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The liver isn’t just the largest internal organ, it’s among the most important. You can’t live without it.
About the size of a football, it’s located in the upper right part of the abdomen and protected by the ribcage. As part of the digestive system, the liver must process everything that the stomach and intestines digest and absorb. For nutrition, one of its main jobs is to produce bile, a chemical that converts fat into fuel the body can use. Without your liver, eating a cheeseburger and milkshake would make you very sick.
In fact, the liver can be credited with performing at least 500 vital functions. It regulates blood sugar, makes vitamins, maintains blood at the right thickness and keeps muscles from tremoring. It filters toxins from the blood and clears medications and alcohol. When your muscles grow with regular exercise, your liver makes it possible. It’s very important to heart health. The liver even helps us think more clearly.
A healthy liver is undoubtedly a key element to a healthy life. But, when the liver gets sick, many problems can follow. And unfortunately, liver disease is on the rise for millions of Americans.
The liver performs over 500 functions and, if it gets sick, problems can follow. Dr. Arul Thomas has the details. @MedStarWHC via https://bit.ly/3lKiWk2.
Autoimmune Liver Disease
The liver is prone to autoimmune disorders—a situation that occurs when the body’s immune system gets confused and attacks healthy cells. These disorders include autoimmune hepatitis, when the immune system attacks the liver causing inflammation and damage; primary biliary cholangitis, a condition that inflames and destroys the bile ducts; and primary sclerosing cholangitis (PSC), another autoimmune liver disease that recently took the life of screenwriter James Redford, the 58-year-old son of actor Robert Redford.
PSC is a rare liver disease, a chronic condition that attacks bile ducts, the network of vessels that transport bile to the intestine. It often strikes in young people. When healthy, the ducts keep bile moving. Problems occur when the bile backs up and lingers longer than it should. PSC can start in a patient’s 20s, and no lifestyle modifications can prevent it. It is highly associated with liver and bile duct cancer. We have some treatment options—for example, we can place stents to open the bile ducts and improve flow. But mortality rate is high, and most PSC patients require liver transplants and there aren’t enough available livers.
Lifestyle and Liver Disease
Liver problems can also be caused by inherited diseases like hemochromatosis and Wilson disease. In hemochromatosis, the body absorbs too much iron, which is toxic to the liver and other organs. In Wilson disease, the toxin is copper. Much more common are diseases that come from environmental factors, including alcohol-related liver disease, viral hepatitis and nonalcoholic fatty liver disease.
It’s estimated that about 100 million Americans have nonalcoholic fatty liver disease. It is also the most common liver disease in children, with instances doubling in the past few decades. Obesity is suspect, but since the disease can also affect those of normal weight who exercise regularly, there are likely genetic or other factors at work. Those with high blood pressure and type 2 diabetes are also at higher risk for developing this disease.
As fat builds up in the liver, the liver swells and works less efficiently. Over years, the swelling can lead to cirrhosis, irreversible scarring that further reduces liver function and can turn cancerous.
Early detection is key. Any liver disease can progress to the point of no return; when the damage is done, it is unlikely to turn around. Caught early, some conditions can be reversed via a modified lifestyle. This is why it’s critical to have liver function tested on a regular basis—a simple blood test can indicate if a disease process is underway.
The ABCs of Hepatitis
Viral hepatitis is caused by certain viruses and, like other liver diseases, may cause inflammation that leads to cirrhosis and liver cancer.
- Hepatitis A is the least dangerous form, and a modern-day success story. Since the vaccine was introduced in 1995, occurrences have dropped 95 percent. Hepatitis A is frequently linked to fecal-oral contamination; for example, eating raw shellfish is a risk if the clam or oyster lived in contaminated water. It’s a bigger problem in parts of the world with lower water quality standards. However, it has been increasing in incidence in the U.S.
- Hepatitis B is spread via body fluids—blood, semen and vaginal secretions. Sexual activity, tattoos and intravenous drug use are risk factors. It can spread to healthcare workers exposed to infected blood. And women can pass it to infants during childbirth. Hepatitis B is best controlled through prevention. We have a vaccine, recommended for those with risk factors. Like hepatitis A, most adults will clear it on their own. But as many as 5 percent will not, and for them it becomes a chronic or lifelong condition that should be managed by a specialist.
- Hepatitis C is our greatest concern. It is the leading cause of liver failure, end-stage liver disease, and liver transplants. And it can be a silent killer. The Centers for Disease Control and Prevention estimates 3.2 million Americans are infected, but, since the hepatitis C virus (HCV) shows no symptoms in its early stages, as many as three-quarters of them don’t know they have it. There are excellent treatments available now that can offer a cure to many infected patients.
