Liver Disease


There are over 100 different forms of liver diseases. We will talk here about the most common types: Hepatitis A, Hepatitis B, Hepatitis C, Fatty Liver and Cirrhosis.

Each of us are exposed to harmless viruses like the common cold (i.e. rhinovirus) and the body`s immune system will wipe out the virus. However, not all acute infections are so harmless. Viral infections such as influenza (including avian flu and influenza A) can be fatal although the majority of people will recover over a short period of time.

Viral infection also attacks specific organs in the body. Hepatitis A, B and C are all viruses that attack the Liver.

Hepatitis A

Hepatitis A is:

  • The most commonly seen hepatitis virus
  • A type of acute viral infectious disease
  • A highly contagious liver disease that has the potential of making the patient critically ill
  • Commonly perceived as being contracted during travel but many cases of hepatitis A infection are non-travel related
  • Preventable by appropriate vaccination 

Globally hepatitis A affects 1.5 million people on a yearly basis. Some reports indicate that the actual number of infections may be up to 10 times higher since the disease is often asymptomatic (does not have noticeable symptoms) and so goes undiagnosed. In Canada, there were 3500 cases diagnosed in 1991 but less than 400 cases in 2003.  In adults, 25% of the cases required hospitalization. 

Transmission & Risk Factors

This particular virus is transmitted primarily by the fecal-oral route when a person ingests food or drinking water that has been contaminated by the feces of an infected person. Transmission usually occurs in places where people are in close proximity, co-habiting, or ingesting contaminated food or water. The virus can survive in water for up to 10 months.

Other risk factors or routes of hepatitis A infection include:

  • Food and drinks prepared by infected personnel who do not follow all safety protocols
  • Through consuming contaminated imported food
  • Having close contact with an infected person
  • Travel in areas were the disease is common – whether living abroad, visiting for pleasure, or visiting for work (Africa, Asia, Latin America, Eastern Europe, Mexico and the Caribbean)
  • Children – as it is usually asymptomatic for children, they could unknowingly spread the virus to other children or adults
  • Poor sanitation standards
  • Eating raw/uncooked seafood and shellfish products

Once infected with hepatitis A the majority of the population will have lifetime immunity against the virus after they recover. However, approximately 15% of the patients do not recover completely and will relapse in a year’s time.

Hepatitis B

Hepatitis B is:

  • A common virus
  • Approximately 400 million people carry this virus worldwide
  • Approximately 75% of Hep B carriers live in Asia
  • Amongst the carriers, approximately 20-25% will die of liver cancer or cirrhosis
  • In the majority of Asian countries approximately 10% of the population are carriers. Although it is a serious problem imposed on the public health system public awareness of this disease is relatively low. One of the reasons is due to the nature of this disease as a chronic asymptomatic disease (has no noticeable symptoms).

Transmission and Risk Factors

The Hep B virus is spread through blood and other bodily fluids, not food. A common misconception is that if I am careful with what I eat, I will not contract the hep B virus. As mentioned earlier, the majority of the carriers are infected with this virus at birth – vertical transmission (from mother to baby during pregnancy or childbirth).

Other routes of transmission include:

  • Coming in contact with contaminated instrument during dental appointments
  • Sharing syringes
  • Receiving repeatedly used needles that are not cleaned properly during acupuncture
  • Body tattoo or piercing with contaminated instruments
  • Sexually transmitted
  • Receiving contaminated blood products during blood transfusion (rarely happens nowadays)

As with any other illness, the sooner you get treatment for hep B the better the result. The effect and results will certainly be better if the treatment is started at a younger age because much damage may have already occurred to the liver at an older age. There is no current treatment to completely eliminate or cure this virus. However, in the past 10 year it has been proven that drugs can effectively suppress and control the virus to minimize the damage to the liver.


“Carrier” is a term often mentioned when we talk about liver disease. What is a “carrier”? How is this state generated? How is it detected? Also, why is it harmful to be a carrier?

When the hepatitis B virus (or any virus) enters the body, our defense system (i.e. immune system) will respond immediately by sending out antibodies to deal with the intruders (i.e. viruses). If the antibodies win the battle, the virus will be wiped out. The person does not become ill as long as the antibody level remains above 10 IU/L. However, a person should have a booster vaccine if his/her antibody level is below 10.

