Bringing Awareness to Liver Diseases
Viral hepatitis. Fatty liver. Cirrhosis. At Cleveland Clinic, patients with these conditions are treated at the Mikati Center for Liver Diseases, which was established to sustain and improve the lives of those with liver diseases through advances in research, innovation, and education. Christina Lindenmeyer, MD joins Butts & Guts to discuss symptoms and treatment plans for these and other liver diseases.
Bringing Awareness to Liver Diseases
Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Hi again everybody and welcome to another episode of Butts & Guts.
I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at Cleveland Clinic in beautiful Cleveland, Ohio, and today we're very pleased to have Dr. Christina Lindenmeyer, who's a physician in the department of gastroenterology, hepatology, and nutrition in the Cleveland Clinic's Digestive Disease & Surgery Institute. She's an assistant professor of medicine at the Cleveland Clinic Lerner College of Medicine, and is also the co-director of the medical intensive liver unit. Christina, thanks for joining us on Butts & Guts.
Christina Lindenmeyer: Thank you for having me. Pleasure to be here.
Scott Steele: So today we're going to talk about liver disease, and there's a lot of different diseases that can happen in the liver. To kind of set the stage, these diseases that affect our liver, at Cleveland Clinic, patients are treated at the Mikati Center for Liver Diseases, and if I'm right, it was established initially with a mission to sustain and improve the lives of those who have liver diseases through advances in research and innovation and education. So with that kind of as a background, we're going to touch on a lot of different stuff, but I like to with all of the people that we have here on the Butts & Guts, first tell us a little bit about yourself, where you were from, where'd you train, and how did it come to the point that you are here at the Cleveland Clinic?
Christina Lindenmeyer: Well sure. Well, I'm actually from outside Philadelphia, Pennsylvania. I spent my younger years there, went to college in Pennsylvania at Penn State. I trained, I did medical school and residency training in Philadelphia, and then I came out to Cleveland to do my gastroenterology, hepatology, and transplant hepatology fellowships, and this is my second year on his staff.
Scott Steele: Oh, fantastic, and we're so glad that you're here. So if I've done my math right, there's more than a hundred types of liver disease that patients can have, but today we're going to talk a little bit about the most common one. So let's first play a little bit of game of kind of truth or myth with each of these, okay? So within the background, viral hepatitis, a common one right there. So what is it and what's the difference between A and B and C and these different ones?
Christina Lindenmeyer: Sure. So there are many different kinds of viral hepatitis. So hepatitis A, B, and C are probably the most common ones that you'll hear of on the streets. The most commonly communicable one is actually hepatitis A, and hepatitis A is a foodborne illness that you can contract. It's a fecal oral route, and you commonly transmitted it by food that you can buy at grocery stores or even at restaurants. It's only an acute illness, meaning that it's an infection that you can get that will cause a self-limited course of disease. It does not develop crenicity and it cannot form chronic liver disease, but very common. We unfortunately have no treatment for it other than just supportive care, but there is a vaccine against it so it's easily preventable by being vaccinated.
Scott Steele: And B?
Christina Lindenmeyer: B is born by the blood and is less common in the United States. It's certainly more common in other regions of the world. Here the prevalence is less than 2% in the United States. The prevalence has dropped significantly since developing a push towards a vaccine program and babies are now vaccinated. So it's uncommon to get, especially as an adult. The majority of people in the United States who have hepatitis B are patients who were born outside of the United States and who now live here.
Scott Steele: C?
Christina Lindenmeyer: C is an important virus to know about and is a hot topic in that we have new treatments for it and it is now newly curable. So hepatitis C has been around for a long time. We initially called it non-A, non-B, viral hepatitis, but now we have a name for it and we know that there are six different strains of hepatitis C in the globe. All strains are now treatable. Like hepatitis B, it's also born by the blood, and so commonly communicated by sharing needles or any kind of blood exposure with an infected individual. As I mentioned, we have new medications that make this virus very easily treatable, but unlike hepatitis A and B, there is no vaccine against the disease. So the only way to prevent getting hepatitis C is to prevent exposure to the virus.
