May 2022
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Liver Disease – An Emerging Silent Epidemic in Kerala
This state of Kerala has achieved improvements in material conditions of living, reflected in indicators of social development, comparable to those of many developed countries, even though the state’s per capita income is low. Achievements such as low levels of infant mortality and population growth, and high levels of literacy and life expectancy, along with the factors responsible for such achievements have been considered characteristic results of the popularly known Kerala. Even though Kerala has long been known for spectacular feats in the field of health and boasting of social development indicators comparable to developed countries, an alarming increase in cases liver diseases is threatening to put its reputation in jeopardy.

Liver is one of the largest glands in our body and its main function is to assist in regulating the process of digestion. It also helps in eliminating toxic substances from the body and in removing dead Red Blood Cells , helps immune mechanisms to thwart infections in addition to regulating metabolism of sugar, protein and cholesterol in the body. Cirrhosis is a slowly progressing disease in which healthy liver tissue is replaced with scar tissue, eventually preventing the liver from functioning properly.

According to the World Health Organization (WHO), liver diseases are 10th most common causes of death in India. Over 2 lakh people lose their lives every year in India due to liver disease , one in every five Indians suffers from liver problems and the most frequent causes are alcoholic liver disease, Hepatitis B, Hepatitis C and obesity-related liver disease.There has been a paradigm shift in the dynamics of liver cirrhosis and about 10 lakh new patients are diagnosed with it every year in India! It is difficult to get a figure of those affected by liver diseases in Kerala. But Chronic liver diseases including cirrhosis, are now fast catching up among Keralites like other lifestyle disorders, including diabetes and hypertension. According to a recent study, 5000 to 10,000 people die every year in the state due to liver diseases, compared to the national average of 70,000.

Sedentary lifestyles, eating habits like consumption of junk food, high-fructose drinks, less consumption of proteins, lack of physical activity clubbed with high liquor consumption are the most important factors. Moreover Obesity and rising incidence of diabetes and other lifestyle disorders have all contributed in varying degrees to this crisis,
Alcohol still remains the major cause of Liver disease in India and especially in the State of Kerala The state, which has a high per capita

consumption of alcohol, India’s highest per capita alcohol consumption, at more than eight litres per person per year which is double the national average. But alcohol alone is not the only cause. Non alcoholic fatty liver disease (NAFLD) is the leading cause of liver dysfunction worldwide and is a rapidly growing health problem in regions such as the Middle East, Far East, Africa, the Caribbean, and Latin America. Nonalcoholic fatty liver disease (NAFLD) is emerging as an important cause of liver disease in India.

Non-alcoholic fatty liver disease (NAFLD) is the term for a wide range of conditions caused by a build-up of fat within the liver cells. A healthy liver should contain little or no fat. Most people with NAFLD only carry small amounts of fat in their liver, which doesn’t usually cause any symptoms. This early form of the disease is known as simple fatty liver, or steatosis. Simple fatty liver is very common in India are reflecting the number of people who are obese or overweight. It is one of the most common forms of liver disease, with an estimated 30-40%% people in India having early forms of NAFLD. In most people, simple fatty liver is unlikely to cause harm, but that doesn’t mean it’s not a serious condition.

NAFLD progresses through various stages before progressing to End Stage liver disease. The stages are described below.

Stage 1: Simple fatty liver (steatosis)
Hepatic steatosis is stage 1 of the condition. This is where excess fat builds up in the liver cells, but is considered harmless. There are usually no symptoms, and you may not even realise you have it until you have had an Ultrasound scan test.

Stage 2: Non-alcoholic steatohepatitis (NASH)
Only a few people with simple fatty liver go on to develop stage 2 of the condition, called non-alcoholic steatohepatitis (NASH). It is estimated that around 5-8% of the Indian population has NASH. NASH is a more aggressive form of the condition, when the liver has become inflamed.  Inflammation is part of the body’s response to injury, which suggests that cells in the liver are being damaged and that some liver cells are dying.

Stage 3: Fibrosis(scarring of liver)
Some people with NASH go on to develop fibrosis, which is where persistent inflammation in the liver results in the generation of fibrous scar tissue around the liver cells and blood vessels. This fibrous tissue replaces some of the healthy liver tissue, but there is still enough healthy tissue for the liver to function normally.

Stage 4: Cirrhosis( chronic liver disease)
This is the most severe stage, where bands of scar tissue and clumps of liver cells develop. The liver shrinks and becomes lumpy (known as cirrhosis).

However, this can happen much earlier in some people. Fatty liver is often found  among people in the age group of 25 to 40 and if not addressed in time, it will progress to cirrhosis by the age of 50 to 65 following many years of liver inflammation associated with the early stages of the disease. Once the patient is diagnosed as cirrhotic, there are very less chances of reversal of the disease,  Cirrhosis is associated with other complications such as ascites (fluid build-up in the abdominal cavity), hepatic encephalopathy, chances of variceal bleeding and other infections. Once these complications begin, the maximum a patient can survive without a liver transplant is 2 to 3 years

Nonalcoholic fatty liver disease is considered a manifestation of the metabolic syndrome and thus occurs frequently with the other manifestations of the syndrome( Diabetes, Hypertension, Hypercholesterol and Obesity). Occasionally it may occur without the other abnormalities of the syndrome.

