Liver disease is on the rise among middle-aged Americans, but many don’t know they have it—or that they could develop it.

The liver performs critical jobs, including cleaning toxins from the blood, storing energy and nutrients, digesting fats and processing medications, alcohol and food. But a host of ills and abuses can wreak havoc on the liver, from heavy drinking and infection with hepatitis B or C to a scourge known as fatty-liver disease linked to diabetes and obesity. Over time, the liver can become fibrous and scarred, eventually developing cirrhosis, the replacement of normal tissue with hard tissue. The damage that occurs increases the risk for liver cancer.

September report by the Centers for Disease Control and Prevention found that death rates for chronic liver disease and cirrhosis rose 31% among those age 45 to 64 between 2000 and 2015. And cases of liver cancer rose more than 20% in the U.S. between 1990 and 2015.

Death Rates for Chronic Liver Disease and Cirrhosis, by Sex and Age Group — National Vital Statistics System, United States, 2000 and 2015

Yet liver diseases often have no symptoms until they are far advanced, making it all the more important to identify and test those at risk.

“With baby boomers, we may focus on heart disease, dementia and cancer, and don’t always think about the liver,” says Anna S. Lok, director of hepatology at the University of Michigan and president of the American Association for the Study of Liver Diseases.

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