Scott Steele: So you beat me to the punch on a couple of my truth or myths, but let's talk about this first one. So truth or myth, you can spread hepatitis to others through casual contact?
Christina Lindenmeyer: Truth.
Scott Steele: And which one of those again is one of the ones that is the more common one for that?
Christina Lindenmeyer: So through casual contact, so not blood exposure would be hepatitis A. So not washing your hands and potentially putting your hands near your mouth, you could easily spread hepatitis A from one individual to another.
Scott Steele: And this is more for our listeners out there with short term memory, truth or myth. Hepatitis A, B, and C can be prevented by vaccination.
Christina Lindenmeyer: Unfortunately, that's a false statement. Hepatitis C cannot be prevented by vaccine.
Scott Steele: Very interesting what you talked about in terms of this, my take home, not obviously being a hepatologist or having a lot of this background, is that we've come a long way towards dealing with these, first identifying and seeing exactly what they are and then dealing and treating these ones. So what are the treatment options for all of them? You mentioned a little bit that they're treatable. What is it?
Christina Lindenmeyer: So hepatitis A, we don't have a direct acting antiviral agent against hepatitis A. It's typically a self-limited course of disease and will resolve just with time. There are a small proportion of patients who can get quite ill with hepatitis A, especially if you have underlying liver disease and contract hepatitis A on top of it, and in those cases in rare forms a liver transplant may be needed for acute liver failure from hepatitis A.
Hepatitis B, unfortunately is not curable as yet, although there is certainly a lot of research in this area, and this is certainly a global initiative and a priority that's been made even towards pushing towards the elimination of hepatitis B globally by 2030. We do have medications that can control the disease, that can suppress the virus from replicating and can help prevent spread from one individual to another, but overall it is not curable.
Hepatitis C has been truly a revelation. We've had medications for a long time, for decades for the virus that had been very poorly tolerated, that have terrible side effects, but in the last five to 10 years, we've developed a new cohort of medications that are very well tolerated and the cure rates are very high.
Scott Steele: So another truth or myth, something that comes out of the pop culture type magazines, when you read about the fact that some celebrity here got a viral hepatitis or chronic hepatitis associated with a tattoo, that's common. Truth or myth.
Christina Lindenmeyer: That is common. True.
Scott Steele: So how does that occur? What occurs in that particular one? So obviously we're in a little bit of a tattoo culture now where a lot of people have tattoos. How common is that? Is that something that we need to worry about or is it investigating the particular place that you go?
Christina Lindenmeyer: I think it's important to be aware of. So we're probably talking about hepatitis C here, because hepatitis C is much more common than hepatitis B, although both you can contract from blood exposure, which would include a tattoo. Now I'll say this is much less common than it used to be. The majority of viral hepatitis exposures that we see from tattoos are not done in reputable tattoo parlors. They're typically done at home, at tattoo parties, or even when patients are incarcerated, for example. When needles are not appropriately sterilized or cleaned, that's when we see the transmission of the virus.
Scott Steele: Can somebody have hepatitis and not know that they have it and just be a chronic carrier their whole lives?
Christina Lindenmeyer: Absolutely. So that's been the major problem. That's why hepatitis C has been so common in the country. Typically it's asymptomatic when you first contract the virus and it can take 10 to 20 years to develop any significant long-term chronic liver disease from the virus, and up until that point, patients are typically feeling pretty well and asymptomatic.
Scott Steele: So we're talking a little bit about hepatitis, but what about autoimmune hepatitis? Is that similar or different than the others?
Christina Lindenmeyer: So autoimmune hepatitis can behave similarly to viral hepatitis, but is a completely different form of inflammation of the liver in the body. So autoimmune hepatitis, unlike a virus cause is caused by antibodies in the body that attack the liver and cause inflammation and in the long-term can cause scar tissue in the liver.
Scott Steele: And also kind of along with that, can medications cause hepatitis?
Christina Lindenmeyer: Medications can cause hepatitis. So drug induced liver injury is an important cause of liver disease, and in fact certain medications can also cause autoimmune hepatitis.
Scott Steele: So you can have hepatitis that is "treatable," but it can still have long lasting effects on the liver. So is there a chronicity or an aftereffect of developing hepatitis, or can your body completely clear it and have normal liver function?
