The case of the six-year-old girl who developed antibiotic resistance is not an isolated one in the world of antibiotics.
As these super drugs are routinely prescribed, controversies on their abuse and overuse are beginning to throw a big question-mark on whether antibiotics have outgrown their effectiveness.
The question doing the rounds in many medical corridors is: Is the golden age of antibiotics over?
“No, this is not true,” said Dr Sandeep Pargi, Specialist in Respiratory Medicine at Aster Mankhool Hospital, Dubai.
“Antibiotics still have a great scope as new ones are being discovered. There are some old-generation antibiotics that are being phased out due to resistance [issues] but many are being discovered as we speak.”
Dr Pargi believes doctors need to rely a lot on old-fashioned diagnosis before rushing in to prescribe antibiotics. “Antibiotics work against bacterial infections. Very often, doctors prescribe antibiotics for viral fever and infections which would anyway subside within a week.”
Dr Pargi said, “An antibiotic course is either three, five, seven or nine days. None of the antibiotics go beyond 14-day prescriptions except those administered in case of tuberculosis.
“If the course is three days, then that is what one needs to follow. If the course is 14 days, follow that. The danger arises when people self-medicate, get over-the-counter antibiotics and switch from one to another on their own. They might take two or three antibiotics for a longer period and develop resistance.”
Overuse can occur only when there is trial and error with different types of antibiotics which usually occurs when people self-medicate, said doctors.
Patients can be prescribed antibiotics as many times as they need through the year, provided the protocol and guidelines are followed. Every hospital around the world follows a set antibiotic policy. In Scandinavian countries especially, doctors are judicious in prescribing antibiotics. When this strategy is followed, which should be the case in the rest of the world, there is little danger of resistance, said Dr Pargi.
“In tuberculosis, when a person has the disease for the first time, we begin with the first line of multi-drug therapy. Usually, the disease is cured with a course of six months to a year. When a person has TB for the second time, it means the first line of drugs is not likely to be effective so we put him on multi-drug therapy (with a combination of four-seven drugs). When the disease recurs, it means the strain has developed multi-drug resistance (MDR). When this fails, we prescribe XDR or extreme drug resistance therapy,” Dr Pargi said.
Regarding the superbug scare, Dr Pargi refutes the hype. “There is no such thing as a superbug syndrome. In some areas of the world, a lack of hygiene in hospitals gives rise to resistance within the hospital. There is no uniform superbug syndrome. For instance, hospitals in Dubai have no superbugs.” If hospitals do three things, we need not fear superbugs:
1. Follow a definite antibiotic guideline and policy and avoid indiscriminate use;
2. Use them judiciously with ensuring correct protocal of duration, potency and dose is followed; and
3. Maintain hygiene standards in their environment.
Latifa Dumalag, 48, Filipina Came out from a life-threatening pneumonia with judicious and effective use of antibiotics. “I have been suffering from bronchitis and asthma since childhood and have a weak respiratory system. So I did not realise that what seemed to be like a normal cough and cold would rapidly develop into bronchitis and pneumonia. I consulted one clinic first and they gave me medication which was ineffective, and I continued to cough and wheeze. “When I contracted fever and could hardly breathe, I was referred to Aster Hospital under Dr Sandeep Pargi who literally brought me back from death. I was put on IV antibiotics and once I recovered after nearly 10 days in hospital, I was given multivitamins and discharged in the first week of October. “I am 95 per cent cured and still have to get constitutionally stronger. But the right dose of antibiotics saved my life.”
Alicia Del Los R. finally flew home to her loved ones on Thursday with the help of the Philippine Consulate-General in Dubai after lying comatose at a Dubai hospital for four months.
The 53-year-old Filipina suffered a heart attack in June that resulted in hypoxia (lack of oxygen) to her brain rendering her in a vegetative state. For four months, she had been cared for by Aster Hospital Mankhool.
Having entered the UAE on a visit visa and without medical insurance, Alicia’s hospital bill mounted to more than Dh500,000. However, with the help from the Philippine Consulate, she was finally able to fly home on an Emirates flight on Thursday afternoon.
Dr Sherbaz Bichu, CEO of Aster Hospital, said: “It gives me great pleasure and joy to know that Ms Alicia is now home in (the) Philippines, reunited with her family. After her four-month stay in our hospital battling for life, she escaped the mouth of death.”
