The liver - what is damaging our largest gland? Episode 69

Monika Rachtan
Hi Monika Rachtan. I would like to welcome you to another episode of the After First Patient programme. Today we are going to talk about a very special organ, because it is our largest gland in our body. It has as many as 500 functions, but it is not innervated and does not hurt. And when it starts to hurt, it's very bad. Can you guess who we are talking about today? Yes, I am going to talk about the liver with my guest today, Professor Jarosław Drobnik, MD. Welcome, Professor.

Jarosław Drobnik
Good morning, and a warm welcome.

Monika Rachtan
The professor is a specialist in internal medicine, but he also has a lot of other specialisations, very important ones. Among others, he deals with epidemiology and many more with public health.

Jarosław Drobnik
Also family medicine. And this is also the area of my activity that makes us take care of the liver, because we take a holistic approach to the patient.

Monika Rachtan
Professor, liver diseases are diseases that are often very strongly stigmatised, because in most cases we associate someone who has abused alcohol with having a diseased liver, and it is not always the case that alcohol is the main cause. Very often, of course, but it can also be drugs, it can be various other factors that just cause liver damage. What liver diseases do Poles suffer from most often?

Jarosław Drobnik
Editor, perhaps about these diseases I would like to point out one more thing. On the one hand, you say that there is a stigmatisation of these patients, but this probably doesn't happen that often, although of course there may be some association. However, the problem with the liver is something else, that it is a mute organ. If I were to ask the editor honestly what the liver does, you would find it difficult to say. Although it might be easier for you, as you are a bit of a medical professional. Please note that, for most patients, the liver is simply an organ, an organ that is, and I guess it is important because it is, but what it does there, we don't really know, because we don't experience the liver. As I said, in most cases of various diseases it's a silent organ, because that's how we associate the heart, it pumps, it stops pumping a heart attack. The problem. The brain thinks reason, stroke. We see it straight away. And what do we do? We breathe. We eat. We taste. The kidneys excrete urine. And what does the liver do?

Jarosław Drobnik
You know, this liver has also probably been underestimated by us medics. It has only been the last decade or so that has shown what an important function the liver has in the homeostasis of the body. That is, it has been, so that it functions as a whole, but at the same time it shows what links it has to those of the social problems we encounter on a daily basis. It turns out that the liver is a very important correlation with overweight and obesity. That the liver is a very significant correlation with hypertension, with ischaemic heart disease, with atherosclerosis. This is the context of synthesis, for example, of albumin. Without proteins there is no life, no immunity. What is responsible for this? To a large extent, the liver. What is responsible for clotting, To a large extent the liver, what is responsible for cholesterol metabolism and so on, to a large extent the liver. And what has it been associated with so far? Well, with just such an element of stigma, namely alcohol. So alcoholic liver damage and alcoholic cirrhosis, which is not so common, as the end point of such complete decompensation, is also very often associated with what?

Jarosław Drobnik
With hepatitis, or de facto viral hepatitis. But today this epidemiology of liver disease is changing a little for two reasons, or actually one. Why do I say two? Because the one is the lifestyle context. And that is overweight, obesity. And we used to say steatosis of the liver, today we say metabolic hepatitis. In other words, what used to be often ignored because we didn't fully understand the problem. So in the ultrasound there was steatosis of the liver, liver tests were examined. They were even sometimes a little bit elevated, so viruses were ruled out. Generally nothing was happening, these tests were not increasing, so it was thought that this was the beauty. We know today that this steatosis of the liver, which correlates with overweight and obesity, which correlates with hypertension and which correlates with diabetes, triggers mechanisms that are called inflammation, not viral. This can then lead to liver fibrosis and somewhere along the line at the end point to liver fibrosis and very serious consequences. So the lifestyle context is one thing, but also the context of other areas.

Jarosław Drobnik
Because yes. Viral hepatitis, please note, from an epidemiological point of view is no longer a problem. Yes, this is true. And b vaccines c. Here is another problem to detect quickly. That is, people in different risk groups should get themselves tested periodically. Because admittedly we don't have a vaccine, but we do have a fantastic treatment, practically tailor-made for the patient. We can say that in practical terms practically or almost 100% curable.

Monika Rachtan
And what are the risk groups, who should do these tests?

