GiT Updates and More

Stop using herbal and dietary supplements and Ayurvedic and wellness products that remain unproven for disease prevention and management. Before the end, here is an interesting bit from the paper. Milk thistle extract or Silymarin has been mentioned as a treatment option here. But just for one condition, mushroom-related liver toxicity and ALF. This is the only currently recommended indication (based on low quality of evidence nonetheless) for use of milk thistle extract (and to be given as injection, not oral). For eveything else liver related, milk thistle is useless. journals.lww.com/ajg/Fulltext/2…

The latest guidelines on diagnosis and treatment of acute liver failure, also called ALF. ALF is a rare, sudden onset, but potentially reversible condition resulting in severe liver impairment and rapid clinical deterioration in patients without preexisting liver disease - that is sudden onset liver failure in people who have normal/healthy livers. Please note: When liver failure occurs in chronically damaged livers (also called chronic liver disease or CLD in general) or in those with cirrhosis (end stage liver disease, the extreme spectrum in CLD) it is not ALF, but either - acute decompensation or AD or acute-on-chronic liver failure or ACLF. ACLF is the worst. AD can progess to ACLF. To diagnose ALF, four things are mandatory. Patients should be jaundiced (total bilirubin > 3mg/dl) along with abnormal tests on bleeding parameter (called coagulopathy, measured as INR test ≥1.5) and there should be brain failure (also called hepatic encephalopathy) clinically diagnosed as altered behaviour progressing to confusion and then coma. And all of this - from start of jaundice to the development of the other two features must occur within a period no less than 26 weeks, in a person with a healthy/normal liver. The classification goes on further. If the brain failure develops within less than 7 days - it is called hyperacute ALF (seen with paracetamol poisoning/overdose & viral hepatitis due to A and E). If it occurs between 7 to 21 days, it is called acute presentation of ALF and is usually seen with hepatitis B virus infection. Note that hepatitis C virus does not cause ALF and is usually associated with chronic liver disease. In between 21 days to less than 26 weeks is sub-acute type of ALF which has the worst clinical outcome. Hyperacute type of ALF has the best outcomes without a liver transplantation also. Sub-acute ALF almost always end in death or liver transplantation and the main cause for subacute type of ALF include all other drugs, herbal medicines, dietary supplements other than paracetamol. Let us see that bit a little more in detail. ➡️Paracetamol is safe at the usual therapeutic dose of up to 4000mg every 24 hours. ➡️ALF due to paracetamol occurs after a single intentional overdose of greater than 10-15g in 24 hours. ➡️Paracetamol poisoning can also occure when doses go beyond 10g over several days generally when used with other pain killers ➡️In those with significant alcohol consumption, lower doses of paracetamol can still cause major liver injury ➡️Paracetamol poisoning has an antidote - it is called NAC or N-acetyl cysteine. It helps improve clinical outcomes when started as early as possible. ➡️But we know all this and we help prevent such intentional or unintentional toxicities, especially when paracetaol really works for fever and pain and has benefits greater than risks. But here is the most important part. Apart from paracetamol, the next most common cause of liver injury and ALF are antibiotics. Of these, anti-tuberculosis therapy and sulfa-drugs are the commonest class that cause ALF. But there is something that is going to take over their place soon. Complementary and alternative medicines. Yes, herbal and dietary supplements were responsible for an 8-fold increase in ALF over the past 25 years, increasing from 2.9% to 24.1%. Most patients have deep jaundice, with bilirubin levels generally >15 mg/dL. And the worst part? There is no antidote. We cant be sure of specific herbals causing ALF all the time because people use miltiple herbal drugs and multi-herbal products most of the time. Targeted treatments get complicated and people end up wither dying or with a liver transplant. Herbal drugs ALF is almost always sub-acute type of ALF which has worst outcomes. Herbal liver injury related ALF is far more severe with a lower survival rate that modern medicine liver injury related ALF. This is a fact. Since herbal drugs are alternative medicines and they have no known benefits, but well described harms, the best way to prevent it, is not to get exposed to it.