Liver Health Q&A Part 2
At the end of January, we held a live Q&A, in association with the British Liver Trust which gave members of the public a chance to ask Dr Hilary Jones their questions about liver health. We were delighted to receive a large number of questions on this topic; more than Dr Hilary was able to answer during the session.
We have posted the answers to another 10 questions below, but if yours isn't among them don't worry, we haven't forgotten you. In another couple of weeks we will be posting a video with Dr Hilary talking about liver health, and your questions will be featured.
Read on for part two in our Liver Q&A series.
1) Do you think Urso works for people with PSC? - Marvin Gale
The answer to your question remains controversial. For several years Urso or UDCA was prescribed as it was considered beneficial in primary sclerosing cholangitis, as well as being safe. It was thought that it would increase bile flow, protect cells, both directly and indirectly, have an immunomodulatory effect, and also guard against cell death. More recent research however showed that in higher dosages, Urso showed a higher risk for liver transplantation and the development of varices (enlarged veins around the food pipe). Strangely, liver function blood tests improved, even though the patients' clinical conditions got worse.
Consequently, in America, PSC guidelines recommend against using Urso in PSC but European guidelines do not particularly recommend against it, especially at low doses. Neither do European guidelines specifically recommend it. A reasonable answer to your question might be that whilst there is limited data sufficient to specifically recommend Urso in general for PSC, there is limited evidence that it could be protective against colorectal cancer in PSC and therefore, there may well be a value in continuing to take Urso at low dose for this reason.
2) I'm a mum to Jade, who has AIH, PSC and UC. Diagnosed at 12, now aged 20. Can you tell me please if there is a specific reason she is deficient in Vitamin D, calcium, potassium, Vitamin K, iron etc. Is it because her body cannot absorb the vitamins or if her liver finds it hard to process them? Her liver function tests are good at the minute but she has sclerosis. Her doctors give her Vitamin D, potassium etc. intravenously - Liz Phillips
Your daughter Jade obviously has one of the overlap syndromes where features of autoimmune hepatitis are mixed with those of primary sclerosing cholangitis as well as ulcerative colitis. There will be diagnostic criteria for each of them individually, but with features similar and in common to the other two disorders. No doubt your daughter has been considered for immunosuppressive treatment, but unfortunately because of the low prevalence of these overlap syndromes in the population, it is difficult in the absence of clinical trials to know which interventional therapies are the best.
However, to answer your specific question, in Jade's conditions, there may be a failure to absorb certain vitamins and minerals as well as the sclerosis within the liver affecting the processing of such compounds. All of the fat soluble vitamins, namely A, D, E and K are absorbed less well because of the cholangitis because bile salts are needed for absorption of fat soluble compounds. A derivative of cholesterol is changed by the action of direct sunlight on the skin into cholecalciferol, a precursor of Vitamin D. This is then modified by the liver so that it can be more effectively used by Vitamin D receptors in the body. Furthermore, malabsorption of Vitamin K in ulcerative colitis is a problem because Vitamin K is required in the synthesis of clotting factors in the blood. It is for these reasons that Jade is getting intravenous top-ups of certain minerals and vitamins, to ensure optimum nutrition and she will require regular blood tests to monitor such levels.
3) In my lifetime I have abused both alcohol and painkillers. Abdominal pain and bloating is normal. My father died from liver cancer, should I be worried? - Gillian Taylor
Hepatitis that has been caused by drugs, including painkillers and alcohol, involves inflammation of the liver, causing a reaction similar to that of acute viral hepatitis except that the destruction of the liver cells tends to be more extreme. You are not alone with your problem however; as it is thought that about 25-50% of all cases of hepatitis and even liver failure may be due to adverse drug reactions. The fact that you have abused alcohol does mean that your liver has been more susceptible to painkiller toxicity. Your symptoms of abdominal bloating and pain could be related to liver damage, but liver function tests and abdominal ultrasound and maybe an MRI scan could tell you to what extent. Continued severe abuse can result ultimately in liver failure but discontinuing alcohol and painkillers might enable the liver to recover. Liver cancer is not a common complication, so your father's medical history I don't think is relevant.
4) Due to the complexities of PSC do you think that all persons diagnosed with this disease should be initially seen by a consultant who deals specifically with this? I realize gastroenterologists do a great job with ulcerative colitis but are they best equipped to make diagnosis and what follow ups and tests are required once diagnosed? The variations of how PSC affects different people is enormous and very frightening when first diagnosed especially if not directed to a reliable source of information. Seeing a consultant who deals specifically with PSC may allay some of the scariness of this disease - Pam Fieldsend
Primary sclerosing cholangitis (PSC) is an uncommon condition as you know, which affects your bile ducts and liver. Inflammation and scarring of these ducts can progress to liver damage and sclerosis. The cause is not fully understood but the condition can run in families and as you also know, around 4 out of 5 people with PSC also have inflammatory bowel disease, such as ulcerative colitis.
Because PSC affects about 1 in 16,000 people in the UK and at any age, and because it has various complex complications such as vitamin deficiencies, infection of bile ducts, cirrhosis and sometimes liver failure, I believe it is best to see a specialist as well as someone who specialises in the ulcerative colitis issue. A specialist can oversee the treatment of symptoms, the medical approach, the management of any complications and in severe cases, be in an excellent position to help with liver transplantation. For further expert advice, I would suggest going to the PSC Support UK who have an excellent and informative website.