Jarosław Drobnik
One such group is now slowly ceasing to exist, because I don't think blood was tested for hepatitis C until '92, So those people who had blood cites earlier may have been exposed to this infection. But such a more common area at the moment is, for example, all sorts of tattoos of that sort of thing. A sizable area of these various cosmetic activities that is not done under a proper sanitary regime.

Monika Rachtan
That is, people who use aesthetic medicine, for example, should too.

Jarosław Drobnik
But from a hairdresser's, for example, where someone somewhere gets snagged, scratched and so on. Because that's the context. On the one hand, of course, we have confidence that someone is disinfecting it properly, but with that it can be different sometimes. Such a very interesting story in my older patients. Once I was and a patient there the context of measuring sugar and by the way she says but because as here I measure myself, doctor, always, and by the way my neighbour and so on, because we sit down and we measure everything just from one puncture, right?

Jarosław Drobnik
So it's such a fairly straightforward route to infection. So that's the area. So viral hepatitis stops being a problem, but just metabolic hepatitis or this so-called non-alcoholic steatohepatitis? The other thing is the alcohol that you mentioned. And this is also an extremely important problem. I don't know if you know how much alcohol Poles drink on average at the moment.

Monika Rachtan
I have no clue, but probably a lot.

Jarosław Drobnik
Almost 12 litres of pure alcohol statistically per head of a Pole. Which if you count, more or less certainly this way of behaving from the age of 15 onwards equates to around 2.5 bottles of wine a week or almost 5 beers from the age of 15 upwards.

Monika Rachtan
This turns out to be a great deal.

Jarosław Drobnik
And drinking styles change too, don't they? I, for one, am outraged by non-alcoholic beer ads because the stimulus is subliminal. Beer. Beer that may be today is non-alcoholic, tomorrow is alcoholic. These alcohols, soft beer, wine becomes such a behavioural element of our behaviour. And what's that for a meal? Relaxation, a drink and so on. That poor liver has to process all that. So alcohol is the second area that is very important. The third area is toxic drug-induced liver damage. There was a very interesting study by PolSenior. They were I think in 2016 20, and the results are 21. Do you know how many, how many drugs, on average. Or perhaps in other words, how many patients or people over 60 are taking 5 or more drugs?

Monika Rachtan
Percentage yes. I think more than half.

Jarosław Drobnik
Exactly so. More than half of our well not quite seniors yet, because these are people in their 60s, So some of them, very active still taking at least five medications. And I think these 12% are taking 10 medications and more. 1/3 of these seniors of ours are taking dietary supplements. Almost 40% people are taking painkillers, anti-inflammatory drugs.

Monika Rachtan
They also take them on a regular basis, because it is not the case that seniors take, say, a tablet once a month because they have a headache, but very often, when you talk to them and observe their behaviour, it turns out that they take these anti-inflammatory drugs, which are in fact available without a prescription, even at the petrol station, three, four or five times a week.

Jarosław Drobnik
Three, four, five times a day. Recently, a patient of mine who I've been struggling with for a while has just had bad liver results. A hundred different things, loads of tests and so on, and at the end the carers confessed that they were buying the lady Pyralgina because she kept crying because she was in constant pain. I think we already have an element of drug dependency and when we counted what she was taking so far, it's four to six Pyralgins a day. You know, we were looking for everything. Obviously a couple of other things are there as well, but nobody sees the seriousness of the problem in terms of Pyralgin abuse. And there are actually a lot of such patients. Because please note that advertisements find solutions to all our problems, but we forget that every tablet taken has what is known as a first-pass effect, meaning that it has to jump into the stomach, then get absorbed and fly through the liver to start further mostly. So that poor liver has to cope with it too. So today the biggest challenges in terms of liver disease are, as I said, this non-alcoholic steatosis, or metabolic hepatitis, alcohol and drug abuse.

Monika Rachtan
I also thought that, in the context of liver disease in general, because, as we established at the beginning, the liver is a mute organ and will not tell us that it is ill, when a patient overuses these medicines, takes so many of them and uses various dietary supplements, he or she may be completely unaware that there is something wrong with the liver. And if he does this without the doctor's supervision or without the pharmacist's supervision, it really becomes very dangerous. And this borderline is already very, very thin.

Jarosław Drobnik
Well, that is another thing. The first thing I said we are not aware of this organ, how important it is to us, That is one, but two. We are living longer. In other words, the time we are given is also, unfortunately, the time where these adverse factors have a chronic effect on the liver. Hence, as long as we abuse a little alcohol, a little medication for a short period of time, the liver will get it. It has quite a high regenerative potential, but if this is spread out over time, or if factors such as overweight, obesity and so on have an impact and trigger this inflammatory process, then later this cascade of changes has time to occur, and of course has certain consequences.

