The introduction is also posted on Spotify as a podcast by “Gerry at The Health Equation”
You can search Spotify for “Gerry at The Health Equation”
Or use the link below
https://podcasters.spotify.com/pod/show/gerrygaj
Below is the specific link
Gerry Gajadharsingh writes:
“Liver fibrosis is the accumulation of scar tissue in the liver, resulting from chronic liver damage. Unlike healthy liver tissue, this scar tissue can disrupt the normal structure and function of the liver. Mild fibrosis itself is not necessarily symptomatic, but if it progresses, it can lead to more serious liver conditions, such as cirrhosis (more extreme fibrosis or scarring of the liver).
Chronic Hepatitis: Hepatitis B, C, and D infections are common causes.
Alcoholic Liver Disease: Long-term excessive alcohol consumption can lead to fibrosis.
Non-Alcoholic Fatty Liver Disease (NAFLD): Related to obesity, diabetes, and metabolic syndrome (which affects about 1/3 of the population).
When the liver is damaged, it attempts to repair itself by producing collagen and other extracellular matrix proteins. Over time, this leads to the formation of fibrous scar tissue. The continuous cycle of damage and repair can eventually distort the liver’s architecture, leading to impaired function.
In the early stages, liver fibrosis may not cause any symptoms.
As fibrosis progresses, symptoms might include fatigue, mild discomfort in the upper right abdomen, or jaundice (yellowing of the skin and eyes).
More advanced fibrosis can lead to symptoms of liver dysfunction, such as fluid accumulation in the abdomen (ascites), easy bruising or bleeding, and confusion (due to hepatic encephalopathy).
Hepatic encephalopathy (HE) is a neurological disorder that arises as a complication of severe liver disease, typically chronic liver failure or cirrhosis. The condition occurs when the liver is unable to effectively remove toxins from the blood, particularly ammonia, which is a byproduct of protein metabolism. These toxins then accumulate in the bloodstream and affect the brain, leading to a range of cognitive, psychiatric, and motor impairments.
Testing for liver function with blood tests usually involve the parameters Alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Testing for platelets is common with blood tests measuring haematology. And once you know the patient’s age, you can use a very useful algorithm called Fibrosis 4 (FIB 4).
Below are examples of using FIB 4
27-year-old woman, where her ALT is above the normal range
75-year-old man, where both ALT and AST are within the normal range
As this score is above the cut off of 1.45, I would tend to follow this up with another blood test for Enhanced Liver Fibrosis (ELF) and sometimes imaging such as Abdominal Ultrasound. The patient’s ELF score was 9.22 which suggests mild to moderate fibrosis.
The latest article on Medscape looks at patients with dementia who may instead have hepatic encephalopathy (HE) and should be screened with the Fibrosis-4 (FIB-4) index for cirrhosis, one of the main causes of the condition, new research suggests.
The study of more than 68,000 individuals in the general population diagnosed with dementia between 2009 and 2019 found that almost 13% had FIB-4 scores indicative of cirrhosis and potential HE.
The findings, recently published online in The American Journal of Medicine, corroborate and extend the researchers’ previous work, which showed that about 10% of US veterans with a dementia diagnosis may in fact have HE.
With the aging population, including those with cirrhosis, the potential for overlap between hepatic encephalopathy and dementia has risen and should be considered in the differential diagnosis, the authors wrote.
It is more important for specialists in neurology to exclude liver disease and for hepatologists or gastroenterologists to be equipped with tools to exclude alternative explanations for neurocognitive presentations.
It is also important for primary care clinicians such as Osteopaths to be at least aware of the connection between the liver and cognitive symptoms.
The liver has an amazing capacity to repair, assuming the structural damage is not too extreme. The challenge is getting patients to engage in preventative lifestyle change, at a time when they may present with minimal or mild symptoms, before the structural damage becomes too great.”
Medscape
Marilynn Larkin
Patients with dementia may instead have hepatic encephalopathy (HE) and should be screened with the Fibrosis-4 (FIB-4) index for cirrhosis, one of the main causes of the condition, new research suggests.
The study of more than 68,000 individuals in the general population diagnosed with dementia between 2009 and 2019 found that almost 13% had FIB-4 scores indicative of cirrhosis and potential HE.
