Liver disease in women is often untreated

Arvind Sahni

WOMEN are four times more prone than men to develop Auto-immune Liver Disease, which if untreated carries a high (90 per cent) mortality by 10 years. Women of any age can get affected. About 25 per cent of young women with autoimmune liver disease have cirrhosis at the time of initial presentation.

Hepatitis B infection during pregnancy, may cause disastrous complications and if there is a very high blood viral load of hepatitis B, in the mother (> 100,000,000 copies /ml), there is a 90 per cent chance of this virus being transmitted to the newborn baby. This method of transmission of hepatitis B is responsible for significant number of cases who develop hepatitis B during childhood and early adulthood.

Hepatitis C infection during pregnancy is much less efficiently transmitted to the newborn baby (less than 5 per cent). Hepatitis E is a common cause of jaundice. During pregnancy, especially in the late stages, it carries high mortality of 15- 20 per cent.

Women are more prone to develop drug- induced liver injury (DILI), this is especially true with anti-tuberculosis drugs, which may cause fatal liver failure if the offending drug(s) is not stopped in time. Young women on regular oral contraceptive pills (OCPs) may develop liver-related side-effects like jaundice and liver tumours. A woman's liver is twice as susceptible to the side-effects of alcohol as her male counterpart. Nonalcoholic fatty liver disease (NAFLD) is more common in women who have diabetes and are obese.

How to recognise liver disease
Jaundice may be a late manifestation of liver disease. Other symptoms are: Fatigue, anaemia, lethargy, weight loss or gain, loss of appetite, nausea, swelling of feet or abdomen, joint pains, menstrual disturbances, fever, vomiting of blood, passage of black stools, memory lapses and generalised itching. Physical examination by a doctor can detect liver enlargement and other clinical signs of liver disease. This can be confirmed by appropriate blood tests. Liver imaging by various modalities is helpful. Rarely, a liver biopsy will also be needed.

Mode of treatment
Hepatitis B infection may be treated with injections of Pegylated Interferon for one year. Highly effective oral drugs are also available to treat hepatitis B. These oral drugs are generally used long term. These oral drugs may also be used during the third trimester of pregnancy in hepatitis B positive mothers, where the risk of transmission to the new born baby is deemed very high. For hepatitis C, apart from the conventional therapy which includes Pegylated Interferon and Ribavirin, new directly acting antiviral (DAAs) like Sofosbuvir will be available in India very soon. In case of drug-induced liver injury, the offending drug needs to be stopped immediately, before fatal acute liver failure (ALF) sets in.

For auto-immune liver disease, a prolonged therapy (in years) with steroids is helpful in over 80 per cent of cases. However, there is a high likely hood of relapse of 50 per cent at six months and 80 per cent at three years, once the therapy is stopped. Less than 10 per cent of cases of AIH may need a liver transplant.

Preventive steps
All women, particularly of child-bearing age must be tested for and vaccinated against hepatitis B. Three doses of the vaccine are given at day 0, one month and six months. This is an excellent vaccine, with no side-effects and with a protection rate of 90-95 per cent for over 20 years. Babies born to hepatitis B positive mothers must receive Hepatitis B Immunoglobulin (HBIG) and hepatitis B vaccine at birth. There is no vaccine available against hepatitis C. Regular monitoring of liver function test (LFT) and to recognise early symptoms of liver damage, even before the onset of jaundice, may be lifesaving, by stopping the offending drug immediately. Avoid taking over-the-counter (OTC) drugs, which may cause liver damage. To prevent the complications associated with nonalcoholic fatty liver, women are encouraged to lead a healthy lifestyle, avoid alcohol, fast food and do regular exercise for at least five days a week for an hour daily.

The writer is Director- Gastroenterology, Fortis Hospital, Mohali.