If the level of antibodies remains low after six months, the body will produce another substance called “antigen” to help fight against the virus. Although antibodies and antigens both protect the body from viral invasion, they cannot co-exist peacefully. There will be no antibody when antigen is present. Antigen is a type of antibody that is more neutral. Antigen will try to negotiate with the virus, establishing a “non-aggression pact”. If the antigen cannot wipe out the virus, the virus will remain inside the body without interfering with the body. At this time the body has become a “carrier”.

However, if a person’s immune system has been weakened (for example the person became ill due to another disease) then the originally non-invasive hepatitis viruses may start attacking the body. Therefore, being a carrier is similar to living with your enemy. If your immune response successfully eliminates the subsequent pathogen, then the hepatitis virus will continue to be dormant and stay in the human body until another opportunity for invasion comes.

How would I know if I am a carrier? A single blood test can tell. If the blood test result returns positive, then you are a carrier and has the ability to spread the virus to others.

Content by Dr. Francis Ho, Family Practice


Can one get chronic hepatitis B from chopsticks/eating utensils?

The answer is no. Casual contact is not a risk factor for transmission of the virus. Hepatitis B can be found in saliva but provided the family has been immunized for hepatitis B this is not a concern. Patients with hepatitis B employed in food preparation also cannot transmit the virus.

Is the immunization for hepatitis B effective?

Hepatitis B immunization in healthy people has about a 97% success rate after three injections. After only one injection the success rate is about 50% and after two injections 80%. So, it is very important to make sure that if you start immunization that all three injections are given. For people living with people with hepatitis B it is also useful to have a blood test to confirm that you have immunity to the virus after the series of 3 injections.

If I have hepatitis B, how come I feel so well?

The liver is a very capable organ and can carry out all of its functions even with major damage. It is usually only when there is less than 5% of functioning liver cells that patients start to show signs of liver failure. Up until that time patients feel completely well. The opportunity to slow down the liver damage would have been more effective if detected earlier. Therefore, it is important that you see your family doctor to get tested for the virus even if you feel well. Most people have no problems with doing their work or daily activities if they have the infection.

Can the drugs result in a cure for hepatitis B?

There are no effective medications to eliminate the disease but there are drugs that can control the infection. Drugs can also prevent the development of liver cancer. Despite this many people who have chronic hepatitis B do not die of a liver related disease. Therefore, even if you have hepatitis B, you may never need drug therapy.

What kind of diet or what are some other things I can do to prevent worsening of liver disease?

Many of my hepatitis B patients want to be proactive and prevent worsening of liver disease. It is important to eat a well- balanced diet. Avoiding alcohol and maintaining a healthy weight can prevent worsening of liver disease. Some over the counter medications or herbal medications can be harmful to the liver and it is important to discuss this with you family doctor or liver specialist before taking any new medication or supplement.

Hepatitis C

Hepatitis C is a virus similar to Hep A and Hep B in that it also attacks the liver. Acute Hep C usually has no warning symptoms so many people are unaware when they are infected. Hep C will stay in the liver long-term. If the virus is not successfully treated the patient will have it for the rest of their life. Such prolonged viral infection is called “chronic” infection. 

Chronic Hep C affects approximately 1-2% of the North American population. British Columbia has one of the highest infection rates in Canada. It is estimated that in B.C. 45 to 60 thousand people have chronic hepatitis C and that many people have yet to be diagnosed. The natural progression of a hepatitis C infection can last for decades. For most of that time Hep C remains silent (no symptoms are noticeable). It is usually not until later stages that it becomes diagnosed during a blood test. Over time, inflammation and scarring of the liver will gradually and slowly develop in hepatitis C patients with about 10-20% of patients developing severe scarring and cirrhosis. After 20-30 years of infection patients are at high risk of being at the last stage of liver failure.


Hepatitis C is transmitted through coming in contact with contaminated bodily fluid. There was a period of time where testing for Hep C prior to blood transfusion was not a common practice and prior to 1991 there was no such a thing as a blood test. These days blood is tested for Hep C before any transfusions.

