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Announcer: Access to our experts with in-depth information about the biggest health issues facing you today, "The Specialists" with Dr. Tom Miller is on The Scope.

Interviewer: Fatty liver disease affects more than 80 million Americans, and many of them don't even know they have it. Dr. Tom Miller, why does fatty liver disease concern you as a doctor?

Dr. Miller: Well, fatty liver disease is becoming the most common chronic liver disease in the industrialized Western world, and especially in the United States. And it used to be, we had viral hepatitis as a cause of liver disease and a major cause of transplantation, which it still is, but very shortly the major reason for liver transplantation due to liver failure is going to be fatty liver.

Interviewer: And not necessarily caused by alcohol. I always thought it was, you know, people that drank a lot tend to get fatty liver disease.

Dr. Miller: Well, they get liver disease. It's not necessarily fatty liver disease as you would think about it, and it was and still continues to be a cause of liver disease, but because of our lifestyle and the fact that 30% of the people living in the United States have obesity, fatty liver disease is now the most common cause of chronic liver disease.

Interviewer: Yeah, 80 million Americans, that's quite a . . . that's almost an epidemic, isn't it? Like, if 80 million Americans had any other sort of disease, we would be freaking out.

Dr. Miller: Right. I think the term might be just a little bit . . . The categorization of it is a little bit misleading because not everyone with fatty liver disease goes on to develop liver failure. In fact, a small percentage of those people end up with liver failure, but given the large number of people with fatty liver disease, a significant number of Americans will end up with end-stage liver disease.

Interviewer: And what exactly is going on? So I think the name implies that there's some fat, maybe excess fat deposits in the liver, but why is that bad?

Dr. Miller: Fat is a cause, a driver of inflammation, and we don't exactly know why, but when people gain weight, some of that weight is stored centrally and also stored between the cells in the liver. So if you look at a person's tissue from the liver, you will see if they have fatty liver, which is called non-alcoholic fatty liver. You'll see fat stores or globules in between the cells. For whatever reason, this causes inflammation, and inflammation predisposes to damage, fibrosis, and destruction of the active cells in the liver which help us cleanse our body of toxins.

Interviewer: And you're talking about scarring.

Dr. Miller: I'm talking about scarring.

Interviewer: That's why I used those words, yeah.

Dr. Miller: Fibrosis leads to scarring.

Interviewer: Yeah.

Dr. Miller: Now, again, most people with fatty liver don't end up with inflammation, and we don't exactly understand why some people have problems with inflammation related to their fatty liver versus those who don't. And not everyone who has inflammation in the liver goes on to develop cirrhosis.

Interviewer: But it's certainly a path you don't want to go down and find those things out.

Dr. Miller: No, definitely not, and it can be treated.

Interviewer: All right. So, when a patient comes into your office, can you look at them and tell if they have the bad kind of fatty liver disease that could lead to transplant or death?

Dr. Miller: I think the way that we think about it now, I believe the way we think about it now is if you're obese, that is you have a body mass index greater than 30, your chances are pretty high of having non-alcoholic fatty liver disease. So, basically, the same thing that we've talked about on these shows in the past, right diet, right weight, right exercise is your best treatment to prevent it. This is a problem with industrialized countries having too much food and the wrong kinds of food available.

Interviewer: Yeah. And once that scarring happens, there's no cure for it. It eventually will lead to liver failure.

Dr. Miller: Once you start down a path of scarring, your chances of ending up with end-stage liver disease and needing a transplant are pretty high. Not only that, you are predisposed, with that scarring, to liver cancer.

Interviewer: And if you start to lose some weight, I understand it doesn't take, necessarily, a lot of weight reduction to reduce the number of fat cells in the liver and kind of start backing that thing up if scarring hasn't occurred.

Dr. Miller: Right. I think one, again, wants to head for a normal BMI, which is between 18.5 and 25.

Interviewer: Okay.