“Aster Hospital Mankhool appreciates the cooperation and support of Philippine Consul-General Paul Raymund Cortes who has been involved in her repatriation. Living up to our promise of ‘We’ll treat you well’, our efficient team of doctors and nurses went over and above the call of duty and rendered compassionate care to her. During her stay in our hospital, she became our extended family member. Our health-care providers built therapeutic relationships with her. To our nurses and paramedics, she was like a mother. To our team of doctors, she was like a sister and so on. And as declared in the UAE this year as the ‘Year of Giving’, the Aster DM Healthcare initiative of Aster volunteers took a true stance in this survival story.”
For his part, the Philippine Consul-General earlier said that the Assistance-To-Nationals (ATN) section of the consulate had communicated with the hospital regarding Alicia’s case from day one and was assisting in her repatriation. Her travel date was finalised last week.
Universal Medical Transfer Services facilitated the medical repatriation of Alicia from Aster Hospital up to her admission in Angono Medics Hospital in Angono, Rizal using the ATN Funds reserved for Filipinos in need of assistance. The consulate also gave Dh20,000 to the hospital as partial payment of Alicia’s hospital bills. Alicia’s son is planning to approach charitable institutions to help him settle the remaining bill amount with the hospital.
Alicia is just one of the four “stretcher” cases that have been assisted by the consulate for repatriation so far this year, said Aldrine Perez, ATN officer in charge of medical cases. Such repatriation costs between Dh40,000 and Dh60,000 each.
The consulate, through its ATN section, repatriated 1,080 Filipinos from January 1 to September 30. The section also released $559,162.72 (Dh2.05 million) from the ATN Funds to assist Filipinos in the first nine months of the year.
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Nobody wants to meet Alicia De Los R., not even her son, as she blinks and shuts her eyes in a city hospital with the staff being her only companions.
The 53-year-old Filipina, who suffered hypoxia (lack of oxygen to the brain) during a cardiac arrest, has been lying in a vegetative state at the Aster Mankhool Hospital for the last four months, awaiting repatriation to her country with no one coming forward to help.
It is also a sad reminder about the fate of many such patients either on vsit or expired visas lying in a coma state in public and private hospitals in the country with nowhere to go.
Dr Chaitanya Prabhu, a specialist in internal medicine and an intensivist attending on De Los, told Gulf News that the patient who had worked in the UAE for 14 years was on a tourist visa, visiting her son.
On June 7, she was brought to the hospital emergency by a cab driver. She was feeling uneasy and, instead of calling for an ambulance, hailed a cab and asked to be driven to Rashid Hospital emergency, But on the way, she collapsed with a massive cardiac arrest and her brain was deprived of oxygen.
The cabbie rushed her to the emergency section of the hospital where she was resuscitated and stabilised. However, the lack of oxygen and blood supply to her brain resulted in extensive damage to both lobes rendering her in a coma.
Dr Alai Taggu, head of the department of critical care at the hospital attending on Alicia, said: “The patient had a history of diabetes and hypertension and we made sure her air passage is clear and have a tracheotomy tube in her throat to clean the air passage. She is breathing on her own.”
The hospital has in the last four months spent Dh500,000 on her care as she has no insurance cover and her son who is unable to afford the hospital expense has also stopped taking any calls from the hospital staff.
The hospital is facing a typical situation where it wants to free the bed for other needy patients and also make sure the patient is reunited with her family back home which to some extent will emotionally rehabilitate her. They are looking to repatriate her to her country, but the Philippines Consulate has allegedly not yet responded positively to their request.
Dr Sherbaz Bichu, CEO of the hospital, said: “We have done what we could, and see that the patient might be better off if flown home and is with her loved ones. She needs to be in a similar hospital or health-care facility. So far, the authorities at the Consulate have not been able to find a similar hospital to work out her repatriation. There is nothing more we can do for Alicia now. It is very sad.”
Meanwhile, Philippine Consul-General Paul Raymund Cortes told Gulf News that the consulate “has been in charge of Ms Alicia’s case from day one”.
“We have been coordinating with hospital authorities and administration in regard to her condition and to her hospitalisation bills. Secondly, the Philippine government through the Consulate-General in Dubai is taking charge of her medical repatriation and she is scheduled to leave for the Philippines on the 26th of October. Lastly, it is the Philippine government through the Philippine Consul-General in Dubai that has financially assisted Ms Alicia in taking care of her repatriation and her hospital expenses as well. We’ve also visited Ms Alicia from the very beginning and we have never failed on that matter,” Cortes said.
