Liver diseases among people in Sri Lanka are prevalent due to many reasons including alcoholism. But the infrastructure needs to be improved to conduct liver transplants on these patients. During a recent visit to Sri Lanka, world renowned liver transplant specialist Prof. Mohamed Rela assured that he would support Sri Lanka to develop the necessary infrastructure if requested by the government.He made these remarks during a medical conference organized by Dr. Rela Institute and Medical Centre in Chennai. Another significant aspect of his visit was to celebrate the occasion of conducting 100 liver transplants on Sri Lankan nationals in Chennai.   

In a brief interview with the Daily Mirror, Prof. Rela expressed his thoughts on prevalence of liver diseases in Sri Lanka, possible causes and donations.   

• Higher incidence of non-alcoholic fatty liver disease in SL 

Q Have you studied about liver-related issues in Sri Lanka? 

It’s not dissimilar to that of Southern India. The spectrum of liver disease is similar and even incidents are much higher than what is reported in India. The reason for this is because there’s a much higher incidence of what we call non-alcoholic fatty liver disease in Sri Lanka. This condition is related to the dietary habits here. Sri Lankans have a carbohydrate rich diet including plenty of rice and they have it three times a day which isn’t healthy. Alcohol is most probably the second reason for liver diseases in Sri Lanka, followed by Hepatitis B and C. With universal vaccination for hepatitis B the incidents are coming down. Now there is very good treatment available for Hepatitis C which wasn’t there for many years. Once you can control a disease the transmission comes down and over a period of time, Hepatitis C can be abolished but it would take another five to ten years.   

 Now there is very good treatment available for Hepatitis C which wasn’t there for many years. Once you can control a disease the transmission comes down

Q  What about children? 

Liver disease in children is also common in Sri Lanka, the most common cause being Biliary Atresia. This is where children are born with no bile ducts and they get jaundice. There is an important awareness problem here because when children are born with Biliary Atresia the paediatrician has to make a diagnosis immediately after birth and they have to have an operations within two months of life. If they undergo that surgery they can avoid liver transplantation. But most of these children would come for liver transplantation within one year of life. Other common causes include liver cancer and metabolic liver diseases which are genetic disorders which are transmitted from parents to children. This is common if parents are close relatives, cousin marriages and in those conditions also liver diseases are high.   

Q Is it the people in the rural areas that are vulnerable? 

No, it is the urban population. In urban population alcohol may be more common as a cause. In our part of the world, when people are healthy they eat more. If you eat more than what you need the food and fat gets stored in the liver which leads to liver disease. As such it’s common among people who are obese, people who have diabetes, high blood pressure and have higher incidence of heart attacks,. These conditions are completely inter-related. Cirrhosis due to fatty liver is related very much to diabetes and diabetes and overweight is an urban problem than a rural problem. The advantage for people in rural communities is that they work hard and they don’t sit at an office. They don’t sit in front of a computer, go home and sit in front of a television and then eat and sleep. Sedentary lifestyles cause liver problems.   

Q What are the symptoms a person would get if they have a failing liver? 

If the liver is failing the most common symptom is tiredness. Then they can get itching, they would become slow, then they’ll forget things and would get confused. The sleep pattern would be reversed and suddenly they will vomit large amounts of blood because it ruptures the veins inside their stomach. Finally their stomach gets swollen up.  

If you eat more than what you need the food and fat gets stored in the liver which leads to liver disease. As such it’s common among people who are obese, people who have diabetes, high blood pressure and have higher incidence of heart attacks

Q  What happens when there’s a damaged liver? 

It’s generally irreversible. But the liver is an organ that has a capacity to regenerate. It’s like skin, if you scrape the skin it can regrow. If you cut half a liver in an operation it can regrow to is full size in three weeks. But once cirrhosis has set in, it’s irreversible. That doesn’t mean that every person with cirrhosis requires a liver transplant. Patients with cirrhosis have to have specific symptoms like fluid overload, leg swelling, stomach swelling, vomiting blood, confusion in the brain and so on, because the liver affects all these organs. All of these complications need to be seen before a person with a liver disease requires a liver transplantation.   

Q  What are the instances that people would require a liver transplant other than cirrhosis? 

Liver cancer but we don’t do liver transplantation for advanced liver cancer. If you do liver transplantation for advanced liver cancer, the cancer can come back. So we need to diagnose it early. There’s another condition called acute liver failure where there is no cirrhosis. This is a condition where the liver is damaged rapidly and suddenly so patients would be well but they would die of their problem within one or two weeks. The liver completely collapses and they get confusion, brainedema and they would die. Then there are certain metabolic conditions where we do transplants.  

Q  What’s the procedure for donors when it comes to a donation? 

If you donate half a liver, it will grow back to the original shape. So it’s better to donate a liver than a kidney. But donating a liver is a much more complex operation than donating a kidney. Here you need to divide the liver into two and it is a very vascular organ and it needs to be done under special conditions. Donating a liver is more risky than donating a kidney but the long term effects of donating a liver is much less than donating a kidney.   

There is an important awareness problem here because when children are born with Biliary Atresia the paediatrician has to make a diagnosis immediately

Q  Tell us about live donor liver transplants.  

We do live donor liver transplants only for family members. If it is for a child, usually the parents are suitable as donors. They only have to donate around 20-25% of liver when they want to give it to their children. When donating for adults there they have to give about 50-60% of their liver which is a much bigger operation to donate to an adult. But both are very safe for the donors and the recipients have a 90-95% of survival in the long term. In expert hands it’s straightforward but it’s not as easy as one would think. The procedure for the donor operation would take about six hours, the liver transplant operation would take around eight hours.   

Q  After a transplant is done how should a patient take care of him or herself?

They grow and develop normally, they have a normal life expectancy. The difference between a normal person and a person with a liver transplant is that they have to stay on medicine. They need to take immunosuppressive drugs for their entire lifetime. They can be quite expensive too. If they stop taking the drugs the organ can reject which means they would need another transplant or they would die if they don’t get one. So it’s important that they take this medication lifelong and continue to be under medical supervision lifelong. This doesn’t mean that they have to come to hospital every week or month. Some of them come once in six months and after five years, they only have to come once a year. In terms of quality of life it’s much better with liver transplantation. On the other hand there’s no restriction in the diet as long as the person is healthy. People should stay healthy and avoid carbohydrate diet, engage in physical activities and eat healthy in order to keep your liver healthy for a long time. Drinking alcohol too much is not good for the liver and vaccinate children for Hepatitis B.   

Pics by Pradeep Dilrukshana