Dr. Miller: And that's not easy. I mean, I tell you that that's the treatment, but attaining that treatment for everybody is difficult because we don't have a medication for weight loss that works, and basically it's a lifestyle adjustment, which is hard for people given the abundance of food.

Interviewer: And there are tests that you can do to determine, for sure, if there are.

Dr. Miller: There are. So we basically start looking at the issue of inflammation in people who we think might have fatty liver disease by looking at the enzymes that the liver produces on a blood test. If these are elevated, there are a number of causes, but eventually, if you can rule out sort of the medical, the drug-associated causes and other causes, that is if they're not drinking, you can think that this is probably related to a non-alcoholic fatty liver disease. And if you really want to know damage to the liver, you're going to have to do a liver biopsy. There's another test now that's non-invasive, but liver biopsy is still the gold standard.

Interviewer: And we haven't really hit on this, but it often doesn't have symptoms.

Dr. Miller: The vast majority of people with non-alcoholic fatty liver disease are not symptomatic.

Interviewer: Yeah.

Dr. Miller: And, in fact, you're only symptomatic towards the end . . .

Interviewer: When it's kind of too late.

Dr. Miller: . . . with this disease when you have fibrosis and scarring or liver cancer. So, again, we want to look at obesity and lifestyle as a response to prevent this.

Interviewer: So get that body mass index back into a reasonable area?

Dr. Miller: Well, it's the same thing we talk about for all of the things that we now kind of associate with the Western world diet, which is high blood pressure, heart disease, metabolic syndrome, type 2 diabetes. They're all in a basket, including this non-alcoholic fatty liver disease. And, again, the treatment is at our hand, but it's not easy to achieve.

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Interviewer: You have somebody in your life who is entering the alcohol recovery process or is in recovery and you want to be supportive but some of the things you say might actually be harmful.

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Interviewer: We're talking with Dr. Jason Hunziker, psychiatrist at the University of Utah. Dr. Hunziker, people who are recovering from alcohol addiction, it's a really hard process and they need all the support they can get.

Dr. Hunziker: The choice to go into recovery is a big deal for everyone who does it. It's a very difficult process and it does take a lot of support not only internally but from people in the environment and from systems that help people enter the recovery process. We do have to be careful however what we say to people as they are getting ready to enter that process and as they are in that process so that we can motivate them to stay sober and make this big change in their life.

Some of the things I recommend that we don't say are things like, "Hey you can have just one, and it's not going to hurt anything." That clearly is not going to be helpful to somebody who is telling you that their life has been destroyed by alcohol. That's sets you up for failure in your process and in your program and so that's something that should be avoided.

Interviewer: So what are some other things that people say sometimes that you think are supportive but really aren't?

Dr. Hunziker: Somebody is in the program and you think you're being supportive by visiting them and then you say, "You know I'm glad you're doing this right now. It's a good time for you to do this but one day you're going to be able to drink again."

Interviewer: Really? They say that?

Dr. Hunziker: Yes, and again that is not something that is helpful at all to maintain the sobriety that they're looking for. When you stop, you still have the addiction. You just choose now not to use. And I use the word choose pretty lightly because if it was that easy to quit, everybody would just quit. So they make the decision to everyday get up in the morning and realize that they're not going to use and then go through that day not using even though they still have some cravings, they still have some desires and they still fight that impulse to go get some alcohol.

Interviewer: Okay, what are some other things that people might say?

Dr. Hunziker: Other things people say when they don't realize you don't realize you're an alcoholic at all they'll say, "Wait a minute. I see you go to work every day. You have a job. You're still making money. How can you be an alcoholic?" They think that just because you can function that you're not an alcoholic. But that still does not mean that this does not interfere with other aspects of your life.

Some people will say when you've been in the process for a long time and you've been going to your recovery meetings and you haven't had a drink they'll say, "Aren't you done yet? I mean, you've been doing this for years, shouldn't you be cured already?" There's no cure. I mean the cure is to not drink and the only way to not drink is to get positive support and to be actively making sure that doesn't happen.