Common routes of infection are due to:

  • Drug injection on the street (i.e. using the same needle to inject heroin or cocaine)
  • Ingestion of a drug through the nasal canal (i.e. intranasal cocaine)
  • In some parts of the world, Hepatitis C is transmitted via unsterilized medical/dental devices.
  • In many cases the way a patient became infected with Hepatitis C is unknown

Although Hepatitis B and Human Immunodeficiency Virus (HIV) are sometimes transmitted during sex or child delivery from mother to child, these means of transmission are a lot less common for Hepatitis C.

In terms of risk factors that quickens the onset of cirrhosis, alcohol is definitely one of the factors that need to be repeatedly emphasized. Even a small amount of alcohol is enough to contribute towards promoting the development of cirrhosis. Patients should abstain from drinking alcohol or reduce it to an absolute minimum. Infection of other virus, especially HIV and Hepatitis B, are widely believed to accelerate the natural development of Hepatitis C. Another important point to remember is that Hepatitis C virus not only affects the liver, it may also cause other complications including cryoglobulinemia, and this condition may lead to kidney inflammation and failure, arthritis, and skin ulcers. Non-Hodgkin’s lymphoma (a type of malignant lymphoid tumor) and adult onset diabetes are also related to Hepatitis C.

Fatty Liver

Many people have heard of the term “fatty liver” but may not know exactly what it is. The liver is located in the upper right quadrant of your abdomen within the ribcage. The liver is the second largest organ in the human body (after the skin) and weighs approximately 1400 grams. The liver becomes a fatty liver when 5% or more of it is fat rather than liver tissue.

How does fat travel into the liver? There are two main pathways:

  1. Due to the close proximity of liver and intestine, fat cells may enter the liver from the intestine.
  2. Liver cells degeneration: liver cells are broken down and turned into fat cells

Some of the main functions of liver cells are:

  • Store glycogen (the main storage form of glucose in the body)
  • Produce essential body material
  • Eliminate metabolic waste
  • Store vitamins
  • Store minerals like iron and copper- (these are essential building block of red blood cell)
  • Make proteins that are important for blood clotting
  • Eliminate waste like alcohol, certain drugs (e.g. Tylenols, Warfarin, Amiodarone) and other toxic substances
  • Produce bile (stored in the gallbladder) for fat digestion

Hepatitis A

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Hepatitis B

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Fatty Liver

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Hepatitis leading to liver disease and liver cancer is very common and is a major health problem. Hepatitis B data alone shows that China has a tenth of the population (about 130 million) with chronic Hepatitis B infection (carriers). Every minute there is a Chinese person dying from liver disease or liver cancer that originated from Hepatitis B. The majority (80%) of liver cancer are caused by hepatitis. The saying “prevention is better than cure” is accurate. Hepatitis and the resulting liver cancer can be prevented and avoided.

Hepatitis A

Generally transmitted through the intestine. The virus is excreted in the patient’s stool and then passed into the mouth through contaminated food, leading to infection.

Hepatitis A prevention:

  • Personal hygiene – always wash your hands prior to preparing food or eating; immediately flush the toilet and wash your hands after using the bathroom
  • Food hygiene
    • Hepatitis A virus needs to be cooked at high temperature (100 degrees Celsius) for 5 minutes to be killed so drink boiled water, and clean and cook food thoroughly prior to ingestion
    • Take special note of seafood like oyster, clams, and shellfish
    • Food that hasn’t been consumed should be covered or placed in the refrigerator
  • Environmental hygiene – proper disposal of sewage and feces to protect drinking water from contamination

Hepatitis B and Hepatitis C

The route of transmission is similar; mainly by blood or bodily fluid (not food). Because Hepatitis B can survival outside of the body for at least 7 days it is more contagious than HIV by a hundred times.

The following are a few preventive measures:

  • Properly disinfect and bandage any wounds
  • Do not share razors, toothbrushes, needles, syringes or any other products that have the chance of being contaminated by blood or bodily fluids
  • Any medical, dental or other equipment (e.g. acupuncture, tattooing, body piercing, manicure) must be thoroughly disinfected prior to use
  • Avoid sexual promiscuity and use condoms properly

Hepatitis Immunization

Can be divided into two types: passive and active immunization

Passive Immunization

Injecting immune globulin gives a brief instant immunity and protection but cannot produce long-term effects. Appropriate for the following situation:

