The Liver Health Questionnaire

by Dr. Sandra Cabot

http://www.liverdoctor.com/index.php?page=symptoms

Do you suffer with:

Abnormal Metabolism of Fats

Abnormalities in the level of fats in the blood stream
Elevated LDL cholesterol and reduced HDL cholesterol and elevated triglycerides.
Arteries blocked with fat, leading to high blood pressure, heart attacks and strokes.
Build up of fat in other body organs (fatty degeneration of organs).
Lumps of fat in the skin (lipomas and other fatty tumours).
Excessive weight gain, which may lead to obesity.
Inability to lose weight even while dieting.
Sluggish metabolism.
Protuberant abdomen (pot belly).
Cellulite.
Fatty liver.
Roll of fat around the upper abdomen - (liver roll).

Digestive Problems

Indigestion.
Reflux.
Haemorrhoids.
Gall stones and gall bladder disease.
Intolerance to fatty foods.
Intolerance to alcohol.
Nausea and vomiting attacks.
Abdominal bloating.
Constipation.
Irritable bowel syndrome.
Pain over the liver - (upper right corner of abdomen & lower right rib cage).
Blood Sugar Problems
Craving for sugar.
Hypoglycaemia and unstable blood sugar levels.
Mature onset diabetes (Type II) is common in those with a fatty liver.

Nervous System

Depression.
Mood changes such as anger and irritability.
Metaphysically the liver is known as the "seat of anger".
Poor concentration and "foggy brain".
Overheating of the body, especially the face and torso.
Recurrent headaches (including migraine) associated with nausea.

Immune Dysfunction

Allergies - sinus, hay fever, asthma, dermatitis, hives, etc.
Multiple food and chemical sensitivities.
Skin rashes and inflammations.
Increased risk of autoimmune diseases.
Chronic Fatigue Syndrome.
Fibromyalgia.
Increase in recurrent viral, bacterial and parasitic infections.

External Signs

Coated tongue.
Bad breath.
Skin rashes.
Itchy skin (pruritus).
Excessive sweating.
Offensive body odour.
Dark circles under the eyes.
Yellow discolouration of the eyes.
Red swollen itchy eyes (allergic eyes).
Acne rosacea - (red pimples around the nose, cheeks and chin).
Brownish spots and blemishes on the skin (liver spots).
Red palms and soles which may also be itchy and inflamed.
Flushed facial appearance or excessive facial blood vessels (capillaries/veins).

Hormonal Imbalance

Intolerance to hormone replacement therapy or the contraceptive pill (eg. side effects).
Menopausal symptoms such as hot flushes may be more severe.
Premenstrual syndrome may be more severe.

NOTE: All of the above symptoms are common manifestations of a dysfunctional liver. However, they can also be due to other causes, of a more sinister nature.

If you have three or more of these problems, it is likely that you have a dysfunctional liver. We advise you to have your liver function checked by a medical practitioner.

Fatty Liver:

If you talk to radiologists and gastroenterologists who are looking at people's livers today they will tell you that the condition "Fatty Liver" affects more than 50% of people over the age of 50!

Common causes are incorrect diet, excessive alcohol intake, adverse reactions to drugs and toxic chemicals, and viral hepatitis. Dr. Cabot believes it is because modern-day medicine has become sidetracked into treating the symptoms of diseases and not the causes.

Excess weight is a symptom of liver *dysfunction* and not solely due to the number of calories you consume. We have been attacking the symptoms of weight excess with fad diets, obsessional high impact aerobics, stomach stapling and toxic drugs, such as appetite suppressants, laxatives and diuretics.

We have failed to consider the underlying cause of LIVER DYSFUNCTION and indeed we have virtually ignored the hardest-working organ in the body, with dire consequences.

Dr. Sandra Cabot's books on the liver show us these consequences - not just weight problems, but a higher incidence of cardiovascular and degenerative diseases that are the leading causes of death in modern affluent societies.

The Liver and Weight Loss

Vital Points for the Weight Conscious!

The liver is the major fat burning organ in the body and regulates fat metabolism by a complicated set of biochemical pathways. The liver can also pump excessive fat out of the body through the bile into the small intestines. If the diet is high in fibre this unwanted fat will be carried out of the body via the bowel actions. Thus the liver is a remarkable machine for keeping weight under control being both a fat burning organ and a fat pumping organ. If the diet is low in fibre, some of the fats (especially cholesterol) and toxins that have been pumped by the liver into the gut through the bile will recirculate back to the liver. This occurs via the entero-hepatic circulation. The term entero-hepatic circulation describes the recirculation of fluids (consisting mainly of bile acids) from the gut back to the liver. See diagram 3 below.

