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PROTECTING YOUR LIVER

Environmental Toxins

The liver has a unique function of processing the chemicals and drugs which enter the blood stream, via inhalation, ingestion, or injection. Among these are drugs, industrial solvents, and pollutants. The liver helps remove these chemicals from the blood stream by changing them into products that can be readily removed through the bile or urine. During this process, unstable toxic products are sometimes produced, which can attack and injure the liver.

Because of the role the liver plays in removing toxins (drugs and chemicals), almost every known drug has been implicated as a cause of liver damage. Some of these toxins are predictable liver toxins, which are substances that are known to cause liver damage, following high exposure or prolonged exposure. Other substances may only cause damage in a very small percentage of people and are called unpredicatable liver toxins. Examples of predictable liver toxins are below.

Predictable Liver Toxins

Alcohol: Alcohol is primarily metabolized by the liver, and these metabolites can cause liver damage.

Drugs: Numerous medications can damage the liver, ranging from mild, asymptomatic alteration in liver chemistries to hepatic failure and death. Liver toxicity may or may not be dose-related. Dilantin (an anti-convulsant) and isoniazid (an anti-tuberculosis agent) are examples of drugs that can cause 'viral-like' hepatitis.

Chemicals/Poisons Both environmental and industrial toxins can cause a wide variety of changes in the liver. If your work or hobbies involve exposure to toxic chemicals, wear adequate protective gear. Toxic chemical exposure can damage the liver.

The damage incurred by exposure to these toxins varies from person to person and is not necessarily dose-dependent. These exposures may pose no risk to many people and yet cause serious problems to other's who have had just brief exposures. Liver damage that results from toxic exposures can range from mild, asymtpomatic inflammation to fulminant failure or progressive fibrotic changes and cirrhosis. To be safe, always follow the directions on medication and chemical labels. If in doubt, consult with your healthcare practitioner, first. And as always, avoid any unnecessary exposure to alcohol, drugs, and chemicals.

References:
American Liver Foundation. Prevention of Liver Disease. 

Medication Use

A variety of both prescription and over-the-counter medications have been known to cause damage to the liver. The damage may range from mild changes in liver chemistries to hepatic failure and death. Furthermore, drug-related liver toxicity is not necessarily dose-dependent. While most any drug is capable of causing liver injury. Some of the prescription and over-the-counter (nonprescription) medications, as well as herbs and supplements that are more likely to be toxic to the liver are listed below.

Prescription Medications Potentially Toxic to the Liver
  • Some antibiotics such as, tetracylcines or sulfanamides

  • Phenytoin (Dilantin) and valproic acid (Depakene/Divalproex); used to treat seizure disorders

  • Amiodarone (Cordarone); used to treat heart rhythm disturbances.

  • Methotrexate; an anticancer drug that is sometimes used to treat rheumatoid arthritis.

  • Quinidine, Procainamide (Pronestyl) and Diltiazam (Cardizem); drugs used in heart conditions.

  • Chlorpromazine (Thorazine) and diazepam (Valium); tranquilizers

  • Isoniazid (INH) and rifampin; drugs used to treat tuberculosis

  • Halothane and isoflurane; inhaled anesthetics

Over-The-Counter Medications Potentially Toxic to the Liver
  • Vitamin A - Can be liver toxic in high doses.

  • Niacin - Can be liver toxic in high doses.

  • Acetominophen (Tylenol) - It is generally safe to take acetaminophen in the amount specified in the labeling. Acetaminophen is the main ingredient in Tylenol ®, but it is also found in many non-prescription and prescription products for headaches, the flu, sinus problems, arthritis or general aches and pains (e.g. Nyquil, Exedrin, Percocet, Darvocet, Vicodin, Actifed Cold & Sinus).

When acetaminophen is taken in excessive doses, either at once or over a period of time, severe damage to the liver may occur. In fact, an overdose of acetaminophen is one of the most common causes of liver failure, as well as the most common cause of drug-induced liver disease in the United States. Acetaminophen is toxic at lower doses ( greater than 2 grams or 4 tablets per day), in individuals who are regular, excessive (over two drinks each day) consumers of alcohol, which is also toxic to the liver. Overall, persons concerned about liver damage should avoid alcohol use to be safe.