  • Hepatitis A (Immune Globulin A)
    • Appropriate for people who have not been infected with Hepatitis A but wanted to have temporary protection or plan to travel to areas where Hepatitis A is prevalent
    • Where Hepatitis A vaccine is not suitable for the patient (due to allergy, or adverse side effects, etc.)
    • Not appropriate for babies who are less than one-year-old
    • Appropriate for people with weak immunity and failed to produce effect to vaccine
  • Hepatitis B (Immune Globulin B)
    • Accidental contact with blood containing Hepatitis B virus (e.g. acupuncture), preferably inject within 48 hours coming in contact
    • From sexual contact with Hepatitis B patient, can inject within two weeks
    • Newborn baby of mothers who are carriers, it is very important to receive immunoglobulin injection within 12 hours and the baby can also be vaccinated at the same time

Active Immunization

This is the most effective long-term prevention for Hepatitis A and Hepatitis B. This immunization injects hepatitis vaccine into the body, stimulating the body’s immune system to produce enough antibodies to protect long-term from hepatitis viral infection. Only Hepatitis A and Hepatitis B vaccines are available. There is not yet a vaccine for Hepatitis C or other types of hepatitis.

Hepatitis A vaccine:

Involves a total of two injections. After the first injection the body usually takes two to four weeks to produce sufficient antibodies to fight against the Hepatitis A virus. The second vaccine injection (booster shoot) usually happens within 6-12 months to accomplish long-term immunity (10-20years).

The following people in particular should consider having Hepatitis A vaccine:

  • People without Hepatitis A antibody
  • People who travel regularly, especially to places where Hepatitis A is prevalent
  • People who often ingest uncooked food, especially shellfish and seafood
  • People working in the food industry 

Hepatitis B vaccine:

The full course includes three injection within 6 months for the best immune protection. The first and second injection should be a month apart; the second and third injections should be 5 months apart. Hepatitis B antibodies are produced one to two weeks after injection. If the three doses of vaccines are completed in a timely matter about 90-95% of people will produce enough Hepatitis B antibody to enjoy 15 years or more of immunity. People with immunity will not need booster vaccines once a sufficient level of antibody is reached.

The following people should be vaccinated with Hepatitis B vaccine:

  • Anybody who has never been infected with Hepatitis B
  • The family members, sexual partners and people in close contact with a Hepatitis B carrier 
  • Medical personnel as the nature of their work requires coming in contact with patient’s blood and bodily fluids
  • People who are using street drugs
  • People who are on dialysis
  • People who often receive blood transfusion or blood products
  • Newborn babies, especially when the mother is a carrier

Twinrix (Combined hepatitis A and B vaccine)

Hepatitis A and Hepatitis B combination vaccine can protect the person from both Hepatitis A and Hepatitis B viral infection. The vaccination also involves 3 injections within 6 months. It will be effective for at least 15 years. The Universal Immunization plan in Canada provides all elementary school students and new born babies with Hepatitis B vaccination. However, there is yet to be a Hepatitis A vaccination program.

Hopefully with a better understanding of hepatitis and its prevention, along with the wide spread of vaccination plans, hepatitis along with its complications and subsequent disease will completely eliminated in the near future.

Content by Dr. Thomas Ho, Family Practice

Hepatitis A

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Hepatitis B

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Hepatitis C

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Fatty Liver

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Hepatitis A

A suddenly or recently contracted hepatitis A infection can be diagnosed by a blood test. The problem is that some people are asymptomatic when infected and so may not know to go for the blood test.

There is no specific treatment for people with hepatitis A. The only thing that can be done is to treat the symptoms. In mild to moderate cases of infection the infected patient usually takes 4-6 weeks to recover. However, in severe cases the recovery time could last up to several months. Only under very rare and severe circumstance will hepatitis infection result in liver failure and death.

Hepatitis B

Hepatitis B is a very common worldwide problem with over 350 million affected people around the world.  The disease is most common in Asia and about a third of the cases worldwide are in China.  Many people who carry this infection feel well and do not know they have the disease.  It is estimated that in British Columbia there are 30,000 to 60,000 people who live with the infection. Having a blood test is the only way to determine whether you have Hepatitis B or not.

