Liver Disease is clinically silent in its early stages and shows symptoms when it’s too late.
Liver disease encompasses a broad spectrum of conditions with impaired hepatic function. The condition can adversely affect your health and progress to a severely dysfunctional liver requiring medical intervention. In this Special Scoop, let us learn more about liver disease and its care and treatment strategies with Dr. Santi Kulpatcharapong, a gastroenterologist, who shares valuable insights and interesting perspectives on modern liver disease management.
Causes of Liver Diseases
Dr. Santi explains that the liver is primarily composed of two key cellular components, including hepatocytes (liver cells) and the biliary ductal system. Blood tests can detect most liver abnormalities stemming from these components.
“The hepatocytes are evaluated by measuring blood liver enzyme levels known as AST (SGOT) and ALT (SGPT). When the liver is injured or inflamed, these enzymes are released into the bloodstream, resulting in elevated levels, which indicate hepatic inflammation. Another approach is to assess its synthetic function, specifically its ability to make certain proteins, to determine whether these levels are abnormal.
For the biliary system, we assess alkaline phosphatase (ALP). If released from bile duct epithelial cells, it may indicate impaired bile flow or biliary obstruction, leading to elevated serum levels.”
Assessment also includes determining bilirubin levels. Elevated bilirubin levels cause the yellowing of the eyes and skin, known as jaundice.
Subtle symptoms often mask early-stage liver disease.
“Regarding liver disease, by the time discernible abnormalities or symptoms appear, liver enzyme levels have typically risen significantly. For instance, in hepatitis, symptoms such as nausea, vomiting, and abdominal discomfort usually develop only when inflammation becomes markedly pronounced, with enzyme levels often elevated four to five times above normal or, in some cases, up to tenfold, before symptoms become evident,” the doctor explained.
These are why regular liver screening is important, especially for those at higher risk, such as older individuals, those who are overweight, habitual drinkers, or those with a family history of liver disease.
“I am not suggesting that everyone needs to undergo comprehensive testing every year. The priority is to follow the doctor's recommendations. For most people, a general screening suffices. However, once you reach a certain age or if a doctor identifies specific risk factors during your annual health checkups, further specialized testing may be advisable on an individual basis.”
Fatty Liver: The Most Prevalent Condition Doctors Encounter
When asked which liver condition he sees most often in his practice as a gastroenterologist and hepatologist, the doctor answered “fatty liver” without hesitation.
“From our clinical experience and observations, fatty liver disease is the most commonly diagnosed condition. While this condition isn't the leading cause of hospitalizations or liver-related deaths compared to hepatitis B or chronic alcohol use, leaving it unaddressed will undoubtedly lead to serious multiple health complications down the road.”
Alcoholic vs. Non-Alcoholic Fatty Liver: What is the Difference?
"While both involve fat buildup in the liver, non-alcoholic fatty liver is often associated with a range of comorbidities, particularly cardiovascular disease, diabetes, dyslipidemia, and hypertension. These conditions frequently coexist and increase the risk of stroke and heart attacks, which actually account for a higher mortality than liver disease itself. Therefore, if you have fatty liver, it’s a clear signal that your health is likely at risk from more than one underlying condition.”
Heavy and consistent drinking causes even more generalized liver damage. It leads to acute and chronic liver inflammation, eventually progressing to cirrhosis. Whether the cause is heavy alcohol consumption or non-alcoholic fatty liver disease, both can lead to cirrhosis and, ultimately, increase the risk of developing liver cancer.
Other Risk Factors of Cirrhosis and Liver Cancer
In addition to fatty liver disease and chronic alcohol use, viral hepatitis is another cause of chronic liver inflammation. Fortunately, hepatitis B is preventable through vaccination. Although no vaccine exists for hepatitis C, it is now curable with modern antiviral medication under appropriate ongoing care. Other contributing factors include hereditary conditions and autoimmune diseases, which can also trigger liver inflammation.
From Hepatitis to Liver Cancer
If left untreated, liver inflammation progressively worsens, leading to the accumulation of fibrous tissue and scarring. As the liver undergoes repeated cycles of injury and repair, it becomes increasingly stiff and may ultimately progress to cirrhosis, a condition that significantly increases the risk of liver cancer.
“When cirrhosis develops, it has a profound impact on overall health because the liver is the largest internal organ and functions much like a detoxification plant. It is also a primary production site for vital substances, including proteins, blood-clotting agents, and bile, essential for lipid absorption. Once the liver becomes dysfunctional, the complications depend on the severity and extent of damage. Often, noticeable symptoms appear only after significant liver dysfunction has already occurred.”