  • Other medications commonly prescribed that increase the toxic effects of acetaminophen include omeprazole ( Prilosec), phenytoin ( Dilantin), and isoniazid (INH). It is always best to consult with your healthcare providers about taking any non-prescription medications in conjunction with these prescription medications.

  • Acetylsalicylic acid (Aspirin) - Non-steroidal anti-inflammatory drugs (NSAIDs) These medications have the potential to cause drug-induced liver disease. Those that are felt to be most toxic to the liver are: aspirin (ASA), diclofenac (Voltaren), and sulindac (Clinoril). Therefore, individuals with liver disease should avoid using these NSAIDs. Individuals who have developed complications of cirrhosis, (known as decompensated cirrhosis), such as ascites ( accumulation of fluid in the abdomen). or bleeding esophageal varices ( enlarged blood vessels in the esophagus) are best advised to totally avoid all NSAIDs.

  • Iron - You may need to avoid iron supplements. Too much iron can damage liver cells or aggravate liver damage caused by some viruses. Most adults do not need to take iron supplements unless there is a history of obvious blood loss or a known deficiency of iron. Unless your doctor prescribes iron supplements for you, do not take any iron supplements or even multivitamins that contain iron.

Many causes of cirrhosis do not have any treatment available. For this reason, many individuals resort to the use of 'health foods' and 'natural herbs or supplements' to improve the liver. There is no scientific proof that any of these products are of benefit to the liver. Most of them are safe, but there are several herbal remedies that are known to cause liver damage. Be sure to tell your doctor before you begin any herbal products so that he or she may better monitor your condition. Below is a list of herbs that have been reported to cause liver damage and should be absolutely avoided by persons with liver disease.

Potentially Liver Toxic Herbs and Supplements
  • Chaparral

  • Comfrey (Bush tea)

  • Germander

  • Gordolobo yerba tea

  • Jin Bu Huan Margosa oil

  • Mate tea

  • Mistletoe

  • Nutmeg

  • Pennyroyal oil

  • Sassafras

  • Senna

  • Skullcap

  • Tansy Ragwort

  • Valerian

References:

  • American College of Gastroenterology. Patient Information.

  • The Hepatitis Information Network (2000). Update On Liver Disease & Hepatitis Conference.

Managing Stress

Everyone experiences stress to some degree. Although we often think of stress as negative, not all stress is bad. In fact, some stress is a necessary part of life that helps compel us into action, increasing our alertness and awareness. On the other hand, learning to manage stress in one's life is important to avoid the negative effects of 'stress overload'.

What Is Stress?

When we encounter a stress-creating stimulus, our body responds by secreting hormones that stimulate our nervous system and prepare us to move, or react. If the stimulus is mild or perceived as non-threatening, then there is little hormone release and we react in a healthy fashion. An example of positive stress is when you get a job promotion or move to a new home. At times however, excess stress-creating stimuli may overwhelm our abilities to respond and cause a negative effect, often called 'distress'. In this case, the stimuli may present either a 'real' or 'perceived' threat to us. The body responds immediately, pouring out hormones, which result in increased heart rate, blood pressure, and breathing, as well as sweaty palms and cool, clammy skin. Stressful events can also trigger emotional feelings of anxiety, fear, insecurity, and anger.

How Much Stress Is Too Much?

For most people, brief stressful encounters are well tolerated. Prolonged stress, however, has been linked to many health problems including sleep disturbances, ulcers, high blood pressure, heart disease, stroke, and depressed immune function. Scientists have been researching the effects of stress on illness for over fifty years. Many studies have shown a link between chronic stress and impaired immune system function. Researchers believe that chronic stress affects the immune system in a number of ways. For example, the hormones released in response to stress may directly impair the function of immune cells. In addition, stress seems to trigger behaviors such as smoking, alcohol and drug use, and loss of sleep; all of which can suppress the activity of immune cells.

