First, let me get my favourite gripe out of the way: I am often not given the same importance as my colleagues and co-organs, the heart or the brain. I wonder why. Because and let me assure you here, I am just as important for your health. It’s of some consolation to me however that I am also the subject of romantic folklore and tales of great human endeavour, privileges the heart and brain have annexed to exclusivity at times. Of course, I also am connected to flip side of the socio-emotional issues like jealousy and rage, but my esteemed co-organs don’t escape this rap either, so I would say it’s a fair world!
Let me tell you where I live
I am below your diaphragm, behind the left 5th-10 ribs, in close proximity to the gall bladder and stomach. No, you can’t really feel me, but your doc can, under your right ribs. What’s more, unless I am supersizing myself (bad sign), you can’t really feel me.
I have the softest sheath called the Glisson’s capsule covering me, which protects me. Call it my precious pashmina . And when you breathe deep and full like all good healthy human beings should to give their lungs a workout, I, a real sweetie, move off a bit downwards to let my friend the right lung have his moment of glory - and expand. (I told you I am a well-behaved guy.)
My vital stats
I am the heaviest of your glands, weighing a whopping 1.5 kgs. Next to your skin, I am the largest organ you possess. (Did you know that?)
What do I look like? Some say very strong and pretty, others feel I haven’t really won the lottery in the looks department. I am firm, toned and a mass of fragile dark red tissue. Paradoxically, despite my fragility, I endow you with strength and stamina.
My tissues are extensively irrigated by a complex network of blood vessels reaching deep inside my core. In fact, there are two distinct systems of circulation, one set (the portal system) bringing me blood from the intestines and another set (systemic circulation), much the larger, bringing me blood from the heart.
And here comes the smart bit: I am unique from other tissues in one surprising way - I can regenerate my own tissues. If I am cut, for example, and a part of me is removed - as it is when transplanted into another person whose liver is damaged beyond repair - the cells of the remaining part of me can multiply and I become near normal again. How super smart is that?
My job description (and it’s an impressive one even if I say so)
To begin with, I am well disciplined and rarely, if ever, cause problems. Unless you do something really bad to get me all worked up. (More about that later as you read on).
I am essentially a powerhouse in which complex chemical reactions take place every minute of the day. Frankly, you don’t have any idea of the sheer complexity of the work I carry out. I work so silently that sometimes you may wonder if I am present in your body at all. Whether you are watching a movie and mindlessly shovelling the contents of a bucket of popcorn down your gullet, driving to work and downing an energy drink, enjoying yourself at a party and overdoing it, eating a double cheese burger at mid night, or popping medicines at the sound of a sniffle, I am watching you... and when you are done with your indulgences, I clean up after you and take out the trash.
It’s a good thing I work hard because your life depends on it. Trust me.
Allow me to enumerate the things I do to keep you healthy:
1) I work on the glucose you have produced after a heavy meal. You know you eat all those double and triple helpings and what’s the result? You end up with so much glucose, most of which you don’t need at that time. What happens to it? I convert it into insoluble glycogen and save it for a rainy day.
2) On days when you don’t have the time to eat a proper meal or skip it entirely (you did that twice last week thanks to your disorganised boss and his last-minute agenda revisions) my colleague, the blood sugar, tends to act up, or rather down. Since I can’t bear to see you in a slump and have things swimming in front of your eyes, I open the storehouse of glycogen and convert some it back into glucose so the blood sugar behaves itself.
3) I convert non-sugary substances like amino acids into sugars, if necessary, and make several proteins for you, notably albumin and the factors needed for your blood to clot. That nick from your kitchen knife last week? How do you think the blood stemmed and clotted?
4) I also make cholesterol. Aha, now that has got you worried, right? Relax. Don’t get carried away by all this super-scary stuff about cholesterol and its really nasty intentions. You need a certain amount of cholesterol to stay healthy. In fact, if someone were to remove all the cholesterol from your body, you would not be able to live. It is crucial to the production of certain hormones and cellular repair.
I make about 700-900 mg of cholesterol per day. About 300-500 mg comes from your diet (if you eat sensibly.)
5) I convert the highly toxic ammonia (which is a by-product in your body when protein is broken down) into urea which your bloodstream carries to the kidneys and they do a terrific job of getting rid of it. So, I hope you get the drift here. The more red meats and super-heavy proteins you eat, the more I have to hammer away at the ammonia. You can of course imagine what would happen if ammonia was given a free run inside your body.
6) I also make bile which is stored in a small pouch below me - inside my other friend, the gall bladder. This green liquid is essential for fat digestion.
7) I detoxify many poisons and medicines to render them harmless. Yeah, all those OTC drugs and antibiotics and whatever else you pop to banish the sniffles, fever and flu, someone needs to tackle them, right? I do it.
8) I also make cells required for your immunity (from infections). Super important job because without immunity, you are aware of how vulnerable you can be to infections.
My wish list (it’s so humble, I wonder why it’s not granted more often to me)
1) Please eat a balanced diet. There we go again. Yes, I know this is almost become a cliché but don’t you know by now that the clichés are timeless truths? In any case, how difficult is it to eat a balanced meal? Fats, salt, sugar in limited quantities, good, lean protein and complex carbs in healthy quantities, vegetables and fruits in generous quantities? What part of this advice don’t you get? Okay let me out it to you in another way. Imagine you are a house proud person and your spouse is a mess-maker. Every time you put your house in order, he dirties it. Every time you purge your home of unwanted stuff, he brings more of it into your home. Eventually, you get tired of cleaning things, putting them in place, throwing unwanted stuff out because there seems to be no end to it… and the junk keeps piling up. How do you think you would feel? I am like that home trying to keep my clean, efficient and free of junk. You can help me, you know. I hope this makes things more clear about why I insist that you eat a balanced meal and keep the junk out.