Monika Rachtan
And please tell me, Professor, because I think we are watched by patients, maybe not patients, but people who also consider themselves to be healthy, but these are the very medicines that various dietary supplements are very often used for, because I also try very hard in this programme to educate and talk about various possibilities. And such a service has appeared in pharmacies, which is called a drug review, which pharmacists can do. And it also turns out very often that when a pharmacist does such a drug review for a patient, for example, the patient gets one active substance from a cardiologist and the same one under a different name from a primary care doctor. Of course, I don't inform each other about these diagnoses, because people have different ideas about taking care of their health and, for example, checking whether the cardiologist doctor has said the same thing as the primary care doctor that it's worth it after all, or to the primary care doctor, or even to that pharmacist whom Poles supposedly trust so much. To go with all their medicines and show what we are taking. Because not only do we care that we will spend a little less money on medicines, but we can also protect our liver from the consequences of abusing medicines.

Jarosław Drobnik
And not just the liver context. But I would very, very much encourage these kinds of visits to both use the knowledge and experience of pharmacists and GPs, especially in the context of our elderly patients, our seniors. Because they really do get a lot of medication on the one hand. We still have this bit of a philosophy of necessary clinical success. It's still half good if it's controlled somehow, that is, the GP coordinates it, the patient goes to the cardiologist, comes back with information. Consequently, I can review and consider whether I have already included this medication. And it's actually just a confirmation or an addition. But these seniors have at least three to five clinical problems, so when they pass each specialist, everyone has the ambition to prescribe at least one pill or one medicine, which is also the expectation of the patients. This is also a bit frightening. Nothing adds to the problem like a drug. Yes, because it means it's a serious issue and needs to be treated. But they are already skipping. So they take a lot. This is, on the one hand, what we fund, but on the other hand, please notice what is happening in the commercials.

Jarosław Drobnik
In fact, if the patient just survives all these experiments, he finds a solution to all his problems. Young, beautiful, skin, nails, all gastrointestinal complaints with peeing, with potency, with breathing, with sinuses. Pay attention. Get your ears flushed out. And so on, and so on. There is a remedy for everything, or a dietary supplement, or an over the counter medicine. Yes. And these poor patients of ours are just buying it. And all of a sudden it turns out that there is paracetamol in a number of medicines, for example, and it all accumulates. Therefore, these reviews of medicines are extremely important because, in fact, from an epidemiological point of view, apart from certain situations which really do say that there is a need to supplement certain vitamins and micro- and macroelements, in the long term there is only justification for vitamin D3 in the context of the Polish climate. In many cases, B vitamins, B12 or, perhaps more broadly, the B vitamin group, is actually all there is.

Monika Rachtan
Yes. And the magnesium that Poles ingest?

Jarosław Drobnik
But exactly. Please note that this magnesium is getting more and more wonderful, that is, magnesium that is great for the heart, Great for the muscles. Great for the nervous system, great for sleep, and so on, and so on, and so on. More and more great magnesium. And I was taught at school that there is only one magnesium.

Monika Rachtan
Professor, but what has happened to our society? Because I am observing these changes. I observe these changes in the context that the whole world is telling us let's eat more, the whole world is telling us, let's eat more drugs. What has happened to our society that this society cannot verify this? Well, because if I hear from the TV all the time that I should take dietary supplements, well, I can listen to that for a month, two, three. But then I find out that I leave 300 zloty a month at the chemist's, I spend it on supplements, and I'm not any more beautiful, any thinner, any younger, any wiser. What happens to people is that they want to take these supplements so much, and two, that they want to be sick so much. Because you said, Professor, everyone wants to leave the surgery with a prescription.

Jarosław Drobnik
That is exactly right. I think it is two things. On the one hand, the lack of education; if you do not acquire a certain amount of critical thinking, but also basic knowledge from kindergarten onwards, it is difficult to ask these people to reflect later on. Please note that in order to explain why it is necessary to take certain vitamins or not to take them, we would certainly have to spend another few dozen minutes on this. On the other hand, if you take such and such a vitamin, life will be completely different.

