Turning our attention to non-COVID-19 diseases in the throes of a pandemic has been challenging, but is important. This is particularly pertinent in the case of liver diseases, which make up 3% of total deaths in India according to the latest World Health Organization (WHO) data. Compounded by the fact that healthcare professionals are facing the overwhelming task of caring for COVID-19 patients with hepatic complications, there is an urgent need to examine the diagnosis and management of liver problems in the country.
Keeping this in mind, we conducted our 12th Practo Connect webinar on April 23, 2021 with two renowned gastroenterologists – Dr Lorance Peter, HOD and Chief of Gastroenterology at Columbia Asia Hospital, Bengaluru, and Dr Dheeraj Karanth, Consultant Gastroenterologist at Manipal Hospital, Bengaluru.
Understanding non-alcoholic fatty liver disease (NAFLD)
Estimated to affect a third of the general population in India, the incidence of liver diseases in India has increased rapidly in recent years with sedentary lifestyles becoming the norm. “Across the spectrum of liver diseases that exist today, two of the most common are non-alcoholic fatty liver disease and infectious hepatitis,” said Dr Lorance.
If more than 5% of the hepatocytes contain fats, it is considered a fatty liver. Non-Alcoholic SteatoHepatitis (NASH) is a subset of NAFLD where this fat accumulation is associated with inflammation, progressive liver cell injury and fibrosis, leading to further complications. Seen in the older population as well as young adults, NAFLD has become a common cause for chronic liver diseases like cirrhosis.
According to Dr Lorance, progress to cirrhosis in a patient with liver disease is gradual. “A quarter of them move to the NASH phase when they have other risk factors, like being overweight, having metabolic syndrome, Type 2 diabetes, etc. Over a period of time, they start developing fibrosis. Given that this progression sometimes happens over a decade and without any apparent indication, it is important to monitor these patients, especially those with additional risk factors,” he elaborated.
Evaluation and diagnosis of NAFLD
The amount of fat on a liver and the degree of inflammation on the organ can be detected using various tests, including liver biopsy. Liver function tests are also helpful, although inflammations – if any – may not be apparent. In fact, a person with cirrhosis may get a normal result in a liver function test. Similarly, a person with a worrisome result in this test actually may not have a serious injury.
“It is, therefore, advised that multiple tests be performed to assess the health of the liver,” said Dr Lorance, adding, “There are a lot of non-invasive methods that can be used to predict advanced or significant liver injury, including FIB-4, APRI score, NAFLD fibrosis score, Fibroscan and MR Elastography. Even MRI imaging techniques can be used to indicate liver stiffness, helping circumvent certain inadequacies in other tests.”
Once it is clear that a patient has fatty liver and is confirmed to have NAFLD, the next step is to categorize them into low risk, intermediate risk and high risk.
“Low risk patients would include those who are not overweight, are under 40 years and don’t have other risk factors. These patients don’t need major medical intervention,” said Dr Lorance. “Patients in the intermediate category would have BMI of more than 29.9, are above 40 and have multiple other ailments. Here, a call must be made to pursue an aggressive treatment or not. High risk patients have a platelet count of less than 1.5 lakh. For them, a liver biopsy or an MRE should be performed to confirm cirrhosis, followed by an aggressive treatment,” he elaborated.
Treatment and care of NAFLD patients
The best practice would be to make critical lifestyle changes, which includes working towards losing weight, regularly exercising and modifying diet. This is the foundation of any treatment for NAFLD patients.
Additionally, there are certain pharmacologic treatments and investigational therapies for NASH. “Currently available therapies with proven efficacy include Vitamin E, Pioglitazone, Saroglitazar and Obetocholic acid. Moreover, there are studies and emerging treatments for NASH, and the results are encouraging,” he added.
Examining Infectious Hepatitis
Hepatitis can be both blood borne (Hepatitis B, Hepatitis C and Hepatitis D) and water borne (Hepatitis A and Hepatitis E). There are other rare conditions as well that are fatal and are known to happen only among a particular set of people.
According to him, some Hepatitis patients can develop a fulminant condition. “This can happen within 8 days of development of jaundice,” Dr Dheeraj explained. “It is, however, difficult to predict how things will swing in these patients. Some patients worsen despite the best care, and therefore, it is important to closely monitor patients with infectious Hepatitis to avoid fulminant failure,” he further said.
Treating Infectious Hepatitis
If fulminancy doesn’t set in, most Hepatitis patients recover uneventfully.
“Patients of Hepatitis A, B and E require symptomatic and supportive care,” said Dr Dheeraj. “Cases of A and E don’t need regular follow-up, but B and C need careful monitoring to look out for chronicity. For these cases, acute infections don’t need treatment, but if C becomes chronic, these patients can be treated with newly available drugs,” he added.
According to Dr Dheeraj, 90% of patients with Hepatitis C can be completely cured, but that is not the case with Hepatitis B. However, for these patients, presently available drugs can suppress the virus DNA levels to such an extent that progress to chronic levels can be prevented.
“These drugs include Entecavir and Tenofovir,” said Dr Dheeraj. “These enable complete suppression of the viral load for a period of about 5-6 years in more than 90% of the patients. The only caveat is that although these drugs can keep patients away from the risk of cirrhosis, they may still have to be on lifelong medication,” he added.
However, if untreated, Hepatitis B and C can lead to cirrhosis. Also, even after treatment, patients should be screened for hepatocellular carcinoma so they don’t develop this dreaded tumour. A liver function test every six months is recommended, and even if a small alteration is noticed, a proper imaging should be done to make sure that there are no complications.
“What is important is to prevent the transmission of Hepatitis B and C,” elaborated Dr Dheeraj. “In India, the most common route of transmission is mother-to-child transmission and among children. Moreover, certain areas have a very high prevalence of Hepatitis B, but thanks to a nationwide immunization programme, we are also looking at prevention rather than just treating these diseases,” he added.
Join us every month as we partner with leading industry and doctor associations for our educational webinar series, Practo Connect. Hosted exclusively for the doctors, by the doctors, it is intended to help doctors navigate these uncertain times better.
Watch this, as well as previous webinars, here.