Toxic hepatitis is caused by certain chemicals, medicines and over-consumption of Giloy and Triphala without consulting an ayurveda practitioner. This can lead to liver failure. Dr Arvinder Singh Soin, Chairman, Institute of Liver Transplantation and Regenerative Medicine, Medanta Hospital, Gurgaon, demystifies the jargon for World Hepatitis Day
How can we distinguish between acute and chronic hepatitis?
Acute hepatitis happens in a few days and 95 per cent of these cases recover fully. The two common manifestations of acute hepatitis are hepatitis A and E – both of which spread through infected water and food. Now if someone gets yellowness in their eyes, has excessively yellow urine and reports a deranged Liver Function Test (LFT), then they could be suffering from hepatitis A or E. You do not need to be alarmed – with supportive treatment, the condition will resolve in two to three weeks and the patient will be fine. The liver will fully recover.
However, chronic hepatitis is more serious. In India, there are four causes of chronic hepatitis. One is alcohol-related. Then there is non-alcoholic fatty liver disease (NAFLD) which could cause hepatitis B and C. Alcoholic hepatitis develops when someone consumes excessive amounts of alcohol for more than seven to eight years, meaning more than 14 units a week for men and more than ten units a week for women. Each unit of alcohol can be measured as a glass of wine, a mug of beer or 30 ml of whisky. Initially alcoholic hepatitis presents itself as fatty liver. When there is inflammation in that fatty liver, then it is called hepatitis. If excessive alcohol is still consumed, it can further develop into fibrosis, cirrhosis, liver failure and liver cancer. So, to prevent this, moderate your alcohol intake.
The other kind of hepatitis arises from NAFLD that’s found in people with obesity, diabetes, a bad lipid profile and high cholesterol. NAFLD is present in nearly 35 per cent of all adults. But 20 per cent of these patients will eventually develop inflammation of the liver and half of them will progress to even early grades of scarring and fibrosis. Then half of those with fibrosis will progress to cirrhosis and if unmanaged and uncontrolled, can even have liver failure.
The obvious ways to prevent hepatitis due to NALFD is to control diabetes, cholesterol and weight. Do not have a sedentary lifestyle, ensure 30 minutes of exercise a day, have a healthy diet and ensure there is no lack of movement.
Hepatitis B and C are two viral infections which can be transmitted through blood or bodily fluid, much like AIDS. In fact, it can be transmitted through needles, syringes, dialysis machines, infected blood and sexual intercourse. It can be prevented by taking a vaccination. But there is no vaccination for hepatitis C, so precautions have to be taken to prevent its spread through body fluids and blood. These two viruses are much better controlled now as opposed to ten years ago and that is because there are effective medicines available for hepatitis B and C along with the hepatitis B vaccination. So, their prevalence has reduced.
What is toxic hepatitis?
Toxic hepatitis is an injury caused to the liver by certain chemicals, medicines or drugs that are consumed. It is one of the most common causes of acute liver failure. Sometimes it can be a reaction caused by the medicines which harm the liver, sometimes it can be because of excessive doses. Ingesting a toxic substance can cause liver injury, inflammation and liver failure. Around 15-20 per cent of liver toxicity patients suffer from liver failure and the rest recover easily if they stop the use of the toxic substance. A person suffering from toxic hepatitis should always consult a liver expert.
What are the symptoms?
Symptoms of all hepatitis strains are similar, such as jaundice and itching in the body. However, if liver failure progresses, blood can be seen in the vomit, urine or stool with water collecting in the body – the abdomen, legs and the person’s stomach get inflamed due to water retention. In very advanced cases, people may suffer from encephalopathy, which means that the effects of the badly inflamed and damaged liver can be seen in the brain leading to drowsiness, confusion and aggressiveness. Some people may become pre comatose or comatose. Some early symptoms of toxic hepatitis are fatigue and tiredness. After that, the jaundice starts developing.
Who is more susceptible to it? What are the risk factors?
Toxic hepatitis can happen to anyone at any age because its occurrence primarily depends on the consumption of a toxic substance. It could be any person, a child between 10-15 years of age, a young adult or an elderly individual. So, first and foremost, the important thing to understand is the cause. In India, the primary cause, that is known in most cases, is the excessive doses of anti TB drugs/medicines. Approximately, 18 per cent of all liver transplants are due to excessive doses of anti-TB drugs. Additionally, complementary and alternative (CAM) medicines like herbal and ayurvedic concoctions, over-consumption of Giloy and Triphala herbs can also cause liver failure. During the pandemic, we reported several cases of liver damage caused by over-consumption of Giloy without consulting ayurvedic experts or doctors. This has occurred in people with healthy liver and specially in those who had unreported autoimmune liver disease. Also, people who take body-building supplements and anabolic steroids are at a risk of developing liver damage.