Jarosław Drobnik
Definitely better, right? And that's kind of buying into a bit of an illusion that's subliminal in us somewhere. We are a bit complacent, stressed. We want a slightly better world, a better life. So we see these adverts. And on these adverts it looks like that. So, you know, we try. It hasn't worked. The lady's reflection is quite rational, that is, I tried even God sees, my harm went the three hundred. But ok, I learned my lesson. Nothing works. I mean there is no point. So I get a second commercial. No, no, no, but it's definitely working now. And so it works. The other thing is that in certain areas we try to take shortcuts. In other words, for example, this context of weight loss is one of the more guiding elements related to advertising. So to slim down. First of all, you have to put a lot of effort into it, change your lifestyle a little bit. And that's probably the hardest thing to change a lifestyle. But even very much. So it's very difficult and we even are able to change that lifestyle.

Jarosław Drobnik
I don't know, for a month, for two. And it turns out that sometimes for years, if not forever. So we try to take shortcuts like this and Well, and it buys into such illusions and such hopes. We also don't teach people that certain things are involutionary changes. In other words, we are getting older. And now, for example, if we want to be in less pain, I mean, for example, the organs of motion, muscles, joints, then if you don't move, unfortunately it will hurt more and more often. So instead of moving, it's simpler to grab a painkiller. Likewise with that weight. If you keep moving. You don't have to run marathons, just take a good walk, right? Well then there's a chance to at least stop that weight gain and then work on it a little bit, right? And these show us potentially a shortcut. Will you take it? Not only will your liver go down, but your bellies will go down. And so on, and so on. There's a lot of these adverts out there, and we want success here and now.

Jarosław Drobnik
So I think that all this put together gives the situation that they give. And then there's another thing, which is probably the most irritating. Perhaps we are listened to by people who trust doctors. I am counting on it. That being said, I at least wonder whether this Drobnik is saying something clever or not. Please note how many so-called celebrities speak out on medical or peri-medical topics and have all sorts of strange golden advice.

Jarosław Drobnik
People are buying it, swallowing it like fish bait. Although lately it's even those fish that don't always want to play, given what's happening in the rivers and with this drought. But you know, these are some authorities. I don't understand that And what's worse, I sometimes meet at such discussions and imagine that this is an equivalent participant in the discussion. I don't dare comment on being a celebrity, because I don't know how to do that. I don't dare comment on being a good singer, because I don't sing very well and I don't know how to sing. Whereas the other person is happy to argue with me, and in order to be where I am, I've spent years learning it and I've experienced a lot of things with patients as well, so I have an element of humility and that's also what keeps us going. And the kind of icing on the cake of all this I'm talking about is the anti-vaccine movement, right?

Monika Rachtan
Professor, but what you just said about celebrities was the subject of my conversation with my husband. We often discuss such things and I always say how is it possible that I invite all these doctors and professors to this programme of mine. I am absolutely here to ask you questions and pass on knowledge, but I am passing on knowledge that you put out. And I am only here to ask questions. Sometimes I may say some of my beliefs about how society behaves, what people's habits are, but I absolutely do not make statements. I try not to comment on medical topics. If I don't know something or I don't hear from you and I also do it under control, because you would probably give me a slap on the head here if I started saying that covid doesn't exist or some other disease doesn't exist. But what has happened to our society that a celebrity who eats dietary supplements on Instagram is a greater authority for a Pole than a doctor? A professor who spent six years studying medicine, then there was an internship, then there was a residency, or vice versa?

Monika Rachtan
Well said.

Jarosław Drobnik
Specialisation. Residency is years to get to where we often are.

Monika Rachtan
Well, just how many years has the professor spent in hospital? How many hours? And Mr Professor has the right to speak about medical things. But absolutely no influencer, who may be a lawyer by training, whoever, and should really be speaking in that field, should be speaking on health issues. Is the keto diet healthy or is it not?

Jarosław Drobnik
I won't comment on that either, because I'm not a nutritionist and I'm really humbled by it. However, as I say, I think that social media is such a shortcut, looking for easy, simple solutions to our difficult problems, and in the end, it very often turns out that the foundation of these difficult, our problems, is so that our psyche again, we return to a lifestyle that also has a big impact on the liver, but also on our psyche. And often these various health problems are a mask for, for example, depression, anxiety disorders, adaptive disorders. This is also something we need to bear in mind and we as GPs recognise this, we see it. So this is also a challenge. Well, and the problem with solving this problem, because the availability in the area of psychiatry is not at all rosy. At the moment in Poland I am no longer talking about children, but also about adults.

