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EXPERT opinion mayo clinic q&a

Mayo Clinic Q&A: nonalcoholic fatty liver disease; episiotomies

Nonalcoholic fatty liver treatment

I've been diagnosed with nonalcoholic fatty liver. My doctor told me I need to lose at least 60 pounds to help with inflammation. I have tried to lose weight in the past but nothing I do seems to work. Should I consider weight loss surgery, or are there other ways to treat this disease?

The most successful treatment for nonalcoholic fatty liver disease usually does include weight loss. Controlling high blood pressure, diabetes and triglycerides also can help. As you develop a weight-loss plan, work with your doctor and other health care providers, such as a dietitian and endocrinologist, to create an approach that's best for you.

Nonalcoholic fatty liver disease develops when fat builds up in the liver of people who drink little or no alcohol. It's the most common liver disease in the Western world. Between 75 and 100 million adults in the United States have this disorder. In most people, nonalcoholic fatty liver disease progresses very slowly. It usually doesn't cause any symptoms and results of liver tests are normal. The disease often is found on imaging exams being done for another reason.

In some cases, nonalcoholic fatty liver disease can eventually damage the liver to the point that cirrhosis develops. This serious and sometimes life-threatening condition involves extensive scarring of the liver. Cirrhosis can make it difficult for the liver to work properly and may lead to liver failure.

In some people with nonalcoholic fatty liver disease, the disorder can manifest as a more aggressive form of liver disease called nonalcoholic steatohepatitis, or NASH, that causes liver inflammation and scarring. In some patients with NASH the liver tests are abnormal, but they can remain normal in a significant proportion of affected patients, despite the presence of liver damage. If your doctor is concerned about inflammation in your liver, your condition likely has progressed to NASH. If so, then this condition puts you at higher risk for liver cancer and for faster development of cirrhosis.

The best way to combat this liver disease for most people is with weight loss because it can help to reduce liver fat, inflammation and scarring. Typically, weight loss of at least 3 to 5 percent of body weight is necessary for fat to start disappearing from the liver cells. A weight loss of 10 percent is needed to improve inflammation and scarring.

Weight loss is best achieved with a low-calorie diet and increased physical activity. Your health care team can work with you to craft a weight-loss program. If you are obese or have medical problems related to obesity, then your care team may recommend weight-loss, or bariatric, surgery.

For those who do not qualify for bariatric surgery or who are not ready to commit to a surgical procedure, new endoscopic techniques to assist with weight loss may be another option. One of these procedures involves placement of a balloon in the stomach to help decrease the amount of food you can eat and limit your calorie intake. The balloon is removed after six months. Although this is not an established treatment method for nonalcoholic fatty liver disease or NASH, it may be an effective way to jump-start your weight loss. Once the balloon is removed, you need to maintain a healthy lifestyle.

If you are not already doing so, consider working with a physician who specializes in liver disease to monitor your condition. He or she can help you review the treatment possibilities that are right for your situation, as well as assess your liver disease over time to watch for any disease progression or other complications.

Alina Allen, M.D., Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minn.

EXPECTANT MOM LOATH TO HAVE EPISIOTOMY

I am 32 weeks pregnant with my first baby. My doctor mentioned that an episiotomy is sometimes needed, but I really don't want one. Why would it be necessary?

Episiotomies used to be a routine part of labor and delivery, but that's no longer the case at most medical centers. There are some situations, though, where an episiotomy is used to help speed up delivery and ensure the baby's health. If you feel strongly that you don't want an episiotomy, let your doctor know. Having a conversation about it now will make it easier to arrive at a decision if a situation comes up during your labor that would call for an episiotomy.

An episiotomy is an incision made in the perineum, the tissue between the vaginal opening and the anus, during childbirth. In the past, almost all women who delivered a baby vaginally had an episiotomy. They were done in an effort to prevent more extensive vaginal tears during delivery. Research now shows, however, that in uncomplicated deliveries routine episiotomy actually may increase the risk of an extensive tear.

An episiotomy may be necessary if the baby appears to be in distress. For example, if the fetal heart rate is dropping and delivery is not imminent, then an episiotomy can be used to accelerate the birth. If forceps or vacuum extraction is required, then an episiotomy is sometimes necessary to prevent serious tears. It may also be considered if a baby is large or in an abnormal position. Some women opt to have an episiotomy when labor is long, and they are exhausted from pushing, because the incision can shorten the time to delivery.

In an effort to lower the risk of complications, the technique many doctors now use for an episiotomy is different than it used to be. Traditionally, a midline or median incision was used. This type of incision extends from the vaginal opening straight down toward the anus. An alternative approach that is becoming more common is a right mediolateral incision, or RML. It's done at an angle away from the vaginal opening.

An RML usually is preferable because it reduces the possibility that an extended tear during delivery will affect the anal area. That kind of tear is called a third- or fourth-degree laceration. It can lead to fecal incontinence and other related problems.

Before you decide whether or not you want an episiotomy, talk to your doctor. Ask in what situations he or she usually does them, as well as what the risks and benefits of declining an episiotomy would be. If a doctor knows you have a strong preference against an episiotomy, he or she may be able to take steps to help reduce your need for one. Understand that if you decline an episiotomy, in some cases, such as when the health of the baby is at risk, the alternative may be a C-section.

Keep in mind, too, that you don't have to make a firm decision about this right now. It's perfectly reasonable to express your desire not to have an episiotomy. Then if a situation comes up during delivery that may call for one, you and your doctor can talk about it and decide what's best, given those circumstances.

Vanessa Torbenson, M.D., Obstetrics and Gynecology, Mayo Clinic, Rochester, Minn.

Mayo Clinic Q & A is an educational resource and doesn't replace regular medical care. Email a question to MayoClinicQ&A@mayo.edu. For more information, visit mayoclinic.org. © 2016 Mayo Foundation for Medical Education and Research. Distributed by Tribune Content Agency, LLC. All rights reserved.

Mayo Clinic Q&A: nonalcoholic fatty liver disease; episiotomies 02/18/16 [Last modified: Thursday, February 18, 2016 4:12pm]
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