The entero-hepatic circulation is very large, with approximately 95% of the bile acids being reabsorbed from the last section of the small intestine (ileum), into the portal vein to be carried back to the liver.

The liver recirculates these bile acids back into the small intestines and the entire bile pool recycles through the entero-hepatic circulation six to eight times a day. If this recirculated fluid is high in fat and/or toxins, this will contribute to excessive weight.

A high fibre diet will reduce the recirculation of fat and toxins from the gut back to the liver. This is vitally important for those with excessive weight, toxicity problems and high cholesterol. The inclusion of plenty of organic raw fruits and vegetables as well as ground-up raw seeds will increase both soluble and insoluble fibre in the gut, and reduce recirculation of unwanted fat and toxins. Some people find that rice or wheat bran, psyllium husks and unprocessed homemade muesli can boost fibre efficiently.

If the liver filter is damaged by toxins or clogged up (blocked) with excessive waste material it will be less able to remove small "fat globules" (chylomicrons) circulating in the blood stream. This will cause excessive fat to *build up* in the blood vessel walls. This fat may then gradually build up in many other parts of the body, including other organs, and in fatty deposits under the skin. Thus you may develop cellulite in the buttocks, thighs, arms and abdominal wall.

If the liver is "dysfunctional", it will not manufacture adequate amounts of the good cholesterol (HDL), which travels out of the liver to scavenge the unhealthy cholesterol (LDL) from the blood vessel walls.

If the liver filter is healthy it allows "dietary cholesterol" to be shunted into the liver for metabolism or excretion through the bile. A healthy liver filter is essential to properly "regulate" blood cholesterol levels.

Poor liver function may increase your chances of cardiovascular diseases such as atherosclerosis, high blood pressure, heart attacks and strokes. If the liver does not regulate fat metabolism efficiently, weight gain tends to occur around the abdominal area and a protuberant abdomen (potbelly) will develop. This is not good for the waistline! Another sign can be a roll of fat around the upper abdomen, which I affectionately call the "liver roll." This is often a sign of a fatty liver. It can be almost impossible to lose this abdominal fat until the liver function is improved.

Once this is done the liver will start burning fat efficiently again and the weight comes off gradually and without too much effort from you. It is not necessary to make yourself miserable by following a low fat, low calorie diet. What is effective in the long term is to eat the correct foods and nutrients for the liver to improve its fat burning function.

A good liver tonic containing the liver herb St. Mary's Thistle, and sulphur containing amino acids will help the liver to burn fat more efficiently and thus is an aid to weight control. Many middle-aged people with excess fat in the abdominal area have a "fatty liver". In this condition the liver has stopped burning fat and has turned into a "fat storing" organ. It becomes enlarged and swollen with greasy deposits of fatty tissue. Those with a fatty liver will not be able to lose weight unless they first improve liver function, with a liver cleansing diet and a good liver tonic.

If you have a fatty liver it is vital to be patient, as it can take between 3 to 12 months, depending upon the amount of fat deposited in the liver, to remove the excess fat from the liver. After this accumulated liver fat has been removed, weight loss will occur easily. If you have a very severe case of fatty liver it can take several years to lose all of the excessive weight. However, this is very successful in the long term and provides the best chance of restoring your figure and your health. Fatty liver is common and doctors often tell their patients with this problem not to worry too much because it is not serious.

I disagree with this, because if you have a "fatty liver", your chances of high cholesterol, cardiovascular disease and mature-onset diabetes are significantly higher. Unfortunately, it is not uncommon to find a fatty liver in adolescents who consume a diet high in processed and fast foods. If you overload the liver with the wrong type of hormone replacement therapy, drugs or toxins, the liver's "biochemical pathways" will have less energy reserves left over to perform their function of "fat metabolism". Thus these things can lead to weight gain.

For menopausal women with a weight problem, the best type of hormone replacement therapy is that which bypasses the liver, natural progesterone creams or buccal lozenges.

Post subject: Liver Test

http://www.liverdoctor.com/Section2/09_livertest.asp

The purpose of this page is to assist people to understand the reasons for the tests that are generally performed and make some sense of the results. It is not intended to encourage "self diagnosis" A reliable diagnosis of a liver condition can only be made by a qualified medical practitioner after many factors have been investigated and ruled out. This will involve taking a full medical history and more than likely more tests will need to be performed. Therefore if it is always recommended to see your physician if you suspect you have a liver problem.