Christina Lindenmeyer: Absolutely. So that depends on where you're treating the hepatitis in the course of disease. So you mentioned that many patients with viral hepatitis feel fine and are asymptomatic. So often patients that we see in the clinic will have had hepatitis C for 10 or 20 years before it's diagnosed, and by that point patients may have significant scar tissue or inflammation. We certainly try our best to treat the virus at that point, but they may have already developed long-term chronic liver disease that will continue to need to be managed despite treating the hepatitis.
Scott Steele: So we're going to switch gears now and talk about something that's kind of out there, and especially within maybe some of the lay press, and they talk about fatty liver disease. What is fatty liver disease, and how would a patient know symptom wise that they may have it?
Christina Lindenmeyer: So there are two forms of fatty liver disease overall, alcohol-related fatty liver disease and non-alcohol related fatty liver disease. Non-alcohol related fatty liver disease is now the most common form of liver disease in the country and is the leading indication for needing a liver transplant. Fatty liver disease that's related to the metabolic syndrome or non-alcohol related fatty liver disease is commonly asymptomatic, until in the advanced stages where there's significant inflammation and scar tissue. So patients typically feel very well. On the other hand, when patients have fatty liver disease related to alcohol, those patients may feel quite unwell and in a severe inflammatory event of the liver related to alcohol, patients may develop acute symptoms including bleeding and turning yellow and even fluid in their abdomen.
Scott Steele: So truth or myth, fatty liver disease can be caused by a weekend of binge drinking?
I would say myth. One isolated weekend of binge drinking will not cause fatty liver disease.
Scott Steele: So what degree of alcohol consumption? I mean I know that obviously there's people out there, we talk on one hand that it's good to have a glass of red wine and you hear all these different things in there, but are we really talking about alcoholics, or are certain people more prone to potentially their reaction to alcohol that might result in fatty liver disease?
Christina Lindenmeyer: So overall fatty liver disease related to alcohol is associated with an excess intake of alcohol, and we think that there probably is a genetic predisposition to developing chronic liver disease or even acute liver disease related to alcohol that we don't fully understand. However, in general, it's recommended that women drink no more than one drink per day or on average seven drinks per week and that men drink no more than two drinks per day or 14 drinks per week. Anything more than that theoretically would place you at risk for developing fatty liver disease related to alcohol.
Scott Steele: Another truth or myth, fatty liver disease can be treated without medication and really only changes with lifestyle habit changes.
Christina Lindenmeyer: I would say true, and I would say that that is true in both kinds of fatty liver disease. So in alcohol related fatty liver disease, stopping alcohol intake. The liver is actually quite resilient and can regenerate to a high degree, and so stopping alcohol intake can actually reverse scar tissue inflammation and fat in the liver. The same is true for non alcohol-related fatty liver disease. This is the liver disease that's related to the metabolic syndrome, so impaired fasting glucose or diabetes, carrying your weight in your abdomen, and altered cholesterol panels which include a high triglyceride level or a low good cholesterol level cause what's called the metabolic syndrome, which causes fatty liver disease. Control of these factors, weight loss and a healthy diet also can reverse scar tissue inflammation and fat in the liver.
Scott Steele: So the patients that have essentially morbid obesity or are classified as that, do they always have fatty liver disease?
Christina Lindenmeyer: No, and this is part of the reason we also don't fully understand non-alcohol related fatty liver disease. There are cohorts of patients that are obese and have all of these risk factors and for some reason never develop fatty liver disease, whereas there are patients who may just have mild obesity, centripetal adiposity where they just carry their weight more in their abdomen than other parts in their body and may have only three of the five risk factors for metabolic syndrome, and for some reason those patients develop chronic liver disease and even cirrhosis.
Scott Steele: So let's switch gears one more time and talk a little bit about something that most people have heard of, and that's cirrhosis. So what's the difference between fatty liver disease and cirrhosis, or hepatitis and cirrhosis?