Hepatitis B is caused by a virus.  This virus infects all cells of the liver by becoming a part of the liver cell’s genetic material.  When our immune system recognizes the virus, it tries to destroy the virus in the liver cell.  It is this immune response to the virus within the liver cell that causes progressive damage to the liver.  Since most cases of chronic hepatitis B start as an infection early in life, our immune system at that time is immature and has difficulty recognizing this infection.  If the infection is not recognized by the immune system, these patients have a relatively inactive form of the disease called hepatitis B carrier.  These patients still have the virus and are infectious but do not have significant active liver damage.

Some people with hepatitis B have more severe liver damage. Over a long period of time, these people with chronic active hepatitis B can develop liver cirrhosis (a condition in which the liver does not function properly) and decompensated liver disease.  The virus can also cause liver cancer over time. Most people will feel completely well until they develop decompensated liver disease or liver cancer.

Some of the initial symptoms include:

  •   Fatigue
  •   Jaundice
  •   Weight loss
  •   Abdominal distension
  •   Gastrointestinal bleeding

It is therefore critical that if you have this infection you see your family doctor regularly to determine if you need treatment.  The aim of treatment is to avoid complications from this disease.

For a long time in British Columbia there was very little provincial funding for the treatment of hepatitis B.  These medications work well but are expensive and until recently there was no political will to fund effective treatment for those who need it.  However, on March 25 2008 the government announced that it will start funding effective drug treatment through the Pharmacare program.  This is due in part to pressure from the Asian community and recommendations by physicians who treat hepatitis B.

There are two types of treatment medication:

  •   Interferon – administered by injection:
    •  Increases the strength of the immune system
    • Provides a boost to the immune system so that your own body can get rid of the infection
    • Interferon treatment is successful in about 30% of people to inactivate the virus
    • Patients prescribed this medication are often treated with injections one to three times per week for about 12 months.
    • Patients taking this medication often feel like they have the flu (fatigue, muscle aches, headaches) for the duration of the treatment.
  •   Nucleoside analogues – administered orally:
    • Interferes with the production of more of the virus
    • Suppresses the replication of viruses but does not eliminate the virus
    • Needs to be taken every day and often the duration of treatment is indefinite
    • Since viruses are living organisms, resistance to this antiviral medication can develop.  It often takes years to develop resistance to medication but once it occurs a change in medication is necessary otherwise the amount of virus will increase again and more liver damage can occur.
    • Medications are a temporary measure to decrease liver damage.  Therefore, patients with severe active liver disease benefit the most from treatment.  Some patients have severe liver damage but feel completely well and have no symptoms related to hepatitis B.  Only your family doctor and liver specialist can determine if your liver disease is serious and requires treatment.  Some patients need to undergo tests to determine this including regular blood testing or taking a tissue sample from the liver (a liver biopsy).

If you are prescribed medication for hepatitis B it is important that the medications are taken as instructed.  If treatment is interrupted or incomplete there is a higher chance for developing drug resistant forms of hepatitis B.  This would make it more difficult to treat in the future.  If the side effects are intolerable your family doctor and liver specialist can provide support to carry on with treatment.  Only your family doctor and liver specialist can determine whether you need treatment as many patients do not need treatment.

Hepatitis B is very difficult to cure completely.  We have new medications to control the disease but there are side effects.  The best form of treatment for hepatitis B is prevention.  Prevention involves identifying your own risk for the disease, getting tested and immunization.  Immunization does not benefit those patients who already have the infection.

Hepatitis B is spread by bodily fluid or blood contact.  The following people are at high risk of contracting Hepatitis B virus and hence should be tested:

  •   People born in Southeast Asia are at highest risk as approximately 8% of the population has hepatitis B
  •   If you had childhood immunizations in Southeast Asia with shared needles
  •   Sexual transmission can occur with an infected partner without protection
  •   Many infections are caused by transmission of the virus from mother to child at the time of childbirth
  •   If you have had a family member develop liver cancer or have a household contact with hepatitis B
  •   Children and infants are at highest risk for developing chronic hepatitis B

These groups should be immunized as the best protection against acquiring the infection.  The only effective prevention is to have all household contacts immunized for the virus.  The immunization is a series of three injections separated by at least 4 weeks between injections.  Patients receiving hemodialysis where there is a greater risk of infection by needles are routinely immunized.

