Updated: Jun 8, 2021
Prevention of Liver Disease
The liver is the largest organ in the body. It weighs nearly 1.5 kg. It is located in the right upper part of the abdomen, under the right ribs and extending to the central and left upper abdomen. The liver is the metabolic factory of the body and all major metabolic processes needed for life take place in the liver.
Carbohydrate, Protein and Fat metabolism takes place here so does the detoxification of unwanted substances as well as the synthesis of a substances needed to sustain life like those needed for immunity
The liver has two major lobes the right and the left. The basic functional unit of the liver is known as the lobule.
Many channels (bile ducts and blood vessels)are present between the liver cells. Blood coming from the intestine flows through the portal via these channels into the liver.
This incoming blood is rich in nutrients, medication as well as toxic substances. Once these substances reach the liver, these substances are processed and depending upon the need either stored, altered or detoxified, and passed back into the blood or released in the bile channels and subsequently into the bowel to be eliminated.
The purified blood then enters the general circulation through the hepatic vein.
Whenever there is excess of sugar in the body, it is converted to glycogen which can then be stored, a process which is called glycogenesis.
Similarly if the need arises, this glycogen can be reconverted into glucose for energy by a process called as glycogenolysis.
Once the glucose stores are exhausted and there is need, the liver can also synthesize glucose from proteins by a process called as gluconeogenesis.
Similarly when there is excess sugar or carbohydrate available and the glycogen storage capacity of the liver is exceeded, the liver converts this carbohydrate into fat for storage outside the liver in adipose tissue which is then reclaimed by the liver at the time of need.
The major protein metabolic pathways are also located in the liver. Transamination and deamination of proteins as well as their conversion into glucose takes place here, the synthesis of amino acids and albumin all take place in the liver.
In addition to its synthetic functions, the liver is also responsible for the removal of waste from the body by converting it into a form which can then be excreted in bile.
There is a high prevalence of liver disease in our country:
Nearly 25% of the population suffers from fatty liver,
There are an estimated 40 million carriers of hepatitis B and 10 million carriers of hepatitis C and with prosperity and changing lifestyle both alcoholic liver disease as well as immune mediated liver also disease are rising. Despite this, liver disease is a neglected entity as the public awareness about the liver, its functions, liver disease and its prevention is probably the lowest among the major organs like the brain, heart, liver and kidney. This is manifest by the existence of very few preventive public health programmers focusing on liver disease.
The major causes of liver disease include:
Non Alcoholic Fatty Liver disease (NAFLD or Fatty Liver)
Alcoholic liver diseae (ALD)
Drug induced liver disease (DILI)
Other relatively rarer causes are:
Autoimmune Hepatitis (AIH)
Primary biliary cirrhosis (PBC)
Primary Sclerosing cholangitis (PSC)
Diseases of copper (Wilsons disease)
Iron (Hemochromatosis) metabolism
Liver infections like amebiasis, malaria, Hydatid disease, salmonella etc.
Increasing prosperity has brought about major lifestyle and social changes in our country in the last two decades. It has been estimated in a number of population based studies both from India and abroad that the prevalence of fatty liver varies between 16- 25% of the general population. Of these nearly 8-10% are going to develop inflammation within the liver (NASH:Non Alcoholic Steato Hepatitis) and 1% are going to develop frank cirrhosis.
Alcohol consumption is rising and the major states facing increasing alcohol related diseases are Kerala and Punjab. Alcohol effects nearly all organs of the body and its manifestations can be seen in the nervous system, cardiovascular system, urogenital system and GI tract.
There are 5 major hepatitis viruses: A, B, C, D and E.
A and E are water borne and are spread through contact with contaminated food and water.
Whereas B,C and D are blood borne and are spread by needle prick injuries, blood transfusions, dental treatments, dialysis etc.
All Liver diseases, irrespective of the cause pass through the following stages:
1. Acute Hepatitis
2. Chronic Hepatitis
3. Compensated Cirrhosis
4. Decompensated Cirrhosis and
5. Liver Cancer.
Acute hepatitis is manifest by deep Jaundice, loss of appetite, lethargy, weakness, nausea and vomiting.
The liver tests reveal a high bilirubin and SGOT, SGPT (In thousands). This is most commonly seen in viral hepatitis which, in most, is aself-limiting condition and resolves in a few weeks’ time. Howeverin those infected by the hepatitis B (10%) and C (90%) it can progress to develop chronic hepatitis, Cirrhosis and Liver Cancer. Infections with the hepatitis A and E virus do not progress to chronic hepatitis. Acute hepatitis can also be seen in drug induced liver injury and alcohol related liver disease.