Alicia’s case is not an isolated one. Last week, Gulf News reported the sad plight of a 27-year-old Ethiopian maid in a coma at the International Modern Hospital waiting to be repatriated to her home country.
Dr. Bichu also pointed out that such cases where tourists or family members of blue-collar workers who came without a travel insurance proved to be tricky. “We are bound to help them but need someone to step in now. There are also many cases of underprivileged families, flying in their parents for a holiday and finding their aged parents in similar medical conditions. We want to caution them that there is no arrangement to pay bills and many of those have lost all their life’s savings by paying off hospital bills.”
There is another case of an Indian expatriate journalist, who is currently out of job and who suffered a cardiac arrest, admitted to the same hospital. “This gentleman, who is in his seventies, was lucky to have suffered a cardiac arrest while at the outpatient department of the hospital. But he is out of job and without an insurance. His condition is stable but he continues to be at our hospital. We have no clue what to do with such patients as hospital bills mount. It is sad because these patients need to be with their loved ones and are indefinitely trapped here,” said Dr Bichu.
A social worker at one of the government hospitals in Dubai confirmed that there were plenty of similar cases of road trauma or stroke victims in comatose conditions lying at hospitals with volunteers of social organisations such as the Valley of Love trying to raise funds for their treatment and repatriate them to their home countries.
While the Dubai Health Authority’s Mossadah Committee raises funds through charities and telethons to help out underprivileged patients, these barely cover the cost of treatment for cancer, dialysis, cost of surgeries and medicines.
The committee was able to pay the medical bills of nearly Dh67 million to help 1,640 patients in 2015. In 2016, the committee raised Dh108 million to help the underprivileged in hospitals. So far this year, the committee has raised Dh250 million that will help nearly 3,000 patients.
However, there seems to be a huge gap wherein many such comatose patients with mounting bills lie in hospital beds as their families and consulates look the other way. The government is in the process of creating a special public fund for such patients. Until this happens, the hospitals are compelled to bear the cost of caring for these patients.
Internal Medicine Specialist
Specialist Physician and the Head of Department of Critical Care Medicine
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My baby is approaching one year now and I want to wean her off the breast and on to formula milk. What is the best way to do this?
For ideal nutrition WHO recommends that a baby must be exclusively fed breast milk for the first 6 months, but you can continue for up to 2 years if you wish, even after the baby is introduced to solid foods. If you wish to wean your baby off breast milk, you can start trying the following steps. First, substitute breast milk with bottle milk once a day and gradually increase the number. Also start offering solid food instead of breast milk at meal times. Make sure your partner also helps during the feeding time as it is best you aren’t always there to feed her. You can also try different bottles/teats and decide on one your baby prefers. Since your child is turning 1 year old you can offer sipping from cups. Don’t expect an immediate result, as the change away from breast feeding will be a slow process.
Medical Director and Consultant in Paediatrics & Neonatology
As a child grows up, his/her parents must track “normal speech and language milestones.” They should also get a hearing test done for every newborn. If the child doesn’t attain adequate speech and language capabilities in time or fails during the initial hearing screening, he or she could be suffering from a rare disorder known as auditory neuropathy spectrum disorder (ANSD).
Auditory dyssynchrony, also known as auditory neuropathy, is a condition where transmission of sound impulses including speech sounds is not in proportion or synchronous from the inner ear to the brain thus leading to interrupted sound signals leading to understanding problems in the individual. It generally occurs in three to four of every 10,000 children.
In the case of 10-year-old Deepali (name changed) the disorder went undetected until her parents went to Aster Hospital’s audiology department to get a clearance. The parents needed the clearance from a hospital in order to get the child admitted into a school as the child also has cerebral palsy and was undergoing treatment for the same.
Explaining the case, Audiologist at Aster Hospital Mankhool, Mr. Vikas, who was handling the case, told Khaleej Times: “The child required multiple repetitions to understand the speech, and she would lip read to understand what is being said to her. She is unable to express her feelings completely and cannot communicate with others properly.
“Deepali could convey her message with one or two words or gestures which only her parents can understand (that too is limited since she is quadriplegic with cerebral palsy too). Moreover, she faces much more difficulty in understanding if the speaker is not in front of her or is standing far away.”