Monika Rachtan
But I also think to myself that when we have a senior citizen who comes with this thousand different problems to a primary care doctor and doesn't talk about the fact that he has problems just related to depression. This is often a person who is hard to apologise to, to convince to take treatment, that he prefers to hide behind a thousand other problems, to find a thousand other conditions, but will not admit to the doctor, but above all to himself, that he has depression. Because it is still cooling for people, especially seniors, in Poland. There is a sickness of depression. And this is my observation.

Jarosław Drobnik
And I do not agree with that. I most of my patients that I talk to about this subject accept it and want to be treated. But the problem is something else. They have unconscious health problems and for them it is very important to show them that these complaints are not necessarily due to their physical illness or not only due to their physical illness. To show them that this can be the face of depression, that it's worth a try and some of them really convince themselves and work together quite nicely. Me thinks we don't spend enough time on this problem. You know, but we doctors also live in a rush. I have 15 minutes per patient, and to really define something in this area and have a frank discussion, I need 40 minutes. So this is the problem that unfortunately affects us all, but it is undoubtedly an important challenge.

Monika Rachtan
Professor, let me come back to liver diseases, although we talk about them all the time. Hepatic encephalopathy such a disorder. Probably most of you have not heard at all that such a thing can exist. And we are here to define. So let me ask you what this encephalopathy is? What does it consist of, how does it manifest itself?

Jarosław Drobnik
I would like to say to you, Mrs Reding, that very often, encephalopathy is confused with dementia or depression. In other words, it is easier for a patient to say and it is dementia, even toxic alcohol abuse or vascularity, or it is depression. And no, we do not associate it with hepatic encephalopathy. In fact, in such a very classical way, most of us understand the concept of hepatic coma. This is a situation where the liver is seriously ill, leading us to feel weaker and weaker. Our psychomotor ability slowly fades and we move towards coma. And this is such a fairly general perception. On the other hand, this is a dynamic process and it is spread out over time. After all, the liver is not immediately so badly damaged. It also takes time. Therefore, the symptoms of hepatic encephalopathy can be very illusory at first and, moreover, are not necessarily related solely to liver disease. But there are a number of other factors that can make one experience the symptoms of hepatic encephalopathy. Generally, hepatic encephalopathy is when the liver cannot cope with the detoxification of ammonia and then there is just such a psychomotor slowdown.

Jarosław Drobnik
And of course, somewhere in there the end point is this coma. It's mainly due to damage to the hepatocyte, or liver cell, for the various reasons we've talked about. But as I said, it's a staggered process and at the beginning it can have a completely different picture, which gives us just these different associations. This is what we call such blind spots, what these very streets look like. So that's it. Concentration problems. There can be a disturbance in the diurnal rhythm of sleep, that is, for example, we are more likely to sleep during the day and have insomnia at night. There can be emotional lability, there can be attraction, which is this disorder related to vision and movement, right? There can be discrete muscle tremors, but what's very characteristic is very often these patients say yes they have a bit of a concentration problem and they say You know, doctor, in the past I could or could do several things at once. Now, to do something well, I have to concentrate very hard on it. And please note that we have again a certain trap and a certain blind spot, because after all, it's so that the natural process of ageing, so sometimes catching it is not so easy, So this holistic approach to this problem allows us to catch this context of hepatic encephalopathy by associating several elements that can show that this situation can occur.

Jarosław Drobnik
This is also important because hepatic encephalopathy, like alcohol, reduces the response to stimuli. We all talk about alcohol in the context of driving. But please note that our seniors are living longer and very often driving is an attribute of independence for them. And yet this liver has all sorts of things behind it. It is still being catalysed with e.g. dietary supplements etc, etc. And they can periodically come to such. We call it Minimal chan, that is 0 1 degree of hepatic encephalopathy, which is Such the most characteristic element, there is such a discrete psychomotor retardation, impaired concentration.

Monika Rachtan
And the follow-up story is that such a patient with encephalopathy. He gets behind the wheel of a car. There is no diagnosis, no treatment. He has no awareness at all, because he says Well I can still Yes. And he may cause an accident in which not only his body or his health may be damaged, but there may be, for example, a mother driving her child to kindergarten from the opposite direction. And we, when we get into a car like that, we have to think about that social responsibility, because it's not just our lives.