Therefore, managing stress is an important factor in maintaining immune function, reducing infections, and fostering healing, all important in liver disease. To manage stress effectively, you need to be aware of your major sources of stress. Since it is easy to underestimate or overlook some factors that create stressful reactions for you, it may help to keep a 'stress diary' for a week or two. In the diary list of all events that seems stressful to you and note what kind of stressful effects you feel. For example: 'being late to work' may be a stressful event, and you may feel 'anxious and get tightness in your stomach' when this occurs. With this information, you can then identify steps to change the stressful situation and monitor your physical response to this change. In this case, you may decide to get up a half hour earlier, to avoid being late to work, and see if this reduces your anxiousness and tightness in your stomach.

Reducing Stress

There are many methods to reduce stress. Some have been shown to be particularly beneficial in maintaining immune function and aid in healing . Furthermore, recent research suggests that maintaining an 'optimistic, positive outlook' can ward off the 'immune-suppressing' effect of stress. Becoming familiar with the major stressors in your life, learning to manage those stressors, and using techniques to promote relaxation, are important steps in maintaining a strong immune system and staying well.

Managing Stress
  • Exercise Regularly. Exercise is the simplest and most effective means of stress reduction and can have beneficial effects on the immune system

  • Limit Stress Triggers. Identify and take control of your stressors. If you feel overwhelmed with responsibility, look for ways to eliminate some commitments. It may mean postponing school, reducing your work hours or getting help with childcare and housework.

  • Seek Support.

  • Secure help from your support network (partner, family, friends and professionals, as needed).

  • Limit Chemicals Which Intensify Stress.

  • Avoid excessive intake of caffeine and other stimulants.

  • Relax Deeply And Often.

  • Learn to reduce stress by using relaxation techniques or meditation.

  • Learn New Skills.

  • Seek out other tools to reduce stress, for example visualization. Your imagination is a powerful tool. Imagining, or visualizing restful scenes and positive, healing images helps to reduce stress and also aids in healing and recovery.

The Meditation Room

We all have stress in our lives, it's what we do about it that makes the difference.

Everyone makes choices about what to do to feel better. We may do mindless things such as eat a whole chocolate cake, buy ten pairs of shoes, get a drastic haircut, drink too much, drive too fast, or take to our bed and sleep to hide. As you nod your head in agreement to having tried at least one of these options, I ask you to consider the exact opposite possibilities. We can choose to take a brisk walk, volunteer your time, visit a friend or family member you've neglected lately, develop a hobby and add mindful relaxation to or meditation to your life. Meditation is the best gift we can give ourselves. It's easier than you think. In fact, you probably do it already without knowing it.

Meditation is not spacing out while you chant repetitively. It's not losing touch with reality, nor is it losing control. It is not hearing voices or having an invisible force tell you how to live your life. Meditation is about mindful relaxation. It's about doing NOTHING. During this period of time you will learn to calm your mind in a way that leads to a deep personal connection that might be called spiritual.

It requires you to give yourself the gift of time. You begin by claiming 20-30 minutes of your day, no matter how busy, for yourself. That move alone begins the process of better self-care. You take this time as if it were a package. Take it to a private,quiet place. Close the door, turn off the telephone, turn on some soothing music, light a candle and sit down. The rest is up to you. With daily practice of the suggested meditations available in the meditation room or one of your own, you will learn to quiet your mind and experience truly "thought-free" moments. NOTHING will occur! You're on your way, now breathe....

Relaxation

Life inherently presents us with challenge and stress is a natural response. Without some stress, motivation to act would be very low. But, if stress is excessive or lasts for a long time, health begins to suffer. The immune system is compromised. Rest and deep sleep can be disrupted. When stress levels are high and self calming skills are low or seldom used, the body becomes more vulnerable to infection, immune disorders and, it is believed, cancer.

Stress management skills are an important skill for living well. They help your body resist and fight cancer, and other major diseases of our times. Without healthy relaxation skills, some people turn to unhealthy patterns such as over-eating, excessive alcohol use, cigarette smoking and withdrawal from physical and social activities. Alone or in combination, these behaviors increase vulnerability to the ill effects of stress.