So you are more likely to develop NAFLD and more severe forms of the disease, such as NASH, fibrosis or cirrhosis if you:

* are obese or overweight
* have type 2 diabetes
* have high cholesterol
* are over the age of 50
* smoke or drink alcohol (this increases the risk of severe liver disease even in non alcolic fatty liver)

80 per cent diabetics have more fat than it is healthy and this may lead them to develop non-alcoholic fatty liver disease. The incidence of diabetes and fatty liver disease together is deadly. In the upcoming decade, non-alcoholic fatty liver disease will supersede alcohol as the most common cause of liver damage. With increased obesity and metabolic diseases like diabetes, non-alcoholic fatty liver leading to hepatitis and eventually cirrhosis is an emerging problem. We always talk about viral hepatitis, but non-viral hepatitis caused by our lifestyle will be the biggest cause of liver morbidity and mortality in the next 20 years. 20% of the people with non-alcoholic fatty liver disease will get liver cirrhosis in 20 years, about the same proportion as among the alcoholics.  With the new vaccines and medicines, the burden of viral hepatitis will slowly reduce while the lifestyle related disease will go up,

Liver diseases are largely silent without causing any signs or symptoms in the patient. The damage that happens at the liver tissue level through the fatty liver, fatty hepatitis and liver scarring is silent until the very late stage where cirrhosis develops. So early detection of the silent liver disease and treatment before permanent damage sets in should be aimed at. Since the liver diseases will not have early symptoms, those with high risk factors should have regular check-up. What makes liver different  from other organs is its capacity to function normally until 80 per cent of it is damaged.

The gold standard for diagnosing NAFLD is liver biopsy, (where a needle is inserted into your liver to remove a very small piece of it which can then be analysed in a laboratory). but this procedure is invasive, painful, and carries risks of complications such as internal bleeding. So, doctors are reluctant to order a liver biopsy unless absolutely necessary. Simple liver function tests, such as AST, ALT, INR, and GGT, can be slightly elevated in early NASH, but they are nonspecific in determining the severity of disease.  Imaging tests such as ultrasound, CAT scan, and MRI can diagnose later stage NAFLD, but they are insensitive in detecting early disease. Fibroscan is a scan similar to an ultrasound which will measure how elastic (or how stiff) your liver is. A healthy liver should be soft and elastic, and if your liver is stiff this is a sign that some damage has occurred. It is a painless procedure which is a new technique similar to ultrasound, that measures the stiffness of your liver. It is a non-invasive, painless, patient friendly alternative to liver biopsy to diagnose Fibrosis and early stages of Liver disease. Your Fibroscan will be carried out at an outpatient clinic appointment with no risks involved.

The first step in treating any level of alcoholic liver disease focuses on removing alcohol from the diet. This can help to reverse some early stages of liver disease. For example, stopping drinking once diagnosed with fatty liver disease may be able to reverse the condition within 2 to 6 weeks. Once a person is diagnosed with alcoholic liver disease at any stage, it is recommended to never resume drinking. Any conditions that have reversed will typically return once drinking restarts.

There are currently no specific medicines for NAFLD, The primary treatment for NAFLD is lifestyle modification. NAFLD is broad spectrum of diseases which if identified in the early stage can be prevented through proper diet and exercise NAFLD is not caused by alcohol, but it may make the condition worse. Hence it is important not to take alcohol when you are predisposed to NAFLD already. It doubles the risk of damage to the liver and hence cirrhosis can set in early. Eating a balanced diet, eating less, and increasing one’s physical activity all promote weight loss and improve or prevent diabetes and fatty liver. It does not take large amounts of weight loss to result in a decrease in liver fat. A less than 10% decrease in weight may be enough. Exercise helps with the disease in several ways.Moderate to high intensity exercise of 30 minutes 3-5 times a week is ideal.Unfortunately, only a minority of patients are able to accomplish these.There is evidence that treating diseases concomitant with NAFLD, such as diabetes and hyperlipidemia, can improve NAFLD and possibly prevent progression of liver disease.

In people who care less to control the disease early in the course end up with liver failure and End stage liver disease, where the liver completely ceases to function. This can be an outcome of advanced-stage liver disease and often means that a liver transplant becomes only option for prolonged survival. A liver transplant is surgery to replace a diseased liver with a healthy liver from another person. A whole liver may be transplanted, or just part of one.The part that you receive as a new liver will also grow to normal size in a few weeks.

Dr Harish Kareem MD DM
Senior Consultant Gastroenterologist

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