Jarosław Drobnik
Of course, I do not want to think so dramatically, but it is undoubtedly worth remembering that the liver, with these various functions, also has a very significant effect on our mentality, but also on our abilities, on our reactions to stimuli, on this concentration of ours. Therefore, this is the context of ammonia. It damages the blood barrier, the brain. So, on the one hand, all toxins affect the central nervous system, it additionally has a neurotoxic effect. It obviously affects the neuroconduction and so on. And this area on the periphery Later we observe. Only as I say, we on a daily basis. If we already see this encephalopathy in a patient, we clearly correlate it with some serious disease that has given the context of cirrhotic fibrosis. Well, and the full consequence. Of course we treat this patient symptomatically, he often feels better and so on, but periodically it is very obvious to us. But these discrete symptoms often escape us. Because, please note, it is much easier to say that maybe we have a dementing element born after all, than to think A maybe it is hepatic encephalopathy? It's much easier to say that maybe our senior citizen or we have depressive features than to think it could be due to liver disease, But not just liver disease.

Jarosław Drobnik
The liver itself is a very important element, because it is the main site of ammonia detoxification. So if the liver is damaged, there is a good chance that to a greater or lesser extent, but encephalopathy periodically can occur, but we have two more sources of ammonia that can further affect that liver. What are these sources? And a second I just want to say yes. The liver is ageing. As a result, it does not get better with age, it only gets worse. And of course it maintains homeostasis, that is, the body despite ageing. If nothing special happens to this liver, it is able to cope with the same stress elements. But if, all of a sudden, ammonia is added from the side, then there is a problem. What additional sources? We say extra-hepatic, in other words intestinal and extra-intestinal, extra-intestinal of course in addition to such stress situations infections and so on. Patient hydration is an extremely important element in seniors. I am catching on to this myself, because if I rush in understanding I make a quick visit, sometimes also a home visit.

Jarosław Drobnik
So naturally I come. It's set up, there's a glass, there's some compote or drink and so on. Do you drink? Yes, yes. Our grandmother or mother, or there dad, grandfather drink? Of course, doctor, and so on. And so they drink, they drink. But sometimes I take the trouble to detail and for them what is correct is, for example, 3 glasses a day. And we know that if one and a half to two litres of that fluid is not provided, that is the context of the fact that our circulatory fluid is reduced, the flow through the liver is reduced, it's all more concentrated and the detoxification functions are worse. The second very important area of ammonia is the bacteria and the gut, that is SiBO or constipation. Well, because the bacteria have to live somehow. Among other things, it metabolises or digests proteins and forms ammonia. And this ammonia has to be detoxified somehow. And again, we are adding to the poor liver, which already has steatosis, already has inflammation, not metabolic, because of diabetes, because of insulin resistance, because of hypertension, because of atherosclerosis.

Jarosław Drobnik
There are such vicious circle mechanisms there that put a strain on this hepatocyte. Indeed. In addition, we have this area of ammonia and periodically all of a sudden these patients of ours are just so sleepy. We delicately say so lethargic, right? So uncooperative, unwilling to do anything. And of course, if we have such a patient, we cannot immediately say that it is hepatic encephalopathy either, but we do rule out some gross things. But it's worth thinking at some stage that this could be a feature of hepatic encephalopathy.

Monika Rachtan
And even if our doctor doesn't think of it, it is also worth simply mentioning to him that it might be worthwhile to run this diagnosis in this direction. But precisely, Professor, Well, because yes, we have symptoms that are practically non-existent, either because they are so scarce that they are difficult to notice, or we explain them with something else. So now what does this diagnosis look like? Is there any diagnostic testing that can be done to see if this hepatic encephalopathy is developing in us? Who should check, should anyone who, for example, at the age of 40, is asleep on the sofa at 4pm have such tests done? What does this look like?

Jarosław Drobnik
A person who, at the age of 40, falls asleep on the sofa should first of all have a diagnosis of diabetes done. This is by the way. Mostly. But it's not that this is the strength of the GP, because we know our patients and we also know the families very often. Therefore, when they signal to us that this patient's psychomotor area is becoming worse or his mentality has just changed, some verbosity, suddenly some emotional lability and so on, then on the one hand we can think of psychological problems, and on the other hand it is worth taking a bird's eye view of this patient, as I say. If he or she has had a history of viral hepatitis, if he or she has diabetes for example if he or she has been or is an obese person, well this context of the impact on the liver we already have, right? If we catch, for example, that he may have abnormal hydration, if we catch that the patient has, often has long-term constipation or used to have and has, for example, SiBO, which is an overgrowth of this bacterial flora in the intestines, well that is some signal that these could be features of hepatic encephalopathy.