Managing stress well does not mean avoiding it altogether. This would be nearly impossible to do.

Instead, become aware of stress and your body's reaction to it. Awareness, positive thinking and effective relaxation skills, will help you meet life's challenges while becoming healthier. Odds are you will probably enjoy the good feelings that also result from these relaxation skills and the time you set aside to practice them.

Recreational Drugs

To maintain liver health, it's clear that one should avoid any unnecessary exposure to liver toxins. Most all drugs have been identified as potential sources of liver injuries, and recreational drugs are no exception. In fact, intravenous recreational drug use is one of the most common methods of exposure to hepatitis B and C infections. Avoiding the use of any recreational drug, particularly, intravenous drugs will greatly reduce your risk of contracting hepatitis.

For those who already have liver disease, it is doubly important to avoid use of any drugs. Drug abuse is often associated with unhealthy lifestyles such as poor nutrition, smoking, and alcohol abuse. All of these behaviors can reduce a person's resistance to infection and depress healing.

If recreational drug use is a habit, it may be prudent to seek the help of drug abuse counselors and treatment programs. Just like heart disease or diabetes, persons with substance abuse disorders, need to learn behavioral changes and may need to take medications as part of their treatment regimen. Behavioral therapies can include counseling, psychotherapy, support groups, or family therapy. Treatment medications offer help in suppressing the withdrawal syndrome and drug craving and in blocking the effects of drugs. The good news is, such treatment programs are very effective in reducing the many health problems associated with drug use, including liver damage and inflammation.

CDC Special Report Recommendations and Reports. Primary Prevention Recommendations. 

Alcohol Use

"You've probably seen them in a magazine or in the doctor's office, or perhaps in an online publication" says one recovering alcoholic. "Twenty questions which determine whether or not you have a problem with alcohol. If you answer 'yes' to three or more questions, you definitely have a problem. Well, of the twenty questions, there was only one that didn't apply to me. I never drank in the morning. Except, Bloody Mary's at brunch on Sunday. But everyone does that, don't they? Still, you couldn't tell me I had a drinking problem. In fact, I was rarely sick and I actually felt better and more in control, when I'd had a drink or two. That is until a year ago when I developed what is called alcohol-induced liver disease (ALD). I had nausea, fatigue and frequent diarrhea. My healthcare provider told me, if I didn't quit drinking, I would likely develop liver failure in the very near future. As a husband and father of a two-year old and a four-year old, I knew I had to quit."

All too often, symptoms of alcohol abuse (high tolerance for alcohol, digestive problems, poor nutrition, and impotence) are ignored until there is major internal damage requiring hospitalization. In reality, chronic heavy drinkers may metabolize alcohol differently so that they may not feel the adverse effects of alcohol (dizziness, headache, nausea, etc.) like most people. Regardless of these metabolic differences, the chronic exposure to alcohol places a heavy toll on the liver.

How Does Alcohol Damage the Liver?

When alcohol is metabolized by the liver, some products are generated such as acetaldehyde that are actually more toxic than alcohol itself. In addition, it is thought that alcohol consumption leads to release of free radicals (substances generated during metabolic processes and normally 'cleaned up' by free radical 'scavengers'). These free radicals can damage liver cells and trigger inflammation in the liver. Long term alcohol consumption results in chronically high levels of free radicals and inflammation, which ultimately leads to destruction of liver tissue and scarring. With progressive scarring, liver function deteriorates to the point of liver failure and its associated complications.

Chronic excessive consumption of alcohol can cause a variety of alcohol-induced liver diseases (ALD) including excess fat in the liver (fatty liver), alcoholic hepatitis (inflammation in the liver), and cirrhosis (permanent scarring of the liver). Roughly one out of five people with heavy alcohol consumption* will develop the devastating health problem of liver cirrhosis. These individuals often die from liver failure and its associated complications such as gastrointestinal bleeding, infection, or kidney failure. In addition, excess alcohol consumption increases the risk of pancreatitis (inflammation of the pancreas), cardiomyopathy (damage to the heart muscle), trauma (accidents occurring during drunkenness), and the development of fetal alcohol syndrome (damage to the unborn child from excess alcohol during pregnancy).