Interviewer: Okay, any other things that people might say they think are supportive to a recovering alcoholic but might not really be that supportive?

Dr. Hunziker: Well I think sometimes people want to down play or minimize the alcoholism in the other person's life and so they will say things like, "Well I eat food every day, that doesn't make me addict so how could you be an addict?"

Interviewer: Because those two things are so comparable.

Dr. Hunziker: Exactly, exactly. So clearly our words are very important when somebody has made the decision to go into recovery and we need to choose those words carefully. We don't shy away from having conversations but I don't think we want to interfere and actively seek out information about the alcoholism. If somebody wants to give it to us, great. Let's listen, let's be supportive but if you start asking a lot questions people feel like you're being intrusive and then when you're intrusive it sets them up for failure.

Interviewer: So what are the words and the conversations that you can say to recovering or you should be saying to a recovering alcoholic?

Dr. Hunziker: It's not so much what you say all the time but some of the things that you do. Be available so if they call you in the middle of the night you don't say, "Oh, you're just drunk again" or " Oh, here it goes again." You're supportive, you're available, and you're encouraging them to use you as a support system so they don't go drink. Other things, you stay positive. Keep giving them encouragement all the time because it is a difficult process.

I mean you could imagine if you had to give up something you really enjoyed doing even if you didn't really think it was causing you that much problems. So you want to make sure that you're positive and they get encouraged by you so they will continue to fight the addiction.

Interviewer: So say you know someone who is thinking, who is considering the recovery process, what can you say to them to kind of motivate them to enter it?

Dr. Hunziker: You know I think normally what you want to do is have them think about how this helps them or doesn't help them. If you can say to them, "Okay, let's make a list of how alcohol helps you in your life, and then let's make a list of how alcohol hurts your."

Interviewer: Doesn't help you in your life.

Dr. Hunziker: Exactly, exactly.

Interviewer: Pros and cons.

Dr. Hunziker: And then people can look at that and then you can provide motivation based on the positive feature say, "Look what you can... You want these, you want that, you want this. The only way to get that is to be sober and if you can be sober, good things are going to come."

Interviewer: So any final thoughts that you have about recovering alcoholics, what you should and shouldn't be saying?

Dr. Hunziker: The only thought I have is that if somebody comes to you and says, "I'm contemplating stopping my drug use or my alcohol use." Please refer them to somebody who has a knowledge of recovery, has a knowledge of treatment, their primary care doctor, Alcoholics Anonymous, Al-Anon, somewhere that they can get that process moved from contemplation to full active recovery.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: March 12, 2019
originally published: November 5, 2014

Dr. Kirtly Jones: Everyone knows you aren't supposed to drink alcohol when you're pregnant. Well how much is not drinking, and when in pregnancy does it matter? This is Dr. Kirtly Jones from the Department of Obstetrics and Gynecology at University of Utah Health Care and this is the scope of drinking and pregnancies on The Scope.

Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Kirtly Jones: In 1987 fetal alcohol exposure was the leading known cause of intellectual disability in the western world. Now this comes before the more recent public awareness of diagnosis of autism spectrum disorder and ADD attention deficit disorder which occupied our thoughts about intellectual disability in children. But we know from controlled studies in animals and observation of human pregnancies that alcohol consumption can stunt fetal growth, damage brain development and lead to problems in children's cognitive function.

Fetal alcohol syndrome is a pattern of mental and physical deficits in a fetus and child associated with high levels of alcohol consumption in pregnancy. Alcohol easily passes through the placenta and can cause growth restrictions in the fetus and damage neurons and brain structure. The consequences can be poor memory, attention deficits, impulsive disorder, and poor reasoning in a child. There may also be secondary problems such as a predisposition to mental health problems and addiction. It isn't clear whether these secondary problems were inherited, the mother was addicted and often depressed, whether these fetal exposures were genetic or a little bit of both. There are also some facial features associated with fetal alcohol syndrome but that's a little controversial.

