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Science Today
- Frankenstein
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Alcoholic hepatitis, the excessive insult and disinterest in our liver health
Every beginning of the year we travel to enjoy the low temperatures of the north of the country, scenarios covered in white. Sadly, nothing is forever. We find spectacular sunsets and the wonderful flora and fauna of the Sierra de Arteaga. But there was no snow anywhere. The solemn meeting and disappointment of the little ones was cushioned by the company of pleasant friends. Once installed in a comfortable cabin we lit the fireplace while advancing the starry evening at the top of the forest: Alejandro Flores in a serious and shocking tone said: “I do not augur a good summer.” To which I immediately asked: Why such an optimistic comment? He went on to explain the following:
Fred Pierce published in 2006 the book When the rivers run dry: water – the defining crisis of the twenty-first century. The very structure of the book is a path to a deeper understanding “of the water problem,” which in much more systemic terms, says: “When rivers dry up: I) crops fail, II) we mine our children’s water, III) wetlands die, IV) floods may not be far away, V) engineers pour concrete, VI) men go to war for water and VII) civilizations fail... dystopian panorama very popularized by movies like Mad Max... However, he also talks about how when the rivers dry up: VIII) we go to look for new water, IX) we try to catch the rain and X) we go with the flow.
Water management is a complex issue (and technically a system), one of those known as “wicked problems” since it has an impact on all aspects of life (ergo complexity). A lack, then, is the effect of a series of causalities. For example, some finds found from southeastern Baja California Sur may illustrate “the roots”:
1) More water use rights have been granted than is available (increasing the deficit).
2) In 20 years, we will need at least 46% more water than we have (increasing the load on the system).
3) The majority of the population does not know the quality of wells and water sources in their region (lack of information).
4) There are different ways to get more water, we must evaluate its economic, social, and environmental advantages and disadvantages (there is no generalized solution).
5) Accelerated growth has been observed in the Eastern Cape (BCS), so more studies and information are needed to plan for the future and prevent a water crisis.
Looking at it that way, the right question is what do we use water for? Flushing a toilet consumes between 7.5 and 26.5 liters of water. In our civilization we do not use water correctly. So many liters of common and clean water to discard approximately between 300 and 450 ml of urine in a urination. Last summer the sultan of the north was scarred because we faced an unprecedented water crisis. Some companies donated 7.5 million cans of water, equivalent to two and a half million liters of the liquid and were distributed in the communities most affected by the water crisis. However, it is here that the judgment of humanity is questioned.
When we define our priorities, making decisions is extremely simple. The problem is who defines those priorities. To give an example: historically alcohol consumption has been a part of human culture. Alcohol has been consumed as part of religious rituals and rites, but also as a safe, nutritious and healthy drink, as it has antimicrobial properties and contains calories. However, alcohol is a toxic substance; it is not produced by the body and is poisonous in high concentrations. Alcohol consumption levels and patterns of alcohol consumption are associated with chronic diseases. In general, light and moderate alcohol consumption (up to 14 g per day for women and up to 28 g per day for men) may be associated with a lower risk of mortality, mainly due to reduced risks of cardiovascular disease and type 2 diabetes.
Alcohol consumption dates back to our primate ancestors. In Greece, in the city of Hierakonpolis, is where the ruins contain evidence of the oldest brewery in the world dating back to 3400 BC. In Athens, the consumption of wine was considered a civic duty almost exactly as in our present age. The Romans were the next great drinking civilization to emerge in the classical world. When Dionysus’ followers arrived in Roman territory in the second century B.C., they were met with suspicion. People who congregated in large groups for the purpose of getting drunk made no sense to this sober society.
The Romans decided it was all part of a sinister plot to overthrow their rule; yes, from the Romans to the present day “Panem et circenses”.
In Christianity, wine could not only quench thirst and inspire joy, but it could also represent the proven blood of the son of God. The Crusades were a series of religious and political wars fought between Christians and Muslims for control of the Holy Land. When the Crusaders returned home, they were surrounded by unlimited opportunities to enjoy alcohol. Everyone in Europe drank and drank several times a day. Arnald de Villanova was a physician and alchemist who promoted the use of alcohol as a cure for any ailment. He believed that wine was suitable for all ages and blessed everyone in good health. He experimented with the science of distillation and called distilled spirits aqua vitae (water of life). Distillation first flourished in Germany, and, in the fifteenth century, apothecaries sold liquors to the public in gulps as a health tonic. In 1492, the Spanish kings, Ferdinand and Isabella, financed a fleet of ships that sailed across the Atlantic to the Americas. In 50 years, the Spanish conquered the Inca and Aztec civilizations and established an empire stretching from Florida to southern Chile.
