of the liver so hard to diagnose?

K.V._Narayanan_Menon,_MD: Autoimmune liver diseases generally do not have a specific diagnostic test and are diagnosed on the basis of laboratory testing, radiology and pathological data. It could also depend on the type of autoimmune liver disease you have.

llongan: What is the best treatment for fatty liver disease, and is it possible to cure?

K.V._Narayanan_Menon,_MD: The best treatment for fatty liver disease is weight loss; this eliminates the fat from the liver.

MarielCarr: What are your thoughts on split liver transplants from deceased donors? I know it is riskier, but if it is perfected, the "two-fer" transplant helps reduce the liver waiting list, especially for pediatric patients.

K.V._Narayanan_Menon,_MD: Split liver transplants are possible only if the donor and the recipient fulfill certain conditions, such as size match, and have the right anatomy for the split.

Jbennett: If diagnosed early enough and treated, will you need to continually take medication, and will symptoms eventually present or remain absent with medication treatment?

K.V._Narayanan_Menon,_MD: I presume you are asking about hepatitis C. The treatment for hepatitis C is a standard course of medication taken for three to six months. There is no need to continue treatment after that.

leslie222: The primary endpoint is SVR12 after the completion of treatment. Have there been any studies looking beyond 12 weeks after successful treatment, e.g.SVR24?

K.V._Narayanan_Menon,_MD: SVR24 was the traditional time point to determine a cure, and we use SVR12 now. SVR12 means that hepatitis C is undetectable for twelve or more weeks after completing treatment.

jamesofoakton: What is the success rate for liver transplants?

K.V._Narayanan_Menon,_MD: The one-year survival rate is about 90 percent. The five-year survival rate is approximately 80 percent to 85 percent. Please refer to the UNOS website if you need further information.

dalala3: Are there any innovations in hepatitis C treatment?

K.V._Narayanan_Menon,_MD: There are new drugs being approved by the FDA on a fairly regular basis. Please refer to the American Association for Study of Liver Diseases (AASLD) for further information,

PBC MTFHR: Can imaging and labs only diagnosed cirrhosis?

K.V._Narayanan_Menon,_MD: The diagnosis of cirrhosis is generally made by imaging or liver biopsy.

MLL288: Is a liver biopsy painful?

K.V._Narayanan_Menon,_MD: Sometimes there is a bit of pain after the biopsy. This can easily be treated with medication.

The Future and Follow-up

PBC MTFHR: What is the general follow-up protocol for monitoring PBC?

K.V._Narayanan_Menon,_MD: Depending on the stage of PBC, you should have liver enzymes and imaging done every six to 12 months.

TammyCope: My husband was diagnosed with hepatitis C several years ago. He was treated with Interferon and Ribaviran and avoided alcohol for the entire treatment. He was retested and deemed "cured" at the termination of the treatment. He socially drinks beer presently, approximately three to four days per week, two to three beers per episode. His PCP annually checks his liver enzyme levels, and they remain within normal levels. Are there any concerns about this amount of alcohol consumption for a man with a history of hepatitis C but is now considered "cured?" And is there anything we need to be cautious about with regard to his lifestyle in order to avoid a reoccurrence of hepatitis C?

K.V._Narayanan_Menon,_MD: We would not recommend alcohol use. It would be important to know the degree of fibrosis, or scarring, in the liver before making any further recommendations. Hepatitis C is transmitted through use of recreational drugs and unprotected sex.

MLL288: What is the survival rate for hepatitis C and other liver diseases if left untreated?

K.V._Narayanan_Menon,_MD: Survival rates are variable and depend on the stage of scarring or fibrosis in your liver. The prognosis is poorer if you have advanced fibrosis (or scarring).

Sammy566: Does the spleen return to normal size, post-transplant?

K.V._Narayanan_Menon,_MD: The spleen generally gets smaller, but may not return to normal size after a transplant.

PBC MTFHR: Is cirrhosis reversible? At what point, or is that tissue dead?

K.V._Narayanan_Menon,_MD: In general, cirrhosis is not thought to be reversible; however, the liver can function for many years, even in the presence of cirrhosis. In rare conditions such as hepatitis B, successful treatment can result in reversal of the cirrhosis.


That is all the time we have for questions today. Thank you, Dr. Menon, for taking time to educate us about liver disease.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at

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Cleveland Clinic

At Cleveland Clinic’s Mikati Center for Liver Diseases, our team has the experience and expertise to accurately diagnose and offer world class treatments for all forms of liver disease, including viral hepatitis, fatty liver, alcoholic liver disease, autoimmune liver diseases, genetic liver diseases and liver cancer. The Center‘s mission is to sustain and improve the lives of those with liver diseases through advances in research, innovation and education. Our physicians are not only skilled clinicians, they are actively involved in both clinical and translational research projects as well as educational programs in our community and across the nation.

More than 100 types of liver disease have been identified. Their common feature is that they all involve damage to the liver that disturbs its ability to function normally. The staff of the Mikati Center is well-versed in new, innovative and comprehensive therapies for any stage of liver disease and brings together all specialists in one setting to help create an individualized treatment plan for each patient.

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