Alcohol exposure can present a risk to the fetal brain at any time in development as the fetal brain is rapidly developing throughout pregnancy. In the first trimester it can affect the actual development of brain structures. In the third trimester it can affect later developing structures that have to do with judgment and memory. It's estimated that 1 in 100 children are affected by alcohol consumption during pregnancy in the U.S. Surveys in the U.S. suggest that 30% of women have consumed alcohol sometime during their pregnancy, and 10% to 15% have consumed some recently. Didn't they read the label?

How much? Here is where it gets difficult. There is no normal consumption of alcohol as in some cultures alcohol is consumed daily, and in some cultures alcohol is forbidden. A study of 400,000 women who had consumed some alcohol in pregnancy suggested that women who had more than 15 drinks a week or about 2 a day had growth problems in the fetus and subsequent cognitive difficulty. The authors of the study suggested limiting alcohol to no more than one drink a day. A number of other studies have suggested that drinking no more than one to two drinks a week doesn't appear to pose a risk to the fetus and subsequent child. But, the only certain way to prevent fetal alcohol syndrome is to simply avoid drinking alcohol during the pregnancy.

The Surgeon General of the United States, the British Department of Health, and the Australian Government National Health and Medical Research Council have made that recommendation. In the United States the Surgeon General recommended in 1981 and again in 2005 that women abstain from alcohol during pregnancy or while planning a pregnancy. Women don't know that they are pregnant until the fetal brain has already started its development. You would want to avoid damage even in its earliest stages, the earliest weeks of pregnancy. So federal legislation has required that warning label be placed on all alcoholic beverages since 1988.

So what's the takeaway? One, plan your pregnancies. If you are trying to get pregnant limit your drinking to one to two drinks a week or none. If you had a single drink before you knew that you were pregnant don't worry. If you're pregnant don't drink alcohol. If you have a sip of champagne at your sister's wedding, okay. But if you know that alcohol goes right to your brain, then think about it going right to your baby's brain. And we don't serve alcohol to minors. Your baby deserves the best start in life and that starts before you're even pregnant. Clean out the incubator, give your kid the best chance, and that's the scope of the issue.

This is Dr. Kirtly Jones tipping a glass of non-alcoholic fizzy grape juice to all of you pregnant ladies and pregnant wannabes. Thanks for joining us on The Scope.

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Interviewer: There's a brand new treatment for patients suffering from chronic or acute liver failure. We'll talk about that next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: There's a brand new treatment that are suffering from alcoholic liver related failure. We're talking with Dr. Juan Gallegos. He's a liver expert here at the University of Utah Hospital. You're really about this new possibility of this treatment which is in clinical trial right now. Tell me a little bit about what's going on.

Dr. Juan Gallegos: Thank you very much Scott. Yes we are very excited to participate in this clinical trial of this new therapy for patients with severe alcoholic liver disease. We're interested in it because alcoholic liver disease is very, very frequent in the United States. It's estimated that about two-thirds to three-quarters of adults in the United States drink some alcohol, most of them do so very mildly and moderately, but a subset of patients drink heavily and these patients are at increased risk of developing liver disease. And most patients have heard about alcoholic Cirrhosis and probably that's one of the top three causes of liver failure in the United States leading to liver transplantation.
But there is another entity called acute alcoholic hepatitis, or excessive alcohol drinking leads to significant inflammation and liver damage which could cause the liver to fail, and those are the patients that we're interested in studying and treating in this trial because up to until now the mortality for these patients, meaning the number of patients that die from this disease is about 70% six months after the initial episode. So there's a very dramatic impact of this condition.

Interviewer: And up until this point really no way to treat it, is that correct?