5) How aware would you say GPs were about hemochromatosis, which can lead to liver disease? - Mike Davis
Haemochromatosis is an inherited disorder, which makes the body absorb an excessive amount of iron from the diet. This then accumulates in various organs of the body but mainly the liver. The excess iron can also be stored in the pancreas, heart, testes or ovaries, skin and joints. As a result of iron accumulation in the liver, this organ can become enlarged and damaged. It is thought that about 1 in 250 people of Northern European origin have the abnormal gene and are likely to be at risk of developing iron overload.
A General Practitioner by the very definition of his job may never see many cases of haemochromatosis and therefore may not be familiar with the presenting symptoms which can be fairly vague at first, but should recognise the tell-tale signs that might be indicated when a patient is investigated through first of all blood tests. They say that GPs are jack-of-all-trades rather than masters of any particular one, and therefore onward referral to a liver specialist is a policy adopted by most family doctors unless they have a specialist interest in this area.
6) Is liquorice good for the liver? - @MrFreaky420 via Twitter
This is a very topical question. I'm afraid that eating liquorice sweeties or using a liquorice stick to mop up your sherbet will in itself not have any healing power for a damaged liver. However, some very recent research conducted in China showed that two compounds in liquorice, known as glycyrrhetinic acid and glycyrrhizic acid naturally accumulate in the liver. Scientists can attach anti-tumour drugs to these two compounds which then become highly effective at targeting cancer cells within the liver. Further clinical trials will be necessary to see how effective this kind of treatment might prove, and so we wait with bated breath and lots of optimism.
7) Is it just the liver that can repair/regenerate? - @MrFreaky420 via Twitter
The liver is probably best known as the organ in the body that is able to regenerate and is capable of doing so from just one quarter of its mass. But other parts of the human body can regenerate as well. The surface of the skin for example is constantly renewed from regenerating skin cells below the superficial dead cells on the surface. The red blood cells are constantly broken down and remade in a cycle of every 120 days. The cells which line the air passageways and the gut are also constantly shed and reformed in a similar way. Bone and muscle are constantly being broken down and build up again. Other parts of the body where cell turnover is very slow such as the brain and peripheral nervous system however, are much less able to regenerate if at all. Huge amounts of work is being done in the area of using stem cells, either from the patient's own bone marrow or from a embryonic cord blood to exploit their pluripotentiality in a host of different human diseases.
8) Earlier this year I had a couple of days of slight jaundice that went away on it's own but recently I have been tired most of the time & often have an upset tummy. Could I have liver cancer? - Warren
There are a number of reasons why you might have become jaundiced earlier in the year, and your current symptoms may or may not be related to that event. However, one possibility is that you developed a viral infection of the liver (viral hepatitis) which in some people causes no symptoms whatsoever, but in others can initially produce symptoms similar to the 'flu and cause muscle and joint pain, a fever, feeling sick, having a headache and occasionally developing jaundice. These initial symptoms can clear up of their own accord, but in many people, the viral infection can become chronic, leading to this persistent feeling of tiredness and having an upset tummy.
In a small percentage of people with chronic hepatitis B or C infection, liver damage can proceed to producing liver cancer, so whilst this is unlikely, I would recommend that you have some investigations carried out to check your liver function and to see if any treatment is currently required. Meanwhile, adopt healthy lifestyle choices such as enjoying a healthy well-balanced diet, taking plenty of regular exercise, reducing your alcohol intake and avoiding any medications that could further harm your liver.
9) My hands are covered in liver spots, I seem to get more each month – have I got liver disease? - Mrs P. Halligan
Don't worry, your liver spots are unrelated to your liver function and are therefore certainly not a sign of liver disease. Liver spots were once incorrectly believed to be caused by liver problems because of their colour being similar to that of jaundice. Also called solar lentigo, senile freckles or old age spots, they are simply blemishes on the skin ranging in colour from light brown to black or red and located in areas most often exposed to the sun, especially the back of the hands, the face, shoulders, arms, forehead and scalp in bald men. They are no threat to overall health and require no treatment, so, hopefully, this is entirely reassuring.
10) I have just found out I am pregnant and my boyfriend has told me he has hepatitis B – what should I do? - Kim
In the UK around 1 in 350 people is thought to have chronic hepatitis B infection. This is a very infectious disease that can be passed on by having unprotected sex with an infected person including having oral sex. An infected mother can also pass the virus on to her baby. It is obviously possible that you may have been infected, so a simple blood test that is usually carried out routinely in pregnancy anyway, is called for. This detects a protein on the surface of the virus called hepatitis B surface antigen, or HbsAg. If the test is positive, other tests may be advised to check on the severity of infection, the presence of any inflammation of the liver and damage. Hopefully, your tests will be reassuring, but if not, your baby can be protected with injections of antibodies and also immunised straight after birth. You would also need information on how to prevent passing on the virus to others.
That's all for now, we hope this Q&A has proved helpful for those who asked questions and also anyone who wants to know more about liver health. If your question was answered, please let us know your thoughts in the comments below.
Keep an eye on our blog and social channels for the next in this series – a video featuring Dr Hilary Jones.
Written by Nicola Beckett.