Pere Ginès, hepatologist: “There will be an increase in cirrhosis and liver cancer because alcohol consumption has not stopped and neither has obesity”

The liver does not hurt or complain when it suffers. At least not at first. Chronic liver disease develops silently for years, without giving symptoms or warning signs, advancing discreetly supported by risky alcohol consumption, hepatitis virus infections or fatty liver disease, associated with obesity and overweight. . Only in more advanced stages, when cirrhosis or liver cancer already plagues an exhausted liver, does chronic liver disease show up.

Detecting this disease early was a pending task for the scientific community, which did not have robust tools to diagnose it in its early stages. Until now. Research published in The Lancet has now validated a risk stratification scale to identify apparently healthy people in the general population who are at risk of developing serious liver disease in the future. Pere Ginès, consultant to the Hospital Clínic Hepatology Service and head of the IDIBAPS Chronic Liver Diseases group, is the coordinator of this index, which measures eight variables: “We have tried to make it easy to calculate, cheap, accessible to all health. It includes eight variables: age, sex and six analytical variables that are in the conventional analyzes that a person performs in a check-up”. The hepatologist (Girona, 66 years old), who warns of a growing epidemic of cases of severe liver disease, aspires to turn this tool into an early detector and a pivot to implement population screening for these ailments.

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Ask. Is chronic liver disease totally silent?

Answer. It does not give any symptoms. Zero. Hence the importance of detecting it early through some measure that is effective, such as this scale. The patient develops cirrhosis, it evolves and there comes a time when the cirrhosis becomes complicated and that is when the person has symptoms. But of course, he has been silently developing the disease in his liver for 25 years and it has not been possible to detect it because we did not have the appropriate tools for it.

Q. What happens inside the liver in those 25 years of silent development of the disease?

R. What happens is that there is something that injures the liver. This something is highly variable, but most often they are hepatitis viruses, which specifically cause infection of the liver; The other major cause is alcohol consumption, which does not necessarily have to be extraordinary, but falls within what many people would think is normal consumption, but if it is continued it can damage the liver; and the other major cause, which at this time is the most frequent, is related to obesity, overweight and diabetes, because this causes fat to be deposited in the liver —the normal liver does not have it— and this fat, with the over time, it generates inflammation in the liver. And in some patients, this inflammation leads to a deposit of scars, they form like wounds in the liver, which is what we call fibrosis. In this situation, the liver loses its elasticity, becomes rigid, hardens, everything changes and leads to cirrhosis. That would be the progression from fatty liver and inflammation to scarring, cirrhosis and, later, liver cancer.

Q. This is in the case of obesity and overweight, but does it follow the same pattern in the case of alcohol or hepatitis?

A. For alcohol, the pattern is similar because risky consumption also causes fat to be deposited in the liver. In virus infections it is different because there is no fat, but the viruses damage the liver cells and this injury causes inflammation. This chronic inflammation also causes scarring and can lead to cirrhosis.

Q. Is cirrhosis always the last stop in the evolution of the disease?

A. Cirrhosis is pretty much the last stop, but it also has several phases. The first is also silent. As the disease progresses because the factor that is damaging the liver does not go away, cirrhosis continues to progress. And there comes a time when the liver is so disorganized that the cells stop working properly and there is also a difficulty in the passage of blood and an increase in blood pressure is generated inside the liver —portal hypertension—, which is which causes most of the serious complications of liver cirrhosis. And because cirrhosis is a precancerous disease, some of these patients, over time, develop liver cancer.

Q. Is the liver grateful? Does it have more recovery capacity than other organs?

A. It is so to a certain extent. The grateful liver is the healthy liver. If a person has a traffic accident and a part of their liver breaks, they undergo surgery, the damaged part is cut out and, after a month and a half, they have a normal liver again, because it grows and has the normal liver again. same volume as it was initially. The diseased liver is less able to do this, but what it can do is that the sooner you detect liver disease, the more likely it is that by removing the cause these scars will disappear or, at the very least, stall their progression. The more advanced the disease is, the less likely it is to be reversed, but the progression can be stopped. And that is what matters to us because people die from the progression of the disease.