For the past 10 years, the child was being treated for other abnormalities and no hearing test was ever conducted. This led to a speech delay which was considered as the result of cerebral palsy. “The best way to improve her condition is to focus on giving specialized speech and language therapy or opt for cochlear implant surgical option.
“Using assistive listening devices like FM systems can also help since this system works on radio frequency thus eliminating background noise.
Although the process is long and cannot be completely cured, speech and language can be made adequate with rigorous training, he added.
“If your child doesn’t attain adequate speech and language capabilities in time or fails during an initial hearing screening, a complete audiological test battery should be conducted to detect the need for therapies.
As per the Joint Committee of Infant Hearing and the WHO, it is recommended that every newborn child is tested for auditory capacity.
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A 26-year-old Pakistani male, F.J., had been suffering from irritation in the throat, sensation of lump in the throat, burping and upper abdominal discomfort – all that were responding poorly to treatments.
On seeing his reports and examining him, Dr Amal Premchandra Upadhyay, Consultant Gastroenterologist at Aster Hospital Mankhool, knew it was not a normal case of acid reflux as the severe discomfort the patient suffered pointed towards the chronic digestive condition known as Gastroesophageal Reflux Disease (Gerd). This is a condition when the stomach contents move up into the esophagus due to a defect in the valve between the stomach and the lower esophagus. If untreated or poorly controlled, it can lead to ongoing symptoms, poor quality of life and possibly serious complications.
It is the increasingly sedentary lifestyles and unhealthy eating habits that result in the disruption of our general digestive process and lead to heartburn and acid reflux.
Medication such as antacids provide only temporary relief. The next level of medication – acid blockers and proton-pump inhibitors (PPI) provide longer relief but is not a permanent solution. Also, continuous or too frequent use of these medications may cause other side effects.
A longer-lasting solution is surgery, however, for people who are not keen on surgery or those who cannot take medication for various reasons or wish to avoid medication, Stretta is the alternative.
“Stretta is a non-surgical procedure that uses radio frequency energy to alter the muscle between the stomach and esophagus and thus improve reflux. The procedure is guided endoscopically and it takes approximately 45 minutes. It is done under deep sedation so that maximum patient cooperation can be obtained and the patient can return back to normal everyday activities within a few days. The procedure helps the patient becomes less dependent on medication to treat his symptoms,” said Dr Amal, explaining the procedure.
Although F.J.’s abdominal discomfort responded to treatment, it was the associated throat symptoms that were bothering the patient. The atypical nature of the symptoms also led to the delay in the patient seeking appropriate treatment. Dr Amal resorted to the Stretta procedure – an upcoming option for patients in the UAE who are suffering from reflux but are not comfortable with taking long term medications. “This is the first case where we have introduced the Stretta procedure to treat the patient at Aster Hospital Mankhool, Dr Amal told Khaleej Times.
Talking about the Stretta effect on the patient’s health Dr Amal said: “The patient reported more than 50 per cent improvement in symptoms after the Stretta procedure. He had never experienced this kind of improvement with medications. Now, he is not completely dependent on medication to control his symptoms. This has significantly improved his quality of life and his ability to participate in normal activities without worrying about the repercussions.
He added: “Typically, patients start feeling the improvement in symptoms within a couple of days. Symptoms continue to improve over time and optimal benefit can take several weeks. Most patients will be able to live without medicines and some patients can manage with a smaller dose of medicines after the procedure.”
The hospital claims it sees an average of 28 to 30 patients with Gerd every month. This is close to double the number of cases they used to see one year ago. According to the scientific and research committee of the Emirates Gastroenterology Society, as of 2014, more than 30 per cent of the UAE population suffered from acid reflux.
“There is great potential for establishing the Stretta procedure as an option for patients in the UAE who are suffering from reflux but are not comfortable with taking long term medications. The procedure itself is internationally recognised as a unique and non-surgical procedure to help patients return to normal life within a few days.”
The international success rate of Stretta is encouraging. Although in use for close to 15 years globally, Stretta is relatively new in the UAE and is gradually being introduced to other countries across the world. A study presented at the United European Gastroenterology Week (UEGW) in late 2016 showed significant relief from Gerd symptoms and elimination of PPI use in 71.9 per cent of patients 10 years after they had Stretta.