Hepatitis C

Hepatitis C is a complex of viruses (many different types) that can be subdivide into six groups of distinct genotypes (G1-6) – in other words the classification is genetic. The most commonly seen genotypes in North America and BC are 1-3. Whether these genotypes are relevant to the development of late stage liver disease is still controversial. However, it is clear that Hepatitis C genotyping is relevant to the response to the different Hepatitis C treatments.

Genotype 1 is the most resistant to treatment and unfortunately also the most commonly seen in North America (close to 70% of Hepatitis C infection is genotype 1). Genotype 2 and 3 are relatively easier to treat. In North America the least commonly seen genotypes (4-6) behave similarly to genotype 1.

Up until the beginning of this century the treatment for Hepatitis C developed very rapidly. However, from 2001-2003 there has not been any new drug treatment products appearing on the market. Right now is a period of transition with some exciting drugs (including a group called protease inhibitor, e.g. Telepravir and Beceptovir) already completed their preliminary study which is required by government regulation. The study is now recruiting patients for clinical trials. These tests are completed under more precise and stringent regulations implemented by the government. The expectation is that these drugs will acquire their commercial license and appear in the market in 2010.  However, with the policy for funding support from the respective government agencies, such as the BC Pharmacare, it may take a lot longer. The second stage testing results of polymerase inhibitor has already been submitted to America and Europe conferences for discussion. According to the report it is more effective in comparison to all the medical drug treatments that are currently available in market.

Throughout the 1990s, the standard interferon (which acts as both an antiviral and to strengthen the immune system) alone is the only medication available. This treatment is also frustrating – less than 20% of patient had virus clearance. In 1998 standard interferon and ribavirin combination treatment appeared. It is a 48 weeks treatment and the results are: 30% of genotype 1 patients became clear of the Hepatitis C virus; and 65-69% of the genetic 2 or 3 patients became clear of the Hepatitis C virus. Additionally, reducing the treatment from 48 weeks to 24 weeks does not appear to be affect the results for genotype 1 or 2 patients.

PEGylated interferon (PEG IFN) & Ribavirin

Pegylated interferon is a long-acting interferon taken once a week. A clear antiviral effect is observed when taken in combination with Ribavirin. PEG-IFN and Ribavirin combination drug is the current go to treatment for Hepatitis C. Genotype 1 patients are expected to be completely clear of Hepatitis C upon taking this medication for 48 weeks. 42-50% of the genotype 2 or 3 patients can clear of 76-80% of the virus after on the medication for 24 weeks.

Side effects: In comparison to the conventional interferon combination therapy, PEG-IFN and Ribavirin is accepted more easily by the body. However, it is still common to see side effects.

Generally, the patient will have:

  •   Fatigue
  •   Joint and muscle pain
  •   Stomach upset
  •   Loss of appetite
  •   Irritability
  •   Some degree of depression

These symptoms can be controlled by simple medications, such as acetaminophen, Tylenol and aspirin. Since the patients will generally get better most people are able to cope with these symptoms.

Depression can sometimes become very serious and some patients may require antidepressants. If patients have had a history of severe depression then the doctor should not provide this type of treatment. The less common side effects include thyroid disease and skin rash. However, PEG IFN will likely stimulate or worsen any disease the patient has. During the time of treatment your doctor or nurse will monitor your blood condition because the cases where blood is affected is very common. Despite the side effects it is important to keep taking the drug as prescribed so it is very important that you do not lower the drug dose unless the side effect is extremely serious.

In summary, Hepatitis C is a serious disease that can lead to cirrhosis, liver failure and liver cancer. The organ supply for liver transplant is insufficient and therefore only a few lucky people will receive a liver transplant. A better practice is to treat the Hepatitis C prior to developing cirrhosis. In comparison to the previous method of treatment PEG IFN and ribavirin combination greatly increased the effectiveness of Hepatitis C treatment. However better drugs should appear in the near future.

Fatty Liver

There is no drug treatment for fatty liver. Patients must abstain from drinking any alcoholic beverages. A healthy diet with plenty of vegetables and fruit is beneficial. Regular exercise helps as well.

Fatty liver and hepatitis both may result in cirrhosis. Once a person has cirrhosis all their liver function will be affected. Cirrhosis has very similar signs and symptoms as hepatitis. Also, approximately 25% of cirrhosis cases become liver cancer. Therefore, please take diligent care of your “precious liver”.

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Content by Dr. Eric Lam, Gastroenterologist