Dr. Mathew Jacob,
Consultant, Multi Organ Transplant Surgeon
Aster Integrated Liver Care
Aster Medcity, Kochi
Alcohol… the word itself does not in any way hint at the destruction it can cause in taking away health, wealth and family. Derived from the Arabic word al-kuhul (kohl) to describe the fine powder used to darken the eyelids, it was only in the 1750s that it was first used in the modern sense of an intoxicating ingredient in fermented strong liquors. Though the word ‘alcohol’ came into usage only in the 18th century, evidence suggests that fermented beverages existed as early as the Neolithic period making alcoholic liver disease the oldest form of liver disease known to man.
In spite of the increase in non-alcoholic liver disease due to changes in lifestyle and rise in diseases like diabetes and hypertension, alcohol remains a major cause of liver disease worldwide. The situation in Kerala with the highest per-capita alcohol consumption in India at more than 8 litres per person yearly is no better. In addition to the social impact, the impact on health of individuals is of major concern. With Kochi being a major centre of business and tourism in Kerala, with the largest number of bars, business and conference venues, and the introduction of the ban on liquor has generated a lot of debate.
Path to Liver damage
The road to severe liver damage due to alcohol starts off innocently. It’s usually a drink to give company to friends, and studies have shown that the age at which youngsters start drinking has come down from 19 years in 1986 to a disturbing 14 years today. This continues during parties and get-togethers in college and once in a job, the work stress usually leads to an increase in consumption and finally results in alcoholism!
The liver damage follows the same path. It starts of slowly with fat accumulation in the liver leading to fatty liver (steatosis), which is usually asymptomatic. As the alcohol abuse continues, inflammation develops in the fatty liver which leads to alcoholic hepatitis, which over time develops into chronic hepatitis with fibrosis, that is, thickening and scarring of the liver tissue and finally cirrhosis. Cirrhosis is the late stage of fibrosis of the liver which is irreversible.
The complications of alcoholic liver cirrhosis result from the scarring and fibrosis of the liver tissue. The normal functioning of the liver is affected. The liver is where proteins responsible for fluid balance and clotting factors responsible for clotting of the blood are produced. The cirrhosis results in interference in the production of these and leads to edema (swelling) and bleeding from gums. The normal detoxification of waste products which occurs in the liver is also compromised which can lead to a condition known as hepatic encephalopathy in which the brain gets affected leading to confusion, problems with memory, and in advanced stages, hepatic coma.
Another complication occurs due to the slow development of Portal Hypertension in which there is an increase in the blood pressure in the portal vein, the blood vessel which carries the blood from the stomach, intestines, pancreas and spleen to the liver. The pressure in the portal vein rises due to the resistance to the flow of blood in the liver due to cirrhosis. As a result, the pressure in the portal vein rises, and blood vessels open up and dilate in the bottom part of the esophagus or food-pipe. If any of these dilated blood vessels burst, then the patient will have vomiting of blood.
In most cases, the individual will continue to consume alcohol without any symptoms of liver disease for some time. This is because the liver can continue to perform most of its functions even with 70-75% of damage. It is when the damaged liver exceeds this that the symptoms of liver disease will be seen.
The diagnosis of alcoholic liver disease can be made from a combination of a history of alcohol intake, clinical evidence of liver disease, ultrasound imaging and results of laboratory blood tests.
The treatment and management focuses on supportive care and counseling to help the individual to give up alcohol completely. Lifestyle modification with diet control ensures that other factors like blood sugar, lipids don’t complicate the liver disease further. Physical exercise is an essential part of the disease management process. Regular follow-up is a must.
In advanced stage of liver disease, liver transplantation is the only definitive treatment.
It is important to spread awareness amongst the public about this dreaded disease including in schools and colleges. Alcoholic liver disease needs to be identified at the earliest and the doctor consulted for treatment and advice, so that management of the liver disease can be started at the earliest.