As liver function progressively deteriorates, protein synthesis declines. Without adequate plasma proteins to retain fluid within the vascular system, ascites, generalized edema, and leg swelling occur. Moreover, inadequate bilirubin excretion will lead to jaundice.
In advanced cirrhosis, intrahepatic vascular resistance increases, impeding blood flow through the liver. These cause the body to form bypass vessels in various parts of the abdomen, leading to intra-abdominal varices (enlarged veins) that are prone to rupture and bleeding. Ultimately, when the organ is chronically damaged and undergoes repeated cycles of repair, the genetic material (DNA) can become mutated. These are primary mechanisms that trigger cancer, which is why individuals with cirrhosis face a significantly higher risk of developing liver cancer.
Liver Disease Management: Preventing Cirrhosis and Liver Cancer
One of the eminently preventable risk factors is viral hepatitis. Nowadays, vaccines are available for hepatitis A and B, and antiviral medications can effectively cure hepatitis C. Dr. Santi recommends that individuals born before 1992 (B.E. 2535) should get tested to see if they have immunity against viral hepatitis. If no immunity is detected, vaccination is highly advisable. Modern vaccines are proven to be highly effective and have a long-standing safety record spanning several decades.
“Hepatitis, whether you are symptomatic or not, if a hepatitis virus is detected, you are a carrier. It carries a risk of liver cancer, so it is vital not to be complacent. Additionally, the virus can be transmitted to others, making it essential to consult a doctor and develop a long-term health care strategy.”
Therefore, if a hepatitis infection is detected—even if it is too late for a preventive vaccine—antiviral medication can suppress the virus, allowing patients to live a normal life. However, strict adherence to the medication is necessary, as stopping treatment can cause the disease to flare up.
Once controlling viral hepatitis risks, how should liver diseases caused by fat accumulation and fibrosis be managed? The doctor recommends undergoing screening, which is highly beneficial.
Painful Screening Procedures May Discourage Patients from Seeking Evaluation.
“Nowadays, we have totally painless options for patients," the doctor quickly reassured.
Previously, definitive assessment of liver disease required an invasive “liver biopsy.”
Given the associated discomfort, it was generally reserved for patients with advanced disease, as those without symptoms were often reluctant to undergo the procedure.
“Advanced diagnostic technology now makes it much easier for us to obtain quantitative data on liver fibrosis, eliminating the need for a biopsy and associated discomfort. These enhance screening, particularly for fatty liver disease, a common condition in which early intervention is far more effective than treatment at advanced stages.”
The doctor highlights FibroScan, a screening tool for fatty liver disease and liver fibrosis. This technology uses a system similar to ultrasound to measure liver stiffness. It provides two key types of data, including the percentage of fat in the liver and liver elasticity, which reflects the degree of fibrosis. The higher the fibrosis score, the closer the liver is to cirrhosis. These enable the detection of abnormalities while patients are still asymptomatic, without causing pain.
“This screening approach encourages asymptomatic individuals who are at risk, such as those with high-risk lifestyle behaviors or a family history of liver disease, to seek evaluation more readily. It enables doctors to intervene earlier, resulting in more effective disease management. If elevated levels of hepatic fat or fibrosis suggest a risk of progression to cirrhosis, a liver biopsy can then be performed for definitive assessment.”
Furthermore, FibroScan can be used to monitor disease progression and track treatment response, by showing how the liver condition changes, reductions in fat accumulation and fibrosis, and treatment effectiveness. These measurements help doctors in evaluating the effectiveness of treatments.
Fatty Liver Disease: Treatable; It’s Not Too Late
“When diagnosed with a fatty liver, the primary focus for patients is weight control. Gastroenterology and hepatology specialists often collaborate with endocrinologists to provide care and nutritional guidance. Patients should also have their blood glucose and lipid levels regularly monitored and limit alcohol consumption.”
If cirrhosis has already set in, treatment focuses on preventing complications. However, Dr. Santi recommends intervening during the fatty liver or fibrosis stages. Once cirrhosis occurs, it is very rare for the liver to regain its original elasticity and function. While some reduction in stiffness or fibrotic thickness is possible, early detection and treatment remain far more effective for long-term health.
“In the event of a liver cancer diagnosis, the medical team will stage the disease and plan a stage-specific therapeutic regimen accordingly, alongside managing liver function and monitoring for potential complications, such as infections, internal bleeding, or ascites, and implementing dietary control to minimize complications and ensure the best possible quality of life for the patient.”
Do not wait for symptoms to appear, as symptomatic liver disease often indicates that the condition has already progressed to an advanced stage. Regular annual health checkups are advisable to assess risk. If you are in high-risk groups, you should undergo screening for early detection and prevention. The tests are simple and non-invasive.