What causes the enzymes to be raised in a Liver Function Test? The reason why all or some of these enzymes become elevated in cases of liver disease is that they are normally contained inside the liver cells (hepatocytes). They only leak into the blood stream when the liver cells are damaged. Thus measuring liver enzymes is only able to detect liver damage and does not measure liver function in a sensitive way. "The Healthy Liver and Bowel Book" Dr Sandra Cabot p 98

Other tests can be done to check the ability of the liver to manufacture its vital proteins. These are tests for the proteins albumin, prothrombin, and various globulins and they show characteristic abnormalities in those whose liver function is abnormal.

This may sound rather technical, however your doctor can easily do all these tests from two or three small vials of collected blood. In the early stages of liver disease there may be no dramatic symptoms and thus you and your doctor may be totally unaware that there is an underlying problem. Often the early stages of liver disease are found coincidentally on a routine blood test that includes tests for liver function.

Tests For Liver Function

What is a Liver Function Test?

Blood samples are analyzed for levels of specific "enzymes" in the blood stream - there are generally 5 - 6 specific things that are checked. Collectively these tests are called a "Liver Function Test" or LFT. These enzymes are what are referred to as 'markers' of disease and dysfunction. This is not to be confused with a 'Functional Detoxification Profile" which tests the function of the detoxification pathways.

How reliable is this test?

The name "Liver Function Test" is actually quite misleading as this test does not actually measure the 'function' of the liver. It is more a marker of the status of the integrity of the liver cell membranes. Most of the standard or routine blood tests that your doctor will order to check "liver function" are in reality only able to detect liver disease. These tests are not sensitive enough to accurately reflect liver function.

It is possible to still have liver disease even though blood tests are normal. Therefore the LFT alone is not capable of making a proper diagnosis of many liver conditions. No test is completely accurate as it is only an indication of what is happening at the time the test was taken. It is therefore common practice to perform the test again on another occasion, especially if any results are abnormal.

This is why it is important for you to consult a specialist in liver diseases (hepatologist), if you suspect that your liver is unhealthy and yet conventional blood tests remain normal. Different diseases of the liver will cause differing types of damage and affect liver function tests accordingly. It can be possible to give an idea of which disease may be suspected from a liver function test, but these tests are not the absolute way of diagnosing liver disease. They are helpful, but not the whole story. They are also useful for monitoring someone with liver disease, but are not always accurate.

As the LFT is really only showing the level of enzymes present in the blood stream it is only showing that some damaging is occurring but does not give an indication of the extent. This is where other tests are required to give a more accurate picture of the extent of the damage after the fact that damage is occurring has been established.

What is checked in a Liver Function Test?

A routine blood test for liver function will be processed by an automated multichannel analyzer, and will check the blood levels of the following:

A Typical Liver Function Test

Result Unit Reference

. AP (Alk Phos) U/L (30 to 120)
. GGT (Gamma GT) U/L (5 to 35)
. LD Lactate Dehydrogenase U/L (100-225)
. AST (Aspartate aminotransferase) U/L (5 to 45)
. ALT (Alanine aminotransferase) U/L (5 to 45)
. Albumin g/L (38-55)
. Clotting Studies (Prothrombin Time) Seconds (11 to 13.5)
. Total Bilirubin - Normal range is 3 - 18 umol/L (0.174 - 1.04mg/dL).

After the result is the laboratories reference range and the units in which the result is expressed eg: U.L

Each laboratory will provide a "reference range" or 'normal values' This is the average reading that is deemed a 'normal' reading for the majority of the population. This will assist the Doctor in determining if the patients results are abnormal. The normal values for liver function tests will vary between men and women, at different times of the day and will change as you get older. Different laboratories may have slightly differing reference ranges.

Liver Enzymes

. ALT - (alanine aminotransferase) - was previously called SGPT is more specific for liver damage. The ALT is an enzyme that is produced in the liver cells (hepatocytes) therefore it is more specific for liver disease than some of the other enzymes . It is generally increased in situations where there is damage to the liver cell membranes. All types of liver inflammation can cause raised ALT. Liver inflammation can be caused by fatty infiltration (see fatty liver) some drugs/medications, alcohol, liver and bile duct disease.

. AST - (aspartate aminotransferase) which was previously called SGOT. This is a mitochondrial enzyme that is also present in heart, muscle, kidney and brain therefore it is less specific for liver disease. In many cases of liver inflammation, the ALT and AST activities are elevated roughly in a 1:1 ratio.

. AP - (alkaline phosphatase) is elevated in many types of liver disease but also in non-liver related diseases. Alkaline phosphatase is an enzyme, or more precisely a family of related enzymes, that is produced in the bile ducts and sinusoidal membranes of the liver but is also present in many other tissues. An elevation in the level of serum alkaline phosphatase is raised in bile duct blockage from any cause. Therefore raised AP in isolation will generally lead a physician to further investigate this area. Conditions such as Primary Biliary Cirrhosis and Sclerosing Cholangitis will generally show a raised AP. Raised levels may also occur in cirrhosis and liver cancer. Alkaline phosphatase is also produced in bone and blood activity can also be increased in some bone disorders.