Christina Lindenmeyer: So all forms of liver disease are really a spectrum of disease. Viral hepatitis just means that there's some kind of inflammation in the liver, and just like if you were to cut your skin, it heals with some kind of inflammation and eventually scar. The same happens in the liver. So any kind of chronic inflammatory event, including a viral hepatitis or fatty liver disease over time can cause chronic inflammation and scar tissue, and the end stage of the scar tissue formation is called cirrhosis.
Scott Steele: So how long can somebody have these inflammatory conditions before it leads to cirrhosis? Or is it left untreated, the natural progression of cirrhosis? Or how does this all occur?
Christina Lindenmeyer: So in viral hepatitis, it can take decades to develop cirrhosis, so 10 to 20 years, whereas in patients who have more acute insults, very severe inflammation like autoimmune hepatitis, drug induced liver injury, unfortunately a proportion of those patients will heal after a sudden event with cirrhosis very quickly.
Scott Steele: How would I know if I have cirrhosis? What are some signs and symptoms, and then what are the manifestations and how does that play into a person's overall health?
Christina Lindenmeyer: So just as the spectrum of liver disease with viral hepatitis and fatty liver is a spectrum and kind of a rainbow of disease, cirrhosis in and of itself is a spectrum. So patients can have cirrhosis and be very well compensated and actually asymptomatic. Majority of patients who have cirrhosis and are compensated will have some mild symptoms. They may feel fatigued and just overall unwell. As the cirrhosis progresses, you can develop what's called decompensation, where the liver develops failure or a high pressure system in the liver called portal hypertension. At the end stage of disease or at the end of the spectrum, patients may develop severe symptoms including bleeding from dilated veins, fluid in the abdomen or in the legs, confusion unrelated to liver disease, or even liver cancer.
Scott Steele: Yeah, I've heard it say that deliver kind of is the toxin cleaner of the body, and the patients that have cirrhosis, are they able to do that as effectively?
Christina Lindenmeyer: Certainly not. So at the end stage, when the liver is not functioning as well and the liver cells aren't able to do their jobs, the liver is kind of like the trashcan of the body. It filters all the of the blood from the body and the abdomen and the legs, it flows through the liver back to the heart, and so it's the liver's job to clear many of the toxins in conjunction with the kidney. So if the liver isn't working well, it isn't able to clear these toxins. These toxins can build up and lead to confusion.
Scott Steele: Truth or myth, a patient with cirrhosis should not undergo surgery.
Christina Lindenmeyer: That's a myth. I think, again, cirrhosis is a spectrum of disease. So certainly when patients have long-term cirrhosis and portal hypertension or a high pressure system through the liver, that can cause problems with dilated veins in the abdomen or elsewhere in the body, and so the decision to have any kind of major surgery should be done as part of a multidisciplinary team. We have certain risk factors or risk stratification scoring systems to help decide how safe it is to have surgery with cirrhosis.
Scott Steele: And I think you answered this one in part, but just to kind of clear it up, truth or myth, even when diagnosed with cirrhosis, the liver can heal itself over time.
Christina Lindenmeyer: I would say that that is a difficult one to answer. It's probably a truth. So there are some forms of mild liver disease. So autoimmune hepatitis, if treated in those patients with cirrhosis, we may see an improvement overall in the long-term and the degree of scar tissue, and there is some recent evidence that suggests that patients with fatty liver disease, if they remove or control their metabolic risk factors that cirrhosis or scar tissue may improve.
Scott Steele: So walk me through, I'm a patient with liver disease that's going to come and see you in clinic. What can a patient expect during that clinic visit?
Christina Lindenmeyer: So diagnosing the form of liver disease or the cause of liver disease is the most important part, especially of an initial office visit, and an office visit will involve a very thorough history taking to identify risk factors associated with acute and chronic liver diseases. We have a new system in the office that we offer in our liver clinic, something called a fibro scan, which can be done in the office the same day as your appointment as long as patients are fasting, and this scan can effectively tell us how much scar tissue or fat is in the liver, which is also an important part of our diagnosis and management planning.
Scott Steele: Do they have to get any invasive tests or biopsies or anything like that as a part of this workup?