How can toxic hepatitis be managed?
Toxic hepatitis can be managed by the early recognition of symptoms like fatigue and jaundice among those who consume aggravating substances. Such people should see a liver doctor and undergo tests for timely diagnosis. The treatment includes specialised liver treatment, which involves stoppage of the toxic drugs. In extreme cases, the patient may need hospitalisation and liver transplants. About 80-90 per cent of the patients recover with supportive treatment but a small percentage could land up with serious liver illness and may even have to undergo liver transplants which could be due to late diagnosis and treatment. The protocol primarily includes stopping the drugs that cause liver damage, management of jaundice and liver damage, following standards for liver protocols in specialised liver units which include counteractive medicines, hepatic encephalopathy and antibiotics, if they have superadded infection. The doctor may prescribe bilirubin lowering drugs, and in some cases, prostaglandins are given. A liver dialysis may be required.
How can we prevent serious liver conditions?
The first and foremost prevention is early diagnosis. That means be regular with your liver function test. Follow this up with identification of Prothrombin time and an ultrasound. If any previous chronic liver disease is suspected, then an endoscopy, CT scan and a liver biopsy are done. The preventive measures could also include understanding the drugs and anabolic steroids which can cause liver damage and stopping their consumption.
People should ensure that they take drugs as prescribed by a doctor and in restricted amounts. Similarly, herbal and ayurvedic medicines should also be taken within safe limits as prescribed by ayurvedic qualified doctors. People should avoid consuming medicines over the counter without a doctor’s prescription and advice. Take appropriate doses without exceeding limits. And if someone is taking anti-tubercular medicines, he/she should follow a routine protocol, including a liver function test every two weeks.
What is the prevalence of hepatitis in India? What are the challenges of treating and diagnosing it?
In rural spaces, expertise and facilities may not be available for diagnosing and treating hepatitis. In that case people travel to bigger cities or now they seek help online – 70 per cent of India is now connected through the internet to online facilities at most major hospitals in the country. So, patients can do tele-consults and seek online help. Generally, when hepatitis is suspected, the doctor will ask you to do a liver function test, ultrasound of the abdomen, sometimes a fibrosis scan besides prescribing medicines to treat the early cases of hepatitis. But once hepatitis has progressed to significant liver damage, scarring and cirrhosis, then it may not be completely reversible.
The world is currently facing a new outbreak of unexplained acute hepatitis infections affecting children. What are the possible reasons? According to you, what are the possibilities of such an outbreak in India?
Worldwide, there have been several cases of unexplained cases of hepatitis in children and these have been associated with COVID infections. Even India is seeing these cases happen to children two months after exposure to COVID. About a third of these children usually have a history of contracting COVID two to three months before, whereas the other children may have had exposure to COVID infection through their parents and family members but never had the infection themselves. Typically, what happens is that these children will become jaundiced, have nausea, loss of appetite, report elevated levels in a liver function test (LFT) and in extreme cases, develop severe liver disease and liver failure. But usually this does not become severe. Only in 10 to 15 per cent cases, the patients develop full-fledged liver failure and may not survive besides being in the ICU or a liver transplant unit. Usually associated hepatitis will be treatable by liver experts with special care and the child will usually respond to medicines.
What are the preventive measures for a non-fatty liver?
Non-alcoholic fatty liver disease can be prevented by living a healthy lifestyle – good diet, controlling sugar, maintaining weight, lipid profile and cholesterol. Ensure that you get enough exercise and drink enough water. Have a balanced nutritious diet with olive oil, whole grain cereals and pulses, fish. Stay away from processed food, red meat, excessive sweet food and excessive alcohol. Hepatitis B can be prevented by taking the vaccine against it. Hepatitis C can be prevented by ensuring that all medical facilities test the blood in the blood bank, use disposable needles and syringes and deploy cleaning protocols for dialysis machines. If someone is known to have hepatitis B and C infection, they can sexually transmit their infection. So, the sexual partner should use a barrier method contraception.