How Much Alcohol Causes Liver Damage?

The amount of alcohol consumed before liver damage occurs is extremely variable. Some people are very sensitive to the effects of alcohol, while others are seemingly invulnerable to its harmful effects. In general, the greater the amount and the longer the duration of alcohol consumption the more likely that injury to the liver will occur.

While the relationship between alcohol and the development of liver disease is not fully understood, research is suggesting several variables that influence one's vulnerability to ALD. Genetic factors may cause functional changes in liver cells that influence metabolism of alcohol and other liver toxins. Animal research indicates that certain dietary factors (high-fat, low-carbohydrate diets) in combination with high alcohol consumption results in more rapid progression of liver damage.

Gender may also play a role. Although the reasons aren't completely clear, women develop ALD after consuming lower levels of alcohol over a shorter period of time compared with men. This may be in some part due to women having a decreased amount of the enzyme needed to metabolize alcohol. In addition, women have a higher incidence of alcoholic hepatitis and a higher mortality rate from cirrhosis than men. Finally, the presence of HCV may increase a person's susceptibility to ALD and influence the severity of alcoholic cirrhosis.

The Solution:

At present there are no laboratory tests that effectively detect one's risk of developing ALD. Likewise, abstinence is the only therapy for ALD. With abstinence, fatty liver and alcoholic hepatitis are frequently reversible, and survival is improved. For those with terminal liver failure, liver transplantation remains the only effective treatment. However, a period of abstinence (usually 6 months), is required even for those who are candidates for liver transplantation. And even for those individuals, there is no guarantee that a donor liver will be available.

The Message: Don't drink!

*These researchers defined 'heavy drinking' as the daily consumption of five to six standard drinks, each drink equivalent to approximately 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of distilled spirits.

References:
U.S. Department of Health and Human Services (1998). National Institute on Alcohol Abuse and Alcoholism No. 42. 
Watterlond, Michael. The telltale metabolism of alcoholics. Science.1983. pgs 72-76.

Smoking and Tobacco

You know smoking and tobacco use is bad for you. But, what's in tobacco and what risk does smoking or tobacco use pose to the liver? Tobacco contains all sorts of things that most people would never even consider exposing themselves to. Tar, arsenic, formaldehyde (which is used to preserve dead mammal tissue), the chemical DDT, carbon monoxide (the noxious byproduct of cars), and nicotine (the addictive drug) are some of the hazardous substances found in tobacco.

In addition to raising the risk of heart attack, stroke, cancer, and chronic breathing problems, tobacco is toxic to your body. Tobacco is the cause of more health problems and early deaths than all illegal drugs. In addition, tobacco is highly addictive. The longer you use tobacco the more your body craves it. Many people try smoking, mistakenly thinking they won't get addicted. If you don't smoke, don't start! If you do smoke, the sooner you quit the better.

The key to protecting the liver, is to avoid any unnecessary exposure to toxins. First and foremost is avoiding toxins from drugs and alcohol. And second in line is avoiding toxins from tobacco. If you want to protect your liver by eliminating alcohol and tobacco you may find these facts motivating:

Heavy drinkers who smoke are more likely to get heart disease, lung disease and cancers of the head, mouth and throat. They are also more likely to die earlier than others in the general public. Smoking and drinking are activities that usually go together. Smoking tends to create a stronger craving for alcohol, and vice versa. So quitting smoking can help to reduce your desire for alcohol.

If you feel that there is too much stress in your life to quit smoking right now, remember, you will always have stressful times. Rather than using stress as an excuse for smoking, consider learning effective stress management techniques such as relaxation or meditation.

Make no mistake, quitting smoking is no easy task. However, there are numerous programs and even medications which have proven very effective in helping smoker's quit. While your on the road to better health, why not quit smoking? Your body will thank you!

References:
American Family Physician: Health Info Handouts. Internet Found November 2000

© 2003 California Hepatitis Resource Center