Christina Lindenmeyer: So after a good history is taken, we'll likely recommend a series of blood tests which can help identify whether a patient is viral hepatitis or non-alcohol related fatty liver disease or autoimmune causes of chronic liver disease. Ultrasounds or other contrast enhanced imaging will probably be recommended as a way to further evaluate the shape and size of the liver as well as the vasculature that supplies the liver. If the blood tests and imaging does not suggest what the cause of liver disease is, then frequently a liver biopsy would be the next step.
Scott Steele: So I know this is hard to tell, especially as you've kind of pointed out that there's a giant spectrum, but if you start to manage my liver disease, how quickly could I potentially see, given that I'm not necessarily symptomatic, but I'm also not dying of liver failure, how quickly can we see some turnaround in the physiology of all this? Is it weeks? Is it months? Is it years? How does that process work out?
Christina Lindenmeyer: Unfortunately for most of these liver diseases, the turnaround can be slow. The development of inflammation and scar tissue in the first place is a slow process, and so the reversal of the physiology can also be a slow one. However, in patients who have well compensated liver disease and hepatitis C, patients may feel well as soon as when they finish treatment, and treatment courses are typically eight to 12 weeks. So it could be months, but in most patients, especially with alcohol or fatty liver disease related liver disease, it can take years to feel better.
Scott Steele: So what's on the horizon as far as liver disease research to help combat or improve these patients' quality of life, or treatment process and the type of conditions that we've already discussed?
Christina Lindenmeyer: So now that we've kind of conquered hepatitis C and we have medications that can cure the virus with a very high cure rate, hepatitis B and fatty liver disease are probably the two most important areas of liver disease that are where we have targeted research. With the metabolic syndrome being so prevalent in the country and fatty liver disease now being the leading indication for liver transplant, there are a lot of drugs that are coming down the pipeline looking at reducing inflammation and scar tissue, and then the same for hepatitis B. We have medications to control the virus, not yet a cure, but we have drugs coming down the pipeline that could eventually affect a cure in the next five to 10 years.
Scott Steele: That's fantastic. So what are some final take home messages for our listeners out there?
Christina Lindenmeyer: So fatty liver disease is certainly the leading cause of liver disease. With the metabolic syndrome being so common, it's important to live a healthy lifestyle, control your weight, control metabolic risk factors, drink alcohol is okay, but to a moderate degree, and then finally with any concerning symptoms, including turning yellow or after having been exposed to someone with chronic liver disease, it's important to seek medical care.
Scott Steele: So we always like to wind up with our guests a couple of quick hitters. So to get to know you a little bit better, what's your favorite food?
Christina Lindenmeyer: My favorite food is probably macaroni and cheese.
Scott Steele: Fantastic. The Kraft in the box or this fancy stuff?
Christina Lindenmeyer: Fancy stuff.
Scott Steele: Oh, that's too bad, and so what's your favorite sport?
Christina Lindenmeyer: Lacrosse. I played in college.
Scott Steele: And is that also to watch or is that just the play?
Christina Lindenmeyer: Also to watch.
Scott Steele: And so what's the last nonmedical book that you've read?
Christina Lindenmeyer: Oh, that's a tough ... actually I think it was When Breath Becomes Air, which was an eye-opening book, especially as we opened our medical intensive liver unit here. It was an important book for us to read.
Scott Steele: Yeah, I think that's the second or third person that said that one, and then finally tell our listeners what's something that you enjoy about living here in beautiful Cleveland, Ohio?
Christina Lindenmeyer: What I love about living here in beautiful Cleveland, Ohio... well I live in an area of the city that's very close to some lakes and has some good running trails. So that's an important part of my daily practice actually. So being able to run outside, even on a yearly basis with some good sidewalks and good trails around is an important part of what makes me happy here.
Scott Steele: Couldn't agree with you more. So for more information on liver disease treatment, research, and innovations, please visit clevelandclinic.org/liver. That's clevelandclinic.org/liver, that’s L-I-V-E-R, and to speak with a specialist in the Digestive Disease & Surgery Institute, please call 216.444.7000. That's 216.444.7000. Christina, thanks so much for joining us on Butts & Guts.
Christina Lindenmeyer: Thank you for having me.
Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.