Alcohol consumption peaked in the 1870s and then began a downward trend. As the world be- came more industrialized, drunkenness was not compatible with a reliable workforce. Currently as in the Hellenic civilization alcohol consumption is everywhere, music concerts, football matches, birthdays, funerals, an entire industry around and no effort to avoid having a risky alcohol consumption. This idea doesn’t sell pleasure, I’m not going to write something ephemeral, these lines sell a long-term reward known as happiness.
Globally, half of deaths due to liver cirrhosis are alcohol-related. In Mexico, liver cirrhosis related to alcohol consumption also accounts for approximately 50% of the causes. This generates a public health problem that directly impacts high mortality and, as a consequence, high costs for the health system. Unlike other regions of the world, Mexicans have the highest alcohol consumption score and a high mortality rate from alcoholic liver disease with an intermediate category level of alcohol consumption per capita. Mexico has a unique history of alcohol consumption that is linked to profound anthropological and social aspects (1).
It is well known that Mexico has the need to implement multisectoral interventions, strengthen psychosocial competencies to achieve the improvement of quality and access to mental health and addiction services. In Mexico, these measures must be implemented from childhood. Patients with alcohol-related liver disease require comprehensive psychiatric evaluation and concomitant management by trained addiction personnel.
Alcoholic hepatitis (HA) is a frequent condition in the Mexican population, which is usually characterized by acute chronic liver failure (ACLF) for its acronym in English acute-on-chronic liver failure, important systemic inflammatory reaction and multiorgan failure, which in the severe variant of the disease implies a high mortality. The Mexican population has a mixed genome inherited from different races, Caucasian, Amerindian and African, with a heterogeneous distribution within the country. Thus, the genes related to alcohol addiction can vary from one individual to another. In addition, they can be inherited as risk or risk-free haplogroups that confer susceptibility or resistance to alcohol addiction or alcohol abuse and possibly liver disease.
Alcohol-related liver disease (AHD) comprises varying degrees of injury ranging from simple steatosis to cirrhosis. Simple steatosis, initially macrovesicular and later mixed (macro and microvesicular), is the earliest change and is present in 90% of individuals who consume alcohol riskily; however, this injury is often reversible after abstinence. Although the prevalence of each histological lesion in AHD is not known exactly, it is estimated that 25% of patients with HD develop steatohepatitis and that about 15% progress to cirrhosis. The cumulative 5-year risk of developing hepatocarcinoma in patients with alcohol cirrhosis is estimated at 1%.
The quantification of alcohol consumption becomes relevant. The WHO, in its guidance on brief intervention to avoid risky alcohol consumption, defines a standard drink as 10 g of pure ethanol and recommends, for both men and women, not to exceed two standard drinks per day. The amount of alcohol contained in a drink varies according to each continental region, and even differs in each country of the world. For the particular case of Mexico, the Official Mexican Standard (NOM) on “Alcoholic beverages. Sanitary specifications. Sanitary and commercial labeling”, published in the Official Gazette of the Federation (DOF) in March 2015, indicates that the approximate alcohol content in a “standard drink” is 13 g considering that its specific gravity is 0.785 g/mL.
The amount of alcohol consumed, regardless of the pattern of consumption, is the most important risk factor for developing AHD. Women are more susceptible to liver damage from alcohol than men. Some studies have even reported that women have a higher risk of suffering from HA by consuming half the dose of alcohol considered risky in men, likewise, women have a higher risk of accelerated progression of the disease and risk of developing cirrhosis vs. men. In patients with other diseases such as metabolic syndrome or chronic viral hepatitis by B virus or virus C, alcohol consumption, even in less than what is considered “risky consumption”, can favor and accelerate the progression of liver damage.
Hepatitis or steatohepatitis (AH) by alcohol has a large number of clinical manifestations ranging from asymptomatic state, with minimal symptoms or clinical signs of disease in its mild form, to a picture characterized by acute liver failure over chronic in its severe form. HA with a MELD (Model for End-Stage Liver Disease) score equal to or greater than 21 has an elevated risk of mortality at 3 months. The main causes of mortality at 90 days were: sepsis 20%, liver failure 24% and multiorgan failure 46%. In this same study it was shown that the amount of alcohol consumed has a negative impact on the survival of patients. Human malnutrition is another factor of poor prognosis. Diagnostic test for liver disease is liver biopsy and can be performed to establish the definitive diagnosis of liver disease related to alcohol consumption, to assess the exact stage and prognosis of liver disease and to exclude additional or alternative causes of liver damage. However, due to being an invasive procedure is not recommended in all cases and the risk against the patient’s benefit should be evaluated individually.