2) Alcohol. Yes, the stuff that makes me want to quit once and for all. You see my friend, it is poison for me. Cleaning it or rather processing it and keeping you safe is a laborious task and the more you imbibe it, the more I get shattered trying to clean up for you. It’s the most hated task for me, to process all that poison so I can keep you safe. I am the happiest when you go off alcohol because every time I have to deal with it, I get damaged a little. But I do it because, well, aren’t we in it together?.
3) Get shot! When you get a full course of Hepatitis vaccines, it’s like throwing me a lifeline. I am saved from self-destructing myself in bad circumstances.
4) Go out and exercise. Yes, that’s right. Like my co-inhabitants, heart, lungs, brain, I too benefit from your exercise. The blood seems to flow much faster through me, a bit like how you drive faster through a street that is clear of traffic.
5) Give yourself a clean chit. Maintain hygiene in your day-to-day life, especially in your food habits, thus avoiding the many infections that transmit through dirty water and food - the so called faeco-oral route. My worst nightmare is to be invaded by germs. That really gets me. It’s a battle I sometimes may even lose because they are nasty creatures, who don’t follow the rules of warfare. Fighting dirty is not my forte, it’s theirs. So be careful about inviting them, okay?
6) Cigarettes. What can I say about them which has not already been said? Every puff you take chokes me. Enough said already.
My nemesis (and it is usually yours too)
1) I may be afflicted with a wide variety of conditions: infections-acute or chronic hepatitis of which there are several varieties, hardening of my substance (cirrhosis), cancer (both local and that carried to me from another part of the body by blood) and what is known as the fatty liver.
2) If I am not well, I usually do not say so at first. I fight it out, I am a valiant being. But if you persist on dumping me with trouble, I guess I do give up out of despair eventually. When a large part of me is affected, I start making noises, so to speak. I mean, if you are harassed by your friend five days a week, won’t you call it quits with him?
3) So when I am giving up on my faith in you, you may get jaundice, a swollen body and bleeding tendencies. You may also tire easily, lose your appetite and have pain in the abdomen.
4) If you do suspect that I am not at my best behaviour, please visit a doctor who will administer some TLC and help me and you get back our respective feet. The doctor will take your detailed medical history and try to delve deeper into your usual lifestyle. He will do a complete physical examination, check your eyes to rule out jaundice and try to feel me with his hand below your ight ribs. (You have to be an expert to actually be in touch with me).
5) The doctor may then recommend a battery of blood and urine tests that will absolve, or implicate me, pretty easily. Since I am a living chemical laboratory for all practical purposes, is it surprising that my illness is reflected readily in the tests? The jaundice may reflect as raised Bilirubin levels of which there are 2 main types. Either type may be raised depending on the nature of my illness. Also, the blood level of a few enzymes may go haywire and may be indicative of serious illness. The more advanced sonography and CT scan tests are, of course, available for finding out my structural abnormalities more precisely.
MEDICINES AND ME
The many medicines available for liver disease essentially serve to buy time till the liver is in a position to mend itself, which it does quite well and quite often. The liver is able to repair itself and carry on while the medicines hold out in the mean time.
INVESTIGATIONS I REQUIRE
1) BILIRUBIN test ( DIRECT and INDIRECT) to ascertain jaundice and its type.
2) ALBUMIN test.
3) TOTAL PROTEINS.
4) ENZYMES ALANINE AMINOTRANSFERASE - ALT
ASPERTATE AMINOTRANSFERASE - AST
GAMMA GLUTARYL TRANSFERASE - GGT
ALKALINE PHOPHATASE
(Elevated levels of the first 2 enzymes indicate liver cellular damage. Elevated levels of the last 2 enzymes indicate obstruction in the bile flow.)
5) PROTHROMBIN levels (show liver synthetic function).
6) VIRAL SEROLOGY FOR HEPATITIS B AND C, CYTOMEGALO VIRUS, EPSTEIN BARR VIRUS AND HIV.
7) AUTOANTIBODY SCREEN.
8) IMMUNOGLOBULIN STUDY.
9) FERRITIN.
10) ALPHA FETOPROTEIN.
11) BIOPSY OF LIVER TISSUE.
The doctor does a complete physical examination and checks for the liver, spleen, free fluid in the abdomen, obesity, lymph nodes, anaemia and jaundice. The history may include questions regarding drugs intake, tattoos, unprotected sex, alcohol intake, occupation, history of diabetes, high lipids in blood and family history.
CAN THERE BE ANOTHER ME?
Sometimes, yes. It’s not a desirable outcome of my association with you but if I am damaged beyond repair, you have to get rid of me and undergo a liver transplant. It is a very complex and time-consuming surgery and can be fatal for 0.5-1% of donors even in the best set-up.
In this procedure, which is a complex procedure, a chunk of the liver tissue is taken out of a donor and fitted into you (LDLT-Living Donor Liver Transplant). The transplanted piece continues to function in the your – its new host - body without missing a beat (so to speak). But does that mean you will now have only a piece of liver as a make-good? And what happens to the donor? Does he have to live with a chunk of his liver missing? If you remember what I told you about myself earlier on, you will know that I have an astonishing ability to regenerate. So I grow and multiply my cells to make myself whole again in both your body and his. So, in 4-6 weeks, the donor liver approaches 100% function. At the end of the day, both parties end up with two full livers respectively. Wonderful, isn’t it?
Liver transplant can also be done as an orthoptic allograft where I am in my diseased entirety is removed and a healthy liver from a recently demised person put in the same place in its entirety. Liver transplant was first performed in 1963 by Dr Thomas Starzl but success rate continued to be dismal till the 1980s.
While you are waiting for a donor, a liver dialysis can be considered while waiting for a donor.