Dr. Juan Gallegos: Well there are some ways to treat it and mainly trying to get these patients abstinent from alcohol and that's the mainstay of treatment. Also adequate nutritional support is very important, and there's a couple of medical therapies that we can use that is medical medications that can be used to treat these patients, but even with that the mortality is still around 30 to 40% at 3 to 6 months after this episode of alcoholic hepatitis.

Interviewer: Okay so this is a dialysis machine, just briefly explain what this machine does then and why you're so excited about it?

Dr. Juan Gallegos: We're very excited about it because this is a machine that yes in a way is a dialysis machine; basically it is able to replace at least for a few days the major function of the liver. So basically what this company has made is a special machine where we have cartridges that are full of human liver cells that are alive and then can actually maintain the liver function for these several days, and these liver cells are grown here in the United States, and they're put in the special cartridges that go into this dialysis machine for the liver. The amount of cells there in these cartridges is equivalent to about 500 grams of liver tissue. Which is about a third of a normal liver.

Interviewer: Does it act as a filter, all those liver cells?

Dr. Juan Gallegos: They not only act as a filter they actually make proteins that are important for the normal physiologic function of the body so they make proteins that help with the clotting factors, they detoxify certain chemicals that are only detoxified by liver cells that in a patient that has acute liver failure are not working.

Interviewer: Is it like a respirator is doing the lungs job eventually this machine would be able to do the livers job?

Dr. Juan Gallegos: So what it can actually do the livers job for a few days but not more than that. Other machines that don't use liver cells really they only act like you mention as filters.

Interviewer: So traditional dialysis would be one of those machines?

Dr. Juan Gallegos: Traditional dialysis in a sense is such a machine is just that traditional dialysis can be used for long periods of time, and substitute the kidney function. The liver function is a bit more difficult to replace, and that's why this is so exciting. So what we are trying to see if it's this machine can help these patients over the hump of the severe or acute liver failure so that they can actually survive this episode and go on to either recover from the alcoholic liver disease, or if they don't necessarily recover but maintain their sobriety for a few months they can then go on to be considered for liver transplantation which we would be the definitive treatment for this alcoholic liver disease.

Interviewer: Yeah so the ultimate goal is the liver transplantation. This machine is by no means something you would stay on for the rest of your life.

Dr. Juan Gallegos: Correct that is not the case it's only basically to treat the acute episode and get you over this acute problem so that over time either you recover because sobriety is very important in some of these patients actually recover and if they maintain sobriety their liver can get back to almost normal.

Interviewer: Really it will heal almost to precondition?

Dr. Juan Gallegos: It might, it depends on how advanced the condition is to begin with. So in those patients that already have severe liver disease, and on top of this have an acute insult they're less likely to recover, but there are patients that don't have a severe liver disease to begin with and if they can get over this acute insult they're livers will recover to a point where they might not require a liver transplant in the future. As long as they maintain their sobriety.

Interviewer: And this is cutting edge technology obviously because it's in trial, the FDA hasn't approved it yet.

Dr. Juan Gallegos: Correct.

Interviewer: The whole process you're going through is hoping to prove...

Dr. Juan Gallegos: Yes we're hoping to prove that this will increase the chances of patients surviving to the point that it will be better than what our current medical therapies are, and the FDA is very interested in this so they have allowed us to participate in this trial. It's a multi-centric trial in the United States, and there are other centers in Europe and other places of the world.

Interviewer: So if somebody was interested in this trial what would they have to do?

Dr. Juan Gallegos: Well generally it will be a physician, or somebody taking care of these patients, they would just need to contact us at the University of Utah. I am the principal investigator so I'm readily available as well as our research coordinators.

Interviewer: Any final thoughts on this topic?

Dr. Juan Gallegos: Well I think that it's important to recognize that alcoholic liver disease is a significant problem in the United States, and that episodes of acute alcoholic hepatitis can be deadly, and we're trying to improve that with this machine, and hopefully people out there will be interested in and contact us.

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