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An 81-year old female patient, suffering from multiple illnesses, was successfully treated at Aster Hospital, Mankhool.
The patient had blockage of the bile ducts and abnormal retention of bile in the liver caused by gallstones; she also had infection (cholangitis) leading to sepsis and was in need of immediate medical intervention in order to survive.
Dr. Amal Upadhyay, Consultant Gastroenterologist at Aster Hospital performed an ERCP procedure to clear the bile ducts and the patient recovered and resumed normal activities within a day after the procedure.
The elderly patient was transferred to Aster Hospital’s Intensive Care Unit from another healthcare facility in a state of shock, complicated by poor kidney function.
Immediate examination by multiple specialists – an intensivist, a nephrologist, a cardiologist and an anesthesiologist determined that it was necessary to conduct ERCP to treat the cholangitis, else the patient’s condition could prove fatal.
However, due to the multiple complications including 2 faulty heart valves, rare but severe hypertension in the lungs and an irregular heartbeat, the risks associated with sedating the patient and conducting ERCP was high. In addition to the above, the patient was on blood thinning medications. These medications could potentially increase the risk of hemorrhage during ERCP, however, these drugs could not be stopped suddenly because of a very high risk of developing another stroke. All these considerations made this case very challenging.
The patient’s sons are doctors in the UK and were impressed with the level of care their mother received at Aster Hospital, Mankhool.
Dr. Mukhtasar Abdul Aziz, a Consultant Pulmonologist in the UK testified to the case, “She received care that was second to none. I can confidently say that Aster Hospital provides international standard care. Considering the pre-existing conditions my mother suffered from, nobody was willing to perform the procedure, given the associated risks, but Dr. Amal was very competent and confident in himself and his team”, said Dr. Aziz.
The patient recovered almost immediately after the surgery and was discharged within 24 hours and advised physiotherapy.
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Can lifting a five-gallon water jar cause you a crippling injury?
Yes, it can, as 63-year-old Efren Manalo Roque discovered the hard way after displacing two of his spinal discs.
The injury caused pain and urine retention that required him to undergo emergency surgery at Aster Hospital, Mankhool, on August 12.
Post surgery, his problems have been mitigated and he was discharged in six days.
Roque, who works as a supervisor at a cargo company, has been lifting five-gallon water jars quite often as part of his work.
On July 23, it was business as usual for him, Roque recalled speaking with Gulf News after his surgery.
“That day, I must have been a little careless because as soon as I hauled the jar I felt weakness and pain in my legs.”
Dismissing it as a localised pain, Roque continued with his work.
When the pain and weakness persisted he sought consultation at a government hospital where he was examined, given pain killers and sent home.
But the pain and weakness persisted and Roque was forced to go to yet another hospital that once again prescribed some more pain killers.
“By day three I was experiencing some trouble passing urine so I consulted another hospital where doctors said I had low potassium levels and prescribed electrolytes. But after a few days I stopped passing urine and then for the next two weeks the hospital put me on catheters. The moment they removed the catheters, I could not pass urine.”
Roque also experienced erectile dysfunction.
Two weeks after struggling to get relief, Roque came to Aster Hospital at Mankhool where the neurologist Dr Suhas Patil conducted MRI and concluded that Roque’s problem was neurological and not urological.
“The patient had urine retention but the MRI indicated he had suffered a prolapse of discs L4 and L5 and that had resulted in the compression of nerves around that area that were going to the bladder and had affected the urine output,” the doctor said.
Dr Vivek Kumar Mishra, Specialist Orthopedic Surgeon from Aster Speciality Clinic, International City, administered injections to ease inflammation in the affected area and conducted a surgery to remove the two prolapsed discs that were compressing the nerves.
While Roque was relieved of the pain and discomfort after the surgery, he is resolved never to haul these five gallon water jars ever again.
Tell us more about brain stroke. What happens to the brain when someone has a stroke?
A stroke is caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients, causing damage to the brain tissue. More than 6 million people die because of stroke each year. Worldwide, cerebrovascular accidents (stroke) are the second leading cause of death and the third leading cause of disability.
Signals from the brain travel through brain stem cells to various parts of the body. When the blood flow to the brain is interrupted, the brain signals also get interrupted further impacting different parts of the body that the signals control causing numbness or paralysis in certain parts of the body.
What are the reasons behind strokes?
