I can’t hide that one of my passions in gastroenterology is consulting liver diseases. I think the love for the liver is because I always knew that it is the “hardest” part of gastroenterology and I always loved challenges. My teacher, Dr. Alfredo Martén Obando (qdDg), was one of the first hepatologists in Costa Rica and he showed me his passion for the liver. When he died, I was in charge of the liver consultation of Dr. Martén at Hospital México, during my last year of specialization.
Later, I arrived at the San Rafael Hospital in Alajuela and began a specialized consultation on the liver and inflammatory bowel disease. I was the only person in charge of that consultation from 2005 to 2011 when I left the institution. I became fond of my patients and learned to love the liver, it is really an area where each case has to be analyzed individually, given special follow-up and the results notorious.
The consultation took place at the Marcial Rodríguez clinic in Alajuela (although it belonged to the HSRA), and it was already known that on Wednesday afternoon it was necessary to pay an extra hour to the secretary who was there because Dr. Navarro never managed to leave on time (at 4 pm). By the way, they never paid me for overtime (in the end it was my fault because I was the one who wanted to listen to my patients and recharged myself with emergencies).
The most common is treating patients with Chronic liver disease known as cirrhosis. Since cirrhosis is chronic, these patients must come frequently for consultation and become great friends. I try to be there for them at all times.
Liver diseases cover a wide spectrum, examples are:
Patients with chronic liver disease require close monitoring. Many support resources are used for this, such as ultrasound, blood tests, gastroscopies, and sometimes more complex studies such as FibroScan, CT, or Magnetic Resonance.
The first thing with chronic liver disease is to find out the cause, this because depending on the underlying disease, so will be the treatment. In most of them an intervention can be made but to do it, it is necessary to identify properly.
Patients with alcohol disease can stop consuming alcohol; those with non-alcoholic fatty liver can lose weight and control their diabetes well (if they have it); Wilson’s disease has specific treatments that prevent more copper from accumulating in the body; there are antivirals for hepatitis B and C; and autoimmune hepatitis, can be treated with immunoregulators.
It usually begins in the first decades of life and in many cases diminishes or disappears with advancing age.
The liver consultation of chronically ill patients should be at least every 6 months. All these patients have an increased risk of liver cancer, therefore there is a need to do an ultrasound and a tumor marker, every six months, to detect this complication early, so that it is treated successfully.
In these chronic patients, gastroscopies should also be performed regularly, to detect the formation of esophageal varices early. If there are varicose veins, it should be assessed whether only oral preventive treatment will be given or if a preventive program for varicose ligation will be started. This last option is the one that I personally prefer because it seems the safest for my patients.
Fatty liver patients without chronic disease will be stimulated to start losing weight, which will help them a lot in their disease. If everything is stable they can keep an annual check instead of semi-annually.
Subsequent complications, such as ascites (fluid in the abdomen) or hepatic encephalopathy (mental intoxication due to cirrhosis), must be strictly monitored and controlled, probably requiring a more strict and frequent follow-up than every 6 months.
In conclusion, the management of the liver disease has two important components: first, detecting the cause of the disease; and then, to give an adequate follow-up, to prevent complications and delay the evolution of the disease.