Fatty Liver and Cirrhosis

Fatty Liver – This One’s Personal

 

Dear Reader,

This is a disease that upsets me deeply, as it is the one which took my Mom.  Until the time of her diagnosis, the only thing I “knew” about cirrhosis was that it was a disease which only affected alcoholics and drug abusers.  I was so wrong.

 

There are, in fact, several paths to liver disease, which I will cover in a separate post.  In my Mom’s case, her cirrhosis developed as a progression from NASH or Nonalcoholic steatohepatitis.  It is also called NAFL (non alcoholic fatty liver), or simply Fatty Liver.

 

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NASH is a common, often “silent” liver disease. It resembles alcoholic liver disease, but occurs in people who drink little or no alcohol. The major feature in NASH is fat in the liver, along with inflammation and damage. Most people with NASH feel well and are not aware that they have a liver problem.

 

Nevertheless, NASH can be severe and can lead to cirrhosis, in which the liver is permanently damaged and scarred and no longer able to work properly.

 

Although having fat in the liver is not normal, by itself it probably causes little harm or permanent damage. If fat is suspected based on blood test results or scans of the liver, this problem is called nonalcoholic fatty liver disease (NAFLD). If a liver biopsy is performed in this case, it will show that some people have NASH while others have simple fatty liver.

 

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NASH is usually a silent disease with few or no symptoms. Patients generally feel well in the early stages and only begin to have symptoms—such as fatigue, weight loss, and weakness—once the disease is more advanced or cirrhosis develops.

 

The progression of NASH can take years, even decades. The process can stop and, in some cases, reverse on its own without specific therapy. Or NASH can slowly worsen, causing scarring or “fibrosis” to appear and accumulate in the liver.

 

As fibrosis worsens, cirrhosis develops; the liver becomes seriously scarred, hardened, and unable to function normally.

 

Not every person with NASH develops cirrhosis, but once serious scarring or cirrhosis is present, few treatments can halt the progression. A person with cirrhosis experiences fluid retention, muscle wasting, bleeding from the intestines, and liver failure.

 

Liver transplantation is the only treatment for advanced cirrhosis with liver failure, and transplantation is increasingly performed in people with NASH.

 

Although NASH has become more common, its underlying cause is still not clear. It most often occurs in persons who are middle-aged and overweight or obese.

 

See Alarming New Liver Statistics

 

Many patients with NASH have elevated blood lipids, such as cholesterol and triglycerides, and many have diabetes or pre-diabetes, but not every obese person or every patient with diabetes has NASH.

 

Furthermore, some patients with NASH are not obese, do not have diabetes, and have normal blood cholesterol and lipids. NASH can occur without any apparent risk factor and can even occur in children. Thus, NASH is not simply obesity that affects the liver.

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My Mom was 73, and had most of the risk factors for NASH, including age, obesity, sedentary lifestyle, insulin resistance and high triglycerides.  Doctors see NASH often, and usually call it “Fatty Liver.” 

Perhaps because it is fairly commonplace, it seems that most physicians don’t adequately impress on the patient the need to make the necessary lifestyle changes to reverse the condition before it potentially progresses to non-reversible cirrhosis of the liver.

 

Fatty Liver can be potentially reversed by weight reduction (if overweight), activity and healthy diet, and avoiding alcohol and unnecessary medications.  Most importantly, a major attempt should be made to lower body weight into the healthy range. Weight loss can improve liver tests in patients with NASH and may reverse the disease.

 

These are standard recommendations, but they can absolutely make a difference. They are also helpful for other conditions, such as heart disease, diabetes, and high cholesterol.

 

People with NASH often have other medical conditions, such as diabetes, high blood pressure, or elevated cholesterol. These conditions should be treated with medication and adequately controlled; having NASH or elevated liver enzymes should not lead people to avoid treating these other conditions.