- It spreads through blood. IV drug users are at risk, as are healthcare workers exposed to infected blood. It can also spread through transfusion and was a significant risk before 1992, when we started screening the nation’s blood supply.
- HCV infects 17,000 new patients each year and kills an estimated 12,000. There is no vaccine, and since so many Americans already have it, the best defense is education, awareness, and more widespread testing. It can be treated, if caught early enough.
- Of those with the disease, three-quarters are Baby Boomers, born 1945–1965. Testing is recommended for everyone in that age group. We don’t know precisely why it’s so prevalent, but research suggests that the Boomer population is more likely to have tried recreational drugs, even if only once. Intranasal cocaine use can also be a risk factor for hepatitis C.
Almost all liver diseases can cause liver cancer. Liver cancer is dangerous and difficult to treat in its later stages—reinforcing the importance of keeping your liver healthy and getting regular screenings.
The classic progression of primary liver cancer starts with damage caused by inflammation. As the liver tries to repair itself, scar tissue forms. As scarring increases, liver function decreases and the risk of cancer grows. Most liver cancer arises from cirrhosis, the more severe form of liver scarring.
But every patient is unique. Someone with hepatitis well under control may still develop cancer, even in the absence of cirrhosis. And it’s not uncommon for cancer to spread to the liver from another part of the body.
The liver is susceptible to more than one kind of cancer, and treatment depends on the type, stage, severity, and underlying medical conditions. It starts by making an accurate diagnosis, which we can often accomplish via CT and MRI imaging.
Treatment options include surgery, radiation and targeted drug therapy. We can destroy small tumors by burning, with ablation or cutting off a tumor’s blood supply with embolization. Sometimes the diseased portion of the liver can be removed. But, for some, once cancer is discovered, it may be too advanced or the rest of the liver may be too damaged. Then, the best option may be liver transplant.
The Miracle of Transplantation
Medical science has a large tool kit to help sick livers. But when those tools fail, we can replace the liver completely through transplantation. Transplants have saved hundreds of thousands of lives. However, the demand for a healthy liver is always greater than the supply, and patients with the sickest livers take precedence.
A patient’s place on the wait list depends on a numerical score that takes into account the severity of his or her condition. All candidates for transplant are thoroughly evaluated to ensure maximal success medically and psychosocially with the new liver. Donor and recipient must have the same blood type, and the new liver must be similar in size to the original. For patients at the top of the list, the wait time for a new liver can be days. For those farther down on the wait list, it may stretch into years.
We still don’t have enough donors; most organs are available only when a donor dies and chooses to donate their organs. The exception is living donation, when a healthy person donates part of their liver. As much as 60 percent of a healthy liver can be donated. It will regrow over a few years. It’s a good option for conditions that strike younger people—rather than waiting for their liver to become damaged to qualify under standard protocols. In these situations, family members will often step up to donate.
Because transplantation is one of the most complex surgeries, we try to get the patient as healthy as possible in advance of the surgery. The heart and lungs have to be in the best shape possible; blood sugar, blood pressure and weight must be under control. We want medical issues managed and the patient prepared emotionally for the best chance of success.
It’s a huge undertaking, and no one can go it alone. The entire MedStar Washington Hospital Center team collaborates to improve the patient’s health while they await a transplant. The skills and experience of nurse coordinators, social workers, dietitians, interventional radiologists and many other experts support the patient’s needs throughout the process.
Last Word: Act Early
At one time, nearly every liver disease was fatal. Those days are behind us: better testing, medications and advanced knowledge have rendered many liver diseases treatable or reversible. But liver disease remains a serious killer and, wherever possible, prevention is always the best medicine.
It comes down to common sense—controlling diabetes, weight and blood pressure, eating a good diet and exercising. Moderating alcohol is critical. Current guidelines recommend limiting alcohol to two drinks per day for men and one per day for women—but I can see that recommendation becoming one drink per day for everyone in the near future.
Every adult should have an annual liver function blood test, which is especially important if you have additional risk factors. Be sure your primary care physician orders a liver panel during your annual physical—ask about it. And be honest with your healthcare provider. No one will judge you. We help you best when we know the whole story.
This year, we’ve entered some uncharted territory with COVID-19. We know it can harm liver function and potentially initiate liver damage. Serious effects have been observed even in people who’ve recovered from the typical respiratory symptoms. It’s uncommon, but it’s happening. So, it’s more important than ever to stay in touch with us through the pandemic, particularly if you’ve been diagnosed with and recovered from the coronavirus.
From screening, imaging and diagnosis to advanced medical treatment to complex transplantation surgery, we have the medical expertise and depth of personnel to manage every presentation of liver disease.