The findings, recently published online in The American Journal of Medicine, corroborate and extend the researchers’ previous work, which showed that about 10% of US veterans with a dementia diagnosis may in fact have HE.
“We need to increase awareness that cirrhosis and related brain complications are common, silent, but treatable when found,” corresponding author Jasmohan Bajaj, MD, of Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, told Medscape Medical News. “Moreover, these are being increasingly diagnosed in older individuals.”
“Cirrhosis can also predispose patients to liver cancer and other complications, so diagnosing it in all patients is important, regardless of the HE-dementia connection,” he said.
FIB-4 Is Key
Bajaj and colleagues analyzed data from 72 healthcare centers on 68,807 nonveteran patients diagnosed with dementia at two or more physician visits between 2009 and 2019. Patients had no prior cirrhosis diagnosis, the mean age was 73 years, 44.7% were men, and 78% were White.
The team measured the prevalence of two high FIB-4 scores (> 2.67 and > 3.25), selected for their strong predictive value for advanced cirrhosis. Researchers also examined associations between high scores and multiple comorbidities and demographic factors.
Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and platelet labs were collected up to 2 years after the index dementia diagnosis because they are used to calculate FIB-4.
The mean FIB-4 score was 1.78, mean ALT was 23.72 U/L, mean AST was 27.42 U/L, and mean platelets were 243.51 × 109/µL.
A total of 8683 participants (12.8%) had a FIB-4 score > 2.67 and 5185 (7.6%) had a score > 3.25.
In multivariable logistic regression models, FIB-4 > 3.25 was associated with viral hepatitis (odds ratio [OR], 2.23), congestive heart failure (OR,1.73), HIV (OR, 1.72), male gender (OR, 1.42), alcohol use disorder (OR, 1.39), and chronic kidney disease (OR, 1.38).
FIB-4 > 3.25 was inversely associated with White race (OR, 0.76) and diabetes (OR, 0.82).
The associations were similar when using a threshold score of > 2.67.
“With the aging population, including those with cirrhosis, the potential for overlap between hepatic encephalopathy and dementia has risen and should be considered in the differential diagnosis,” the authors wrote. “Undiagnosed cirrhosis and potential hepatic encephalopathy can be a treatable cause of or contributor towards cognitive impairment in patients diagnosed with dementia.”
Providers should use the FIB-4 index as a screening tool to detect cirrhosis in patients with dementia, they concluded.
The team’s next steps will include investigating barriers to the use of FIB-4 among practitioners, Bajaj said.
Incorporating use of the FIB-4 index into screening guidelines “with input from all stakeholders, including geriatricians, primary care providers, and neurologists…would greatly expand the diagnosis of cirrhosis and potentially HE in dementia patients,” Bajaj said.
The study had a few limitations, including the selected centers in the cohort database, lack of chart review to confirm diagnoses in individual cases, and the use of a modified FIB-4, with age capped at 65 years.
‘Easy to Miss’
Commenting on the research for Medscape Medical News, Nancy Reau, MD, section chief of hepatology at Rush University Medical Center in Chicago, said that it is easy for physicians to miss asymptomatic liver disease that could progress and lead to cognitive decline.
“Most of my patients are already labelled with liver disease; however, it is not uncommon to receive a patient from another specialist who felt their presentation was more consistent with liver disease than the issue they were referred for,” she said.
Still, even in metabolic dysfunction–associated steatotic liver disease, which affects nearly one third of the population, the condition isn’t advanced enough in most patients to cause symptoms similar to those of dementia, said Reau, who was not associated with the study.
“It is more important for specialists in neurology to exclude liver disease and for hepatologists or gastroenterologists to be equipped with tools to exclude alternative explanations for neurocognitive presentations,” she said. “It is important to not label a patient as having HE and then miss alternative explanations.”
Every presentation has a differential diagnosis. Using easy tools like FIB-4 can make sure you don’t miss liver disease as a contributing factor in a patient that presents with neurocognitive symptoms,” Reau said.
This work was partly supported by grants from Department of Veterans Affairs merit review program and the National Institutes of Health’s National Center for Advancing Translational Science. Bajaj and Reau reported no conflicts of interest.
Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.