. GT - (gamma glutamyl transpeptidase) is often elevated in those who use alcohol or other liver toxic substances to excess. An enzyme produced in many tissues as well as the liver. Like alkaline phosphatase, it may be elevated in the serum of patients with bile duct diseases. Elevations in serum GGT, especially along with elevations in alkaline phosphatase, suggest bile duct disease. Measurement of GGT is an extremely sensitive test, however, and it may be elevated in virtually any liver disease and even sometimes in normal individuals. GGT is also induced by many drugs, including alcohol, therefore often when the AP is normal a raised GGT can often (but not always) indicate alcohol use. Raised GGT can often be seen in cases of fatty liver and also where the patient consumes large amounts of Aspartame (artificial Sweetener) in diet drinks for example.

. Bilirubin is the major breakdown product that results from the destruction of old red blood cells (as well as some other sources). It is removed from the blood by the liver, chemically modified by a process call conjugation, secreted into the bile, passed into the intestine and to some extent reabsorbed from the intestine. It is basically the pigment that gives faeces its brown colour.

. Bilirubin concentrations are elevated in the blood either by increased production, decreased uptake by the liver, decreased conjugation, decreased secretion from the liver or blockage of the bile ducts.

. In cases of increased production, decreased liver uptake or decreased conjugation, the unconjugated or so-called indirect bilirubin will be primarily elevated.

. In cases of decreased secretion from the liver or bile duct obstruction, the conjugated or so-called direct bilirubin will be primarily elevated.

Many different liver diseases, as well as conditions other than liver diseases (e. g. increased production by enhanced red blood cell destruction), can cause the serum bilirubin concentration to be elevated. Most adult acquired liver diseases cause impairment in bilirubin secretion from liver cells that cause the direct bilirubin to be elevated in the blood. In chronic, acquired liver diseases, the serum bilirubin concentration is usually normal until a significant amount of liver damage has occurred and cirrhosis is present. In acute liver disease, the bilirubin is usually increased relative to the severity of the acute process. In bile duct obstruction, or diseases of the bile ducts such as primary biliary cirrhosis or sclerosing cholangitis, the alkaline phosphatase and GGT activities are often elevated along with the direct bilirubin concentration. (See Gilberts Syndrome)

. Albumin - Albumin is the major protein that circulates in the bloodstream. As it is made by the liver and secreted into the blood it is a sensitive marker and a valuable guide to the severity of liver disease.

Low serum albumin concentrations indicate the liver is not synthesizing the protein and is therefore not functioning properly. The serum albumin concentration is usually normal in chronic liver diseases until cirrhosis and significant liver damage is present. There are many other proteins synthesized by the liver however the Albumin is easily, reliably and inexpensively measured.

. Platelet count - Platelets are cells that form the primary mechanism in blood clots. They're also the smallest of blood cells. They derived from the bone marrow from the larger cells known as megakaryocytes. Individuals with liver disease develop a large spleen. As this process occurs platelets are trapped with in the sinusoids (small pathways within the spleen) of the spleen. While the trapping of platelets is a normal function for the spleen, in liver disease it becomes exaggerated because of the enlarged spleen (splenomegaly). Subsequently, the platelet count may become diminished.

. Prothrombin time (Clotting Studies) The prothrombin time is tested to evaluate disorders of blood clotting, usually bleeding. It is a broad screening test for many types of bleeding disorders. When the liver is damaged it may fail to produce blood clotting factors.

How do the liver cell membranes get damaged in the first place? Inflammation is a common cause of damage to the delicate liver cell membranes. Liver inflammation is medically termed Hepatitis (hepato = liver, itis = inflammation). This has many different causes including long term alcohol excess, some medications such as long term antibiotics, cholesterol lowering medications and pain killers, oral synthetic Hormone Replacement, viral infections of the liver such as Hepatitis A, B & C, auto-immune hepatitis, hemachromatosis, primary biliary cirrhosis, exposure to toxic chemicals such as insecticides & pesticides & organic solvents & incorrect diet.

Fatty liver can cause raised Liver Function Test results

One of the most common causes of liver inflammation is fatty liver (see Fatty Liver) Fatty liver is also known as NASH, which stands for Non-Alcoholic Steatorrhoeic Hepatosis. It is very common in overweight persons, over the age of 30 who have had a long term poor diet high in processed foods, sugar, saturated fat and dairy products.