 

Experimental approaches under evaluation in patients with NASH include antioxidants, such as vitamin E, selenium, and betaine. These medications act by reducing the oxidative stress that appears to increase inside the liver in patients with NASH. Whether these substances actually help treat the disease is not known, but the results of clinical trials should become available in the next few years.

 

Over time, more research will help physicians to better understand the liver injury found in this disease. When the pathways that lead to the injury are fully known, safe and effective means can be developed and used along with lifestyle changes to reverse these pathways and help patients with NASH. Recent breakthroughs in mapping the human genome and uncovering the individual steps by which insulin and other hormones regulate blood glucose and fat could provide the necessary clues.

 

My Mom was told that she had fatty liver by her doctor many years ago, but that information was accompanied by only the advice to lose some weight.  It haunts me to think that the disease could have been reversed if she had been warned of the potentially fatal consequences of ignoring it.  I wish somebody had frightened her into changing her lifestyle when it could have made a difference in her future outcome.

It is a sad thought, indeed, that I lost my Mom to a lifestyle disease which could have been prevented or reversed.

 

 

Please share your thoughts or experience with liver issues in the comment section below.

 

 

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Coping With Grief (And What I Did)

How I Coped With Grief

 

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Coping with the loss of a close friend or family member may be one of the hardest challenges that many of us face. When we lose a spouse, sibling or parent our grief can be particularly intense. Loss is understood as a natural part of life, but we can still be overcome by shock and confusion, leading to prolonged periods of sadness or depression.

 

The sadness typically diminishes in intensity as time passes, but grieving is an important process in order to overcome these feelings and continue to embrace the time you had with your loved one.

 

Everyone reacts differently to death and employs personal coping mechanisms for grief. Research shows that most people can recover from loss on their own through the passage of time if they have social support and healthy habits. It may take months or a year to come to terms with a loss. There is no “normal” time period for someone to grieve. Don’t expect to pass through phases of grief either, as new research suggests that most people do not go through stages as progressive steps.

 

If your relationship with the deceased was difficult, this will also add another dimension to the grieving process. It may take some time and thought before you are able to look back on the relationship and adjust to the loss.

 

Human beings are naturally resilient, considering most of us can endure loss and then continue on with our own lives. But some people may struggle with grief for longer periods of time and feel unable to carry out daily activities. Those with severe grief may be experiencing complicated grief.  These individuals could benefit from the help of a psychologist or another licensed mental health professional with a specialization in grief.

 

 

Moving on With Life

 

Mourning the loss of a close friend or relative takes time, but research tells us that it can also be the catalyst for a renewed sense of meaning that offers purpose and direction to life.

 

Grieving individuals may find it useful to use some of the following strategies to help come to terms with loss:

 

Talk about the death of your loved one with friends and colleagues in order to understand what happened and remember your friend or family member.  Denying the death is an easy way to isolate yourself, and will frustrate your support system in the process.

 

Accept your feelings. People experience all kinds of emotions after the death of someone close. Sadness, anger, frustration and even exhaustion are all normal.

 

Take care of yourself and your family. Eating well, exercising and getting plenty of rest help us get through each day and move forward.

 

Reach out and help others dealing with the loss. Helping others has the added benefit of making you feel better as well. Sharing stories of the deceased can help everyone cope.

 

Remember and celebrate the lives of your loved ones. Possibilities include donating to a favorite charity of the deceased, framing photos of fun times, passing on a family name to a baby or planting a garden in memory. What you choose is up to you, as long as it allows you honor that unique relationship in a way that feels right to you. If you feel stuck or overwhelmed by your emotions, it may be helpful to talk with a licensed psychologist or other mental health professional who can help you cope with your feelings and find ways to get back on track.

(Adapted from a post by Katherine C. Nordal, PhD from the American Psychological Association)

 

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On a personal note … as of this writing, I am one month on from my Mom’s death.  For the first two weeks following her passing, I coped by not coping.  In other words, I forced the issue out of my mind and put all my energy into maintaining control.  I did this so that I could put on a strong front for my Dad, as I was worried about his reaction and did not want to compound the family misery. 

