Way back in 1960, when I was a student of the Portuguese Escola Médica de Goa, the revered Dr. Inácio Sá taught us clinical medicine. It was fun to be with him during the ward grand rounds. He was a savant full of verve and enthusiasm. Whenever we found a patient with “liver disease” he would pointedly ask, “Babá tum soró pitá?” If the patient said “yes” he was triumphant. If the answer was “no” he would turn to us and remark, “This man is a liar” and we all laughed heartily. In those days every liver patient was assumed to be an alcoholic. Little did we know about auto-immune diseases and the insidious havoc caused by the hepatitis viruses B and C. When once, I myself tried to I ask a liver patient the same question, “Babá tum soró pitá?” the poor ailing man became infuriated and countered: “Dotor, you are adding insult to injury. All my life I have not touched a drop of alcohol!”
I fondly remember our guru of clinical medicine, Dr. G.K. Salelkar. Armed with an MRCP – no swanky DMs or DNBs – he was among my best teachers in Goa. Soft-spoken and ethical, he sadly passed away from liver cirrhosis. It all happened after a negligent doctor gave him a wrong transfusion introducing hepatitis C virus into his system. Predictably, the dangerous virus slowly played havoc with his liver and cut short a very productive life. Dr. Salelkar was a teetotaler all his life.
Liver is an amazing organ that filters toxins, aids in digesting food, regulates blood sugar and cholesterol levels and helps to fight infection. The commonest cause of liver disease in Goa is alcohol abuse. ALD (‘Alcoholic liver disease’) progresses in stages: from a “fatty liver”, to alcoholic hepatitis and then to cirrhosis. “Fatty liver disease” rarely causes any symptoms but it is an important warning sign that you are drinking at a level harmful to your health. Cirrhosis is the final stage of “alcohol-related liver disease” which occurs when the liver becomes significantly scarred.
But, here is a surprise: If you thought only regular drinkers have to worry about liver problems, think again. “Fatty liver” is now affecting teetotalers too. Doctors note that there has been a significant surge in the number of those affected with “non-alcoholic fatty liver disease” (NAFLD), especially among the obese and diabetics. High consumption of sugary drinks, high-carb diet, lack of physical activity lead to this. A liver can remain “fatty” without disturbing liver function but by varying insults can progress dowbhill to inflammation and cirrhosis. The exact reasons are not known. The prevalence in India of NAFLD has been reported to be in the range of 15-20% in the general population whereas in Type-II diabetic population the prevalence is as high as 50-75%.
“Fatty liver” is also caused largely due to weight concentration in the mid-abdomen section. Out of 100 patients who go for an ultrasound test, 40 test positive for fatty liver. But abdominal ultrasound is a very “subjective” test which lacks precision and leads to over-diagnosis and unnecessary scare. In fact many of my patients suffer more psychologically than physically due to rampant ultrasound over-diagnosis. There are other tests far more reliable but more expensive like “fibroscan” and “MRI spectroscopy”.
But the gold standard for diagnosis of “fatty liver” is the test called “liver biopsy”. But since it involves some risks it must be done in those with an “echogenic bright liver” on ultrasound with persistent elevation of liver enzymes or in those over 50 years with features of the so-called “metabolic syndrome”.
Every year, more than 60,000 die in India due to liver failure. At most, 1,500 lives are saved with timely liver transplant. “The irony of the situation is that more and more people are suffering from liver failure due to fatty liver disease but the number of people who can donate is also reducing due to the same condition”. Recently at a leading hospital in India, a 48-year-old woman suffering from liver failure due to a rare disorder underwent a liver transplant. Her husband, who weighed 85 kg, lost 5 kg in a few weeks to reduce his “liver fat content” so as to be able to eventually donate his organ to his loving wife. “I wanted to save her at any cost,” he said.
The diagnosis of “fatty liver” calls for decisive advice. For those who consume excess alcohol the most effective way to arrest progression is to stop drinking or stick to the recommended daily limits and ideally have at least two alcohol-free days a week. For those who don’t drink and suffer from NAFLD nutritional counseling like diet changes are a must as well as the avoidance of foods containing high-fructose corn syrup and trans-fats. Further, gradual weight loss can improve the process in obese patients. More specifically, walking or some form of aerobic exercise at least 30–45 minutes daily is salutary. Albert Einstein long ago said, “The devil has put a penalty on all things we enjoy in life. Either we suffer in health or we suffer in soul or we get fat.” Is it then true that we can keep “fatty livers” at bay only by depriving ourselves of the “cup that cheers” and the rich food that “gourmets” relish? Well, life is like that and the choices are sadly few. Yet, when I myself feel tempted on occasion to give vent to bouts of intemperance I seek divine protection and console myself “Errare humanum est”…
(Dr. Francisco Colaço is a seniormost consulting physician.)