Considering the history of risky alcohol consumption, bio-chemical alterations, together with the exclusion of chronic viral diseases such as hepatitis B or C, or autoimmune diseases, is usually sufficient to reach the diagnosis of cirrhosis due to EHA. Ultrasound, tomography and MRI can quantify steatosis and help exclude other causes of chronic liver damage, can recognize advanced stages of the disease (cirrhosis) and its complications.
Measurement of liver stiffness by elastography is useful for assessing liver fibrosis in alcohol-related liver disease. Among the radiological methods available to evaluate fibrosis, elastography has the highest validation for the detection of advanced fibrosis, and the best performance in ruling out the presence of cirrhosis compared to its performance in confirming the presence of cirrhosis.
Additional association studies will be required to establish novel strategies for the prevention, care, and treatment of liver disease in Mexico and worldwide. Patients with alcohol use disorder have a high prevalence of psychiatric comorbidity, especially anxiety disorders, affective disorders, psychosis, post-traumatic stress disorders, and schizophrenia. They may also have a history of sexual abuse, physical abuse, or social isolation. This may be a factor that will increase the risk of relapse into alcohol consumption. This is why the consensus recommends a psychological and psychiatric evaluation, who should be responsible for the management of substance abuse, including alcohol. In addition, they are at high risk of developing other addictions, opioids, benzodiazepines and nicotine. The synergy of alcohol and tobacco use is established as a major risk for cardiovascular disease and cancer, including hepatocarcinoma. It is common for patients with chronic liver disease to lose withdrawal and cannot imagine how many times I have heard the phrase:
Laudanum was a medicine that bohemians consumed indiscriminately due to its narcotic properties. These properties were one of the factors that predisposed Mary Shelley to write the future of a patient with a risky consumption of alcohol through Frankenstein. Mary Shelley writes about Frankenstein as if speaking in her own flesh: I saw—with her eyes closed, but with keen mental vision—I saw the pale student of ungodly arts, kneeling beside the being she had assembled. I saw the horrendous ghost of a man lying down, and then, by some powerful ingenuity, I saw him manifest signs of life, and shake with clumsy and semi-vital movement.” It captures with perfect mastery over scientific morality, but also the pleasures of creation and destruction of life and the daring of humanity in its relationship with God.
Dr. Ana Villaseñor-Todd
Scientist, doctor by profession and Mexican businesswoman noted for her studies in minimal hepatic encephalopathy, oxidative stress, quality of life and social cognition. Certified by the Pan American Health Organization (PAHO) as a facilitator of MhGap; CEO VICOMMA Group.
Technical committee: Alejandro Flores Márquez Systemic and strategic thinker with experience in sustainability, social change and conservation for the development and strengthening of local communities as a way to leverage environmental and lasting change.
Sources
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2. Khaderi, S. A. (2019). Introduction: Alcohol and alcoholism. Clinics in Liver Disease, 23(1), 1–10. Retrieved from: https://doi.org/10.1016/j.cld.2018.09.009
3. Velarde-Ruiz Velasco, J. A., Higuera-de la Tijera, M. F., Castro-Narro, G. E., ZamarripaDorsey, F., Abdo-Francis, J. M., Aiza Haddad, I., Aldana Ledesma, J. M., Bielsa-Fernández, M. V., Cerda-Reyes, E., Cisneros-Garza, L. E., Contreras-Omaña, R., Reyes-Dorantes, A., FernándezPérez, N. J., García-Jiménez, E. S., Icaza-Chávez, M. E., Kershenobich-Stalnikowitz, D., Lira-Pedrín, M. A., Moreno-Alcántar, R., Pérez-Hernández, J. L., Torre-Delgadillo, A. (2020). Consenso Mexicano de hepatitis alcohólica. RevistadeGastroenterologíadeMéxico(English Edition), 85(3), 332–353. Retrieved from: https://doi.org/10.1016/j.rgmx.2020.04.002
4. Rodríguez-Aguilar, E. F., García-Alanís, M., Pérez-Escobar, J., Sánchez-Herrera, D., Toapanta-Yanchapaxi, L., Ávila-Rojo, E., Visag-Castillo, V., & García-Juárez, I. (2022). Trasplante hepático en hepatitis alcohólica aguda: ¿debemos decir que no? Cirugía y Cirujanos, 90(5), 700–705.Retrieved from: https://doi.org/10.24875/CIRU.21000523
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