There are two types of stroke, ischemic stroke which is caused by a blood clot in the artery supplying blood to the brain and hemorrhagic stroke, caused by bursting of a blood vessel resulting in blood to pool and create pressure around the brain. In both these types of stroke, hypertension is common risk factor. Apart from hypertension, Diabetes mellitus, smoking, dyslipidemia, obesity, low level of physical activity are known to predispose to ischemic stroke. Sometimes defects in wall of blood vessels in brain which are right since birth can predispose people to certain types of hemorrhagic strokes. Congenital defects in heart, abnormalities of heart valves, and abnormalities of rhythm of heart can also predispose a person to ischemic stroke. People on blood thinning medications for unrelated reason can get brain hemorrhage due to excessive thinning of blood.
Who is at risk for a Stroke? Any potential age group?
Anybody can have a stroke although the risk increases with age. People with a family history of stroke and those over 65 years of age are at a greater risk of having a stroke. Smoking, age, gender and conditions like diabetes, high cholesterol and high blood pressure can also increase the risk of stroke.
Drug abuse and excessive alcohol consumption, unhealthy dietary practices and obesity are also risk factors for stroke.
How do you diagnose a brain stroke?
A stroke is diagnosed based on the symptoms experienced. The doctor will examine the individual in order to understand the type of stroke, its causes and the part of the brain that has been affected.
CT Scan of the brain is the quickest test to differentiate between ischemic and hemorrhagic stroke. In order to understand a stroke, the doctor may recommend blood tests, because low blood sugar levels mimic the symptoms of a stroke. Echocardiogram and Electrocardiogram tests will be recommended in order to check how well the heart is functioning and any heart disorders, respectively. An MRI, Angiography and Cartoid ultrasound are also tests that help investigate the causes of stroke.
What are the symptoms?
The most common symptom of a stroke is sudden weakness or numbness of the face, arm or leg, most often on one side of the body. Other symptoms include: confusion, difficulty speaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking, dizziness, loss of balance or coordination; severe headache.
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1. Please tell me about yourself and your choice of becoming a Hepatologist and liver diseases expert. How long have you been in the field?
I have done my training in Internal Medicine and Gastroenterology from the Postgraduate Institute of Medical Education and Research in Chandigarh, India. We had a very strong hepatology (liver disease) department in the institute, which is quite renowned. A number of original research takes place in the department, which get published in leading medical journals regularly. After getting trained as a Gastroenterologist, I worked in Abu Dhabi for 5 years from 2003 to 2008. I realized that there is a huge burden of liver disease in UAE. There were lots of doctors taking care of patients with liver disease but there were no facilities that could offer comprehensive state of the art care for all aspects of liver disease. I decided to do further training in advanced liver diseases and with a good recommendation from the Hepatology department in Chandigarh, India, I was able to get into the prestigious Mount Sinai Medical Centre in New York, the United States for a one year fellowship in advanced liver diseases and transplant hepatology. I completed that in 2009 and since the last 8 years I have been practicing Hepatology. I kept working between UAE and India and established an Integrated Liver Care (ILC) Team in Bangalore, India, which is a professional group of Hepatologists, hepatobiliary surgeons, liver transplant surgeons, interventional radiologists and liver intensive care experts. Our professional group, the ILC has been working since the past three years with the Aster DM Healthcare Group in India and we have our advanced liver centers at Aster Medcity in Kochi and Aster CMI Hospital in Bangalore, India, where we offer the complete range of medical and surgical care related to all forms of liver diseases, liver, pancreas and biliary tract cancers and multi-organ transplantation. We aim to bring the Aster Integrated Liver Care Program to the UAE so that we can offer cutting-edge, comprehensive care to patients suffering from liver diseases.
2. What causes liver diseases?
The first thing that comes to people’s minds when they think of liver disease is excess alcohol consumption. But in fact, many other liver diseases are more common than an alcoholic liver disease. By far the most common cause of liver disease is fatty liver, which happens in individuals who are overweight, have sedentary lifestyles, diabetes and high triglyceride levels in the blood. Most people assume that fatty liver is an innocuous problem but now we understand that a subset of patients have a progressive form of fatty liver that can damage the liver seriously. There are hepatitis viruses such as Viral Hepatitis A, B, C, D and E, which cause both acute (short lasting) and chronic (long standing) liver disease. Patients with chronic viral hepatitis usually do not have any symptoms and therefore are unaware of the problem. It is important to screen for viral hepatitis so that it can be detected and effectively treated at an early age. Some individuals have a condition called autoimmune liver disease in which their own body’s immune system starts damaging the liver. Excess accumulation of iron or copper in the body can also affect the liver. Children and young adults can suffer from a wide variety of metabolic and genetic liver diseases that may present in infancy or in adulthood. Various forms of cancers either arising from the liver or spread from other organs can also involve the liver.