 

In the last few weeks, I have allowed myself to indulge in sadness, and thankfully, it is not quite as raw as it threatened to be earlier.  I don’t know if that was the “healthy” thing to do, but it felt appropriate to me then.  I’m sure my feelings will evolve over time, and I am open to working through the process, which I will update in future posts.

 

Things which have helped me cope best are the support of my husband, spending time with my dogs and blogging.   Blogging has been particularly cathartic for me.  I want and need to discuss this topic, but it is not one that I can discuss easily (nor is it a topic which many people enjoy in conversation).

 

 

 

Writing this blog enables me to explore the topic of dying and grief through recounting my experiences with my Mom’s two years of progressive terminal illness and eventual death, as well as through researching what “the experts” say.  I feel it is my new purpose to provide help and guidance for patients and loved ones who have questions they need (but perhaps don’t really want) to ask, or who feel they don’t have the right person to ask.

 

 

 

 

 

 

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Do Not Resuscitate

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A “do not resuscitate” (DNR) order indicates that a person — usually with a terminal illness or other serious medical condition — has decided not to have cardiopulmonary resuscitation (CPR) attempted in the event his or her heart or breathing stops. In most situations, a DNR order is written by a physician after discussing the burdens and benefits of CPR with the patient or the patient’s surrogate decision maker.

Why would a person sign such an order?

At some point for late stage terminally ill patients, CPR will not be life-saving, and will only cause harm. If the physicians caring for you or your loved one believe strongly that this is the case, they will discuss with you why it is not being offered as an option.  Various methods of CPR often involve more than chest compressions and mouth-to-mouth resuscitation. CPR also might include the use of powerful drugs or electric shock to start the heart beating again, or might require the insertion of a breathing tube. Although CPR can save lives, it frequently does not work. Even if a person is resuscitated, he or she might suffer painful injuries during CPR or might be left in a worse condition than before. Also, people with terminal illnesses or other serious medical conditions might not want to have CPR performed on them, even if that means they might die as a result.

Some people believe that CPR offers hope. Such hope, however, is not useful if there’s no chance of restoring heart function. The resuscitation procedure is complex, costly, labor intensive (involving many health care providers), and causes physical damage to the patient. Such a demanding procedure should not be performed when there’s no chance of success.

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Physicians are not obliged to provide treatment that can’t possibly work, and the ethics of doing so are questionable. For example, a surgeon can’t be expected to perform surgery that has no chance of success; a physician can’t be obliged to prescribe medication whose use is not supported by evidence.

If you or a loved one are facing a life limiting condition, chances are that you will be asked to sign a DNR order at some point.  My father was asked to sign a DNR order for my Mom, who had late stage liver disease.  The doctor explained it as deciding not to perform heroic measures in an attempt to restart the heart and breathing, as attempts to restore heart function in a person dying from a progressive terminal condition rarely work and often just cause damage.  It is difficult but important to understand that cardiopulmonary resuscitation (CPR) rarely works in these circumstances because the heart has stopped from the burden of illness on the entire body and not due to a problem with the heart itself.

Discussing resuscitation decisions can be very difficult.  Often if feels unnatural not to do anything and everything to prolong life.   Open and honest communication with the medical team is essential, as are having all the facts. 

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It is not honest to offer CPR as an intervention that offers hope in the end stages of a terminal illness, and  therefore, it may not be offered by your physician.  If there is a disagreement among the patient, their family and the health care team, it would be a good idea to obtain a second opinion from another physician.  If the second physician doesn’t support the first physician’s decision, then care may be transferred to the second physician.

Finally, remember that CPR is a vigorous emergency procedure and it is not always successful. Experience has shown that CPR does not restore breathing and heart function in patients who have widespread cancer, widespread infection or other terminal illness.

Please share your thought on DNR orders in the comments below.

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