Pere Ginès, a hepatologist at the Hospital Clínic, is the coordinator of a study that has validated a risk stratification scale for developing chronic liver disease.Albert Garcia

Q. Regarding the precursors of chronic liver disease, how has the profile of patients been changing? People with hepatitis C can now, for example, with the new generation of antivirals, be cured.

R. The profile has changed a lot. 15 years ago, more than 50% of the people we diagnosed with advanced chronic liver disease with cirrhosis had hepatitis C. Or hepatitis C combined with risky alcohol use. Now hepatitis C has been reduced to a minimum. Now the great cause of the current moment is metabolic fatty liver, associated with overweight and obesity. And this will continue to increase in the future: all the forecasts are that severe liver disease due to fatty liver of the metabolic type will increase dramatically.

Q. Regarding obesity and overweight, there are studies that indicate that the consumption of fast food already causes more cirrhosis than alcohol. Do you think the population is aware of this situation?

R. I think it is not conscious at all. And this has been demonstrated for years, 30 years ago. The worse the type of food, the more sedentary the life, the sooner cirrhosis develops. For example, in the United States years ago they began to diagnose cirrhosis in adolescents: adolescents who are subjected to a bad diet, fast food, many carbohydrates, many fats, with few vegetables, without exercising… Well, they earn a lot weight and reach 15, 17, 20 years and already have cirrhosis.

Q. Is it possible for an adolescent to develop cirrhosis?

A. Yes. Actually, when we now diagnose a case of cirrhosis in a person who is obese or overweight, when we ask them when they began to gain weight, most started at 30 or 35 years of age, and develop the disease when they are 60: they have spent 25 or 30 years putting continuous stress on his liver. But if this stress is more intense, if life is even more sedentary, as many children and adolescents do, and the intensity of eating poorly and in greater quantity is higher and, in addition, there is another risk factor, such as alcohol consumption , the risk of liver disease skyrockets dramatically. They have already begun to see the same thing in the United States in England and we will see it here in a short time: the age of diagnosis of cirrhosis due to metabolic causes, which is now more or less 60 years, will progressively decrease.

The age of diagnosis of cirrhosis due to metabolic causes, which is now more or less 60 years, will progressively decrease”

Q. The population probably associates cirrhosis more with alcohol, with a serious alcoholism problem. But you say that extraordinary consumption is not necessary to damage the liver.

A. Most of the people that we diagnose for alcoholic cirrhosis have not been drunk in their lives. What happens is that, of course, you can drink enough alcohol without getting drunk. Getting drunk is the acute effect of alcohol on the central nervous system, on the brain; but the chronic effect is the one that affects other organs and the one that suffers the most is the liver: everything you drink, after a few minutes, is in the liver. So, the amount that is already considered to increase the risk of chronic liver disease is relatively low: between 14 and 21 drink units in men (a drink unit is a glass of wine or a fifth). So, the man who drinks two fifths a day or a glass of wine or a fifth, already has an increased risk compared to those who don’t drink anything and a small percentage of them will end up developing liver disease. The more you drink, the more the risk increases. And if, in addition, you are obese or diabetic, even more so. Women are more sensitive to the toxic effect of alcohol on the liver, and the amount of risk is seven units a week.

Q. What therapeutic alternatives are there for chronic liver disease?

A. We have three: one, is to remove the causative agent and, if this is achieved, it is very effective, especially if it is done early; the second, to correct and try to prevent the complications that are occurring in the patient, such as infections; the last alternative is the most drastic, the transplant. With these objectives of trying to identify liver disease early, what we want to achieve is not having the need to use transplantation.

Q. What do you hope to find when this scale reaches clinical practice? What is the outlook in the coming years?

A. In the next few years, all the models indicate that there will be a very significant increase in liver disease, both cirrhosis and liver cancer because, despite the fact that hepatitis C has decreased dramatically, a major cause, such as alcohol has not slowed down, but has even increased with the pandemic and has no sign of clearly slowing down. And the other cause is related to the obesity epidemic, which is very difficult to stop.

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