3. Are there variations of liver disease? If so, what are these?
In general, liver disease patterns are the same all over the world. But there are variations such as the age of presentation. Patients with chronic viral hepatitis remain undetected for longer periods of time in Asia, Middle East and Africa since people do not get screened regularly. Hence they may present at a more advanced stage of the disease. People from Africa are in particular more prone to develop liver cancer from hepatitis B at a younger age. Hepatitis D virus, which is uncommon in most parts of the world, is common in central Asia and some areas of Middle East. Patients with chronic hepatitis C have a more rapid progression of liver disease in Asia compared to the Western world.
4. If there were variations of liver disease, what are the most common or most prevalent on the global scale, in the Middle East and North Africa, in the UAE?
On a global scale the most prevalent liver disease is non-alcoholic fatty liver disease followed by alcoholic liver disease and chronic viral hepatitis due to hepatitis B and C infections. In the MENA region, including UAE, non-alcoholic fatty liver is still the most common cause of liver disease due to high prevalence of obesity and diabetes with which this disease is linked. Chronic hepatitis B and C is quite common but largely undiagnosed.
5. How different are liver diseases in children compared to those among adults?
Children usually have a different spectrum of liver disease. Newborns and infants may develop liver disease as a result of serious metabolic and genetic defects. They usually present with yellowing of the skin and eyes (jaundice) and poor growth. These conditions can lead to liver failure quite early in the first few years of life. Such kids require liver transplantation. An important cause of liver disease in the first year of life is extrahepatic biliary atresia. In this condition the bile ducts inside the liver do not develop properly during the development of the baby. This leads to progressive jaundice right from the time of birth. This condition needs to be recognized within the first few weeks of life so that a special corrective surgery known as Kasai’s operation can be done. Else the child goes on to develop liver failure and requires a liver transplant. Children in their first decade of life can suffer from autoimmune liver disease as well as a condition called Wilson’s disease, which is a state of excess copper accumulation in liver due to a genetic defect. Once again early recognition of this problem can lead to proper medications to remove excess copper from the body before the liver gets irreversibly damaged. Children also develop liver cancers, which are quite different from liver cancers in adults. These are aggressive tumors but their response to chemotherapy and surgery is quite good. Some kids with a liver cancer need a liver transplantation.
6. How young is your youngest liver disease patient? Has he survived it? How?
We have treated children as young as one month with liver disease. These are usually children with extrahepatic biliary atresia requiring surgery. There are newborn kids who develop liver disease due to a correctable metabolic defect. For example there was a one-month-old girl with
a condition called galactsemia in which the child cannot metabolize the sugar called galactose in the milk. A simple treatment was exclusion of all forms of milk and milk products.
7. How old is your oldest liver disease patient? Has he survived it? How?
There are a large number of old patients above the age of 75-80 years with liver disease. Most of these patients have liver cirrhosis with liver failure. A lot of these patients develop liver cancer as well due to the long standing nature of liver diseases. Most of these patients are challenging because they are often too old and have other coexistent medical problems that preclude liver transplantation or major liver surgery. There was a 79-year-old Emirati gentleman who had liver cirrhosis and liver cancer and underwent a successful liver transplantation in 2006. He is 89 years old now and continues to be on my follow up care. Having said so, in general liver transplant is not offered above the age of 70 years.
8. What is the worst liver condition or disease, which you have encountered in your career? Please tell me about this and about the patient.
The worst liver condition is usually advanced liver cancer presenting with liver failure. In these cases, often no treatment is possible and patient survival is limited to a few months. We recently had an Iraqi gentleman, 65 years old who was detected to have a small 5 cm liver cancer one year ago. He could not get appropriate treatment at that time when it was in a curable stage. The cancer grew over a period of one year and the patient presented to us with liver failure. He had jaundice, accumulation of fluid in his belly, swelling of legs, mental confusion which are all signs of liver failure. The cancer had increased in size to 10 cm, had invaded the blood vessels and spread to the lung. He was brought to our center in Bangalore in a desperate state. He had three sons, all of them willing to donate a portion of their liver for liver transplantation. Unfortunately this was not a correct indication for transplantation. The patient could be offered only supportive care and passed away in three weeks.