Generally an ultrasound of the abdominal area should also be performed. Many cases of fatty liver can be picked up this way. The ultrasound will detect areas 'of increased echogenicity' meaning that the liver tissue is beginning to become infused with fat.

What can be done to lower the readings? In my medical practice where I do a lot of routine blood tests for hormone levels and liver function in overweight patients, I often find slight elevations in liver enzymes which signifies mild impairment of liver function and slight liver damage. This can easily be reversed with the Liver Cleansing Diet principles and specific dietary supplements I have found that it is very difficult for many of my overweight patients to lose weight even though they may be eating only normal amounts, unless I first improve their liver function. Once they are five to six weeks into the "Liver Cleansing Diet" their liver-function tests are usually back to normal and the process of weight loss takes on increased momentum. Yes, the liver is the strategic organ for those who have found it very difficult to lose weight or simply just to maintain a healthy weight as they get older. "The Liver Cleansing Diet" Dr Sandra Cabot p 20.

TESTS FOR LIVER DISEASE

If you suspect that your liver is not working properly or may be diseased ask your doctor to check your liver. The liver can be seen with various imaging techniques, such as ultrasound scanning or CAT scanning, which are done by a radiologist. An ultrasound scan of the upper abdomen will show the size and shape of the liver, gallbladder, spleen, and pancreas. CAT scanning is used to check for cancer or tumors of the liver.

Blood tests can check levels of serum bilirubin and bile acids, which may be elevated in certain types of liver and gallbladder disease. If the bilirubin is too high you may also notice that your bowel actions are very pale and that your urine is a darker color because bilirubin is diverted from the bowels to the urine.

When diagnosing liver disease, often, but not always the most used test in each disease is generally:

Disease Test or Procedure

Fatty liver (NonAlcoholic Steatohepatitis or NASH). Ultrasound. Liver Biopsy
Hepatitis A. Antibody Test (Blood Sample)
Hepatitis B. Antibody & AntigenTests Hepatitis B DNA (Blood Sample). [Liver Biopsy if chronic to assess level of liver damage]
Hepatitis C. Antibody Test/ Hepatitis C RNA (Blood Sample). [Liver Biopsy if chronic to assess level of liver damage]
Primary Biliary Cirrhosis. Biopsy/ Bile duct imaging
Primary Sclerosing Cholangitis. Biopsy/ Bile duct imaging
Autoimmune Hepatitis. Liver Biopsy
Wilson's Disease. Genetic Analysis/ Copper studies (Blood and Urine Samples)
Alcohol Related Liver Disease. Liver Biopsy/ Liver Function Tests

What is a Biopsy?

This procedure involves using a special needle to remove tissue from the liver to be examined in the laboratory. This will be used to assess the extent of scarring, fatty infiltration or liver damage. For the biopsy, you will lie on a hospital bed on your back or turned slightly to the left side, with your right hand above your head. After marking the outline of your liver and injecting a local anesthetic to numb the area, the physician will make a small incision in your right side near your rib cage, then insert the biopsy needle and retrieve a sample of liver tissue. In some cases, the physician may use an ultrasound image of the liver to help guide the needle to a specific spot.

How accurate is this test?

It is still regarded as the most accurate way of assessing the status of the extent of damage to the liver. You will need to hold very still so that the physician does not nick the lung or gallbladder, which are close to the liver. The physician will ask you to hold your breath for 5 to 10 seconds while he or she puts the needle in your liver. You may feel a dull pain. The entire procedure takes about 20 minutes.

Liver biopsy is considered minor surgery and is done at the hospital. However it should be noted that this procedure is not without risk - it is important that it is carried out by a very experienced Doctor. The risks include puncture of the lung or gallbladder, infection, bleeding, and pain. The bleeding in particular is a dangerous complication. It carries about a 1/10000 death rate - some Doctors say its even higher.

Who should NOT have this procedure done?

. People with blood clotting disorders
. People who are on blood thinning medication such as Warfarin, Coumadins, Ibuprofen, Aspirin
. People with hemangiomas (benign liver cyst consisting of twisted congested blood vessels)

What is an ultrasound or sonograph?

This is a non invasive method of assessing liver health. It is an imaging procedure of the internal organs of the abdomen, including the liver, gallbladder, spleen, pancreas and kidneys. The ultrasound machine sends out high-frequency sound waves, which reflect off body structures to create a picture. There is no ionizing radiation exposure with this test. There are many reasons for performing an abdominal ultrasound including looking for a cause of pain, for stones in the gallbladder or kidney, or for a cause for enlargement of an abdominal organ. The reason for the examination will depend on your symptoms.