There are many myths prevalent in society concerning the treatment of acute hepatitis. Acute hepatitis is a self limiting condition and resolves in a few weeks.
Rest and good nutrition are the corner stones of therapy.
There are no specific food restrictions, High calorie foods like sugarcane juice are not needed since the condition is associated with a lot of nausea, fatty foods may be avoided in those who do not tolerate them.
Yellow foods like Haldi need not be restricted and they do not influence the disease.
Indigenous medication has not been found to be helpful.
Jhadphoonk, bathing in holy waters and putting wooden strings on the feet do not influence the disease outcome.
Hospitalization is rare and needed only if the jaundice is prolonged, the liver enzymes are persistently high there is drowsiness, excessive vomiting or poor oral intake.
If the liver insult persists for more than 6 months’ chronic hepatitis sets in. This stage is manifest by persisting lethargy, weakness, nausea, pain the right upper abdomen and mild jaundice. There is a mild rise in the liver enzymes( reaching hundreds). It is important to treat the patient at this stage because if the liver inflammation persists then cirrhosis is likely to set in, which is irreversible. Both chronic hepatitis B and C can be treated with good results. The primary drugs used for the treatment of chronic hepatitis B are Entecavir and Tenofovir and those for hepatitis C are Sofosbuvir and Velpatsavir. The treatment of hepatitis C has been a recent miracle of modern medicine and a disease which was treated with Interferon injections with poor results and bad side effects only a few years ago can now be treated with minimal side effects and complete cure.
Cirrhosis Cirrhosis is the end stage of all liver diseases whatever may be the cause. It results from repeated episodes of inflammation, scarring and consequent shrinking of the liver.
Once the patient develops cirrhosis 24% of patients decompensate in the next 5 years. Decompensation is in the form of Jaundice, Ascites (Fluid in the abdomen), blood vomiting and encephalopathy (changes in consciousness). Decompensated cirrhosis has a poor outcome and has a life expectancy of only 3-5 years. The disease can now be cured only with liver transplantation.
Cirrhosis is a premalignant state. As patients with cirrhosis are now living longer with improved medical management, the incidence of liver cancer in increasing.
Cure of liver cancer is dependent on early detection; hence it is necessary to screen all patients with cirrhosis for liver cancer. Liver cancer when detected early can be cured. Surgical treatments include resection and transplantation. Non-surgical treatments methods are Radiofrequency ablation and acetic acid injection.
For larger tumors non curative treatments like trans arterial chemoembolization (TACE) and Trans arterial radionuclide injection (TARE) are available. Chemotherapy has also improved with a number of new agents coming in recent years ( Sorefenib, Lenvatinib, Nivolumabetc).
Despite the advances in the treatment of liver disease, the treatment of later stages of liver disease i.e. cirrhosis and Liver cancer still has a long way to go.
Prevention of liver disease is the key. The following are the methods to prevent liver disease:
1. Lifestyle changes- Alcohol is a major contributor of liver disease hence stopping alcohol is of paramount important in containing liver disease. Alcohol abusers have a number of nutritional deficiencies which can be corrected with a diet rich in protein, vitamins and minerals.
2. NAFLD can be prevented as well as treated by regular exercise and weight reduction. Various kinds of fad diets are recommended however a logical diet based on locally available foods is considered the best diet. The weight control diet should have less of carbohydrates and fats and more of proteins, greens, fruits and nuts.
3. Vaccination is so far available against hepatitis A and B. Vaccination against hepatitis A is not needed except In the affluent as most of the population has had sublinical exposure and are immune against hepatitis A by the time they reach 18 years of age. A effective vaccine is available against hepatitis B. It is given in 3 doses which are to be administered at 0,1 and 6 months. It is an effective vaccine which has a 98% protection and no minimal side effects.
4. Transfusion of safe blood which has been screened for hepatitis B and C is another important method to prevent the spread of these viruses.
5. Acute Hepatitis is spread by water borne viruses. Hence clean drinking water is the mainstay of preventing hepatitis A and E.
6. Hand washing before meals, taught to us since childhood is another important way to prevent hepatitis A and E.
7. Avoidance of open defecation is a important way to prevent water borne viruses and the recent government Swach Bharat Abhiyan is going to go a long way in achieving this objective
8. Patients given hepatotoxic drugs like anti-tubercular drugs, hormones, agents used for chemotherapy should be screened with regular LFT and the offending drug stopped at the earliest sign of hepatotoxicity.
9. Those who have developed Cirrhosis and are not yet decompensated should be managed at dedicated liver clinics with regular screening for liver cancer.