9. How can liver diseases lead to cancer?
80% of liver cancers occur in livers, which have already developed cirrhosis. Cirrhosis is an advanced stage of liver disease in which the liver becomes scarred due to long standing ongoing damage due any factor such as chronic hepatitis B or C, alcohol use, non-alcoholic fatty liver disease. Cirrhosis is the most important risk factor for liver cancer. Certain causes of liver disease such as hepatitis B and C carry a higher risk of developing liver cancer. Ongoing liver damage over several years leads to repeated cycles of liver cell death and regeneration. Occasionally some of these regenerating liver cells become cancerous. Hepatitis B and C viruses specifically cause genetic changes in the liver cells causing them to turn cancerous. The best way to prevent liver cancer is early diagnosis and treatment of a chronic liver disease so that cirrhosis does not develop. Hepatitis B and C can be treated with effective antiviral drugs and the risk of liver cancer can be significantly reduced. Once a patient develops liver cirrhosis, it is important to do periodic ultrasound scans once in 6 months. This allows detection of cancers at an early stage when they are small and may not cause any symptoms. Small cancers are curable.
10. Your advice on how to avoid liver diseases.
Over 90% of liver diseases are preventable. Fatty liver disease can be controlled by following a healthy lifestyle keeping weight under control, regular exercise, eating a low fat and carbohydrate diet and making sure that other metabolic diseases such as diabetes, if present are well controlled. Hepatitis A and E are viruses that are transmitted through contaminated food, water and drinks. Food hygiene and sanitation in restaurants and eateries is important to prevent these infections. Hepatitis A and B are effectively prevented by a vaccine and these are recommended for all children as well as adults who are at risk of developing these infections. Screening for hepatitis B and C is important to detect these infections and all individuals especially in areas where there is high prevalence of infection should get screened at least once in their lifetime.
11. Is liver transplantation included in all health and medical insurance policies around the world, in the Mena, in the UAE? If not, do you recommend that health insurers consider this? Why?
Insurance coverage for liver transplantation is variable and depends from policy to policy. Most policies do not affect self-inflicted liver disease such as alcohol related diseases. There is also variability between policies in the diagnosis and treatment of Hepatitis B &C, which can contribute to people’s reluctance to get tested and treated. It is WHOs goal to eradicate hepatitis B and C by 2030, which in my opinion will need a combined effort from health care providers and payers to effectively treat these diseases with medications. Insurances would of course pay if liver disease is related to other causes such as non-alcoholic fatty liver and patient needs a liver transplant. At this moment, organ transplant in the UAE is limited, and some patients patients have to go abroad for this procedure. If the insurance policy covers treatment only within the UAE, then the transplant procedure would not get covered.
12. Your opinion on liver organ donation.
It is essential that organ donation be promoted at all levels right from government policies down to public education. There is an immense need for liver transplantation in the Middle East and Asia. Even in Europe and the West, where deceased donor organ transplantation occurs widely, there continues to be a shortage for organs. In Asia, deceased donor organ donations rates are very low and more than 90% of liver transplants being performed are living donor organ transplants. In the Middle East, except for few centers in Saudi Arabia and Egypt, deceased donor organ donation occurs rarely. It is important to have concerted efforts from all the countries in MENA region to establish liver transplant programs and promote deceased organ donation in order to reach and cure more patients.
13. How can we be sure that the liver organ transplantation will be safe for both the donor and the beneficiary?
Appropriate selection of donors for living donor liver transplants is very important. Liver donation by living donors is a major surgery and should not be taken lightly. A donor should have compatible blood group, be absolutely healthy, should not be overweight and should not suffer
from any major illnesses. Most liver transplant centers have well established protocols for detailed evaluation of living donors to ascertain that the surgery will be safe for them. Donors undergo a battery of blood tests, CT scan, liver biopsy, cardiac testing and various multi-specialty assessments to ensure their fitness. The donors should have an adequate volume of liver in order to safely donate a part of their liver to the patient. Healthy individuals can donate upto 65 to 70 % of their liver. The remnant liver regenerates in a few months.