Jarosław Drobnik
And, you know, if it doesn't find a point of grip in these other causes that seem obvious, yes, well, first of all, a priori I can think that this is a feature of encephalopathy and introduce prophylaxis. If it doesn't work, I'm sure the patient won't be harmed by it, So there's no particular danger here, Safety, but before I possibly do this element, I can do two more things. Firstly, I can determine the ammonia in the blood and it may be elevated. And that is already a signal. On the other hand, such psychomotor tests are very useful, that is, for example, such tests of connecting the dots, the clock test. In geriatrics, we often use such tests, for example, minimal mental for this definition. They, of course, are used to define, for example, depressive syndromes and so on, but when we have these features, it's worth thinking about the fact that it could be encephalopathy. And, of course, it's not that I have either depression or encephalopathy at stake, then I immediately choose encephalopathy. Very often I'll choose depression, well I also look at whether I'm having therapeutic effects, because if it's not having an effect, then maybe it's worth going back to that first idea that it could be hepatic encephalopathy?

Jarosław Drobnik
De facto I can proceed in parallel.

Monika Rachtan
Well, can it be both?

Jarosław Drobnik
But of course one does not exclude the other, so I can also introduce prevention or even treatment of hepatic encephalopathy. If I don't have an improvement after a dozen or so days, at most after a few weeks, it means that it is not likely to be the hepatic contact, but the other cause. So here we have some possibilities, we also have to proceed a little intuitively. On the other hand, the fortunate thing is that if we proceed correctly in the pharmacological context, we will not do any harm to the patient.

Monika Rachtan
And what is the prevention of encephalopathy?

Jarosław Drobnik
I mean generally prevention or treatment, it's just the context of the dose. The idea is to trigger. Meaning we have two routes of management. If we have suspected hepatic encephalopathy. On the one hand, liver contact. Very often we have discrete elevated liver tests, so well we have these different risk factors that can give inflammation. Ammonia is therefore mainly metabolised by the liver. It's what's called the urea cycle, and that's the handle points among other things. There are certain amino acids and we have a drug, which is ornithine aspartate, and we can simply include it. I will say more, often this ornithine aspartate is in many dietary supplements. And it's kind of a trap, because it seems to some people that, and there the patient is taking ornithine aspartate, because the patient said what's in there and you can check it after all. Well, if it doesn't work, well we certainly don't have the characteristics of encephalopathy, it's just that we forget about the dosage. Often in these dietary supplements, the dose is 100 200 milligrams, and the minimum prophylactic dose is 3 grams, or 10, 15, 20 tablets.

Monika Rachtan
And this is also information for patients.

Jarosław Drobnik
Very important, so the original preparations only related to this. But you know, this ornithine aspartate has another advantage, because we have a second cycle that also metabolises ammonia is definitely inefficient. The liver is more or less 85% of ammonia, and these 15% in the so-called glutamine cycle. He is in several places, but mainly in the muscles. And why is this also so important? Because such an element of natural ageing is so-called sarcopenia, which means that, unfortunately, our muscle mass, muscle strength and so on decrease. If we have features of liver damage, this sarcopenia can accelerate. Why? Because there can be discrete, elevated ammonia, and it gives acceleration. Autophagy of the muscle cell, and at the same time ornithine aspartate improves the efficiency of this glutamine cycle that takes place in the muscle cell. Therefore, we support the removal of ammonia in general, and at the same time we also reduce or inhibit this element of muscle atrophy, which is extremely important, because the lack of locomotion, the lack of this activity for our senior citizen is a very bad prognostic sign. So here, too, we have an area of certain prevention, or in any case a slowing down of certain processes, including in the context of muscles.

Monika Rachtan
This shows that this liver and these processes that happen in the liver, in fact, as the professor said at the beginning, that it affects virtually every area of our body, that this liver affects every single area that we can think of in the body, it is an extremely important organ and without a healthy liver it is actually difficult to think of this whole body being able to.

Jarosław Drobnik
I would even dare to say that without a healthy liver, there is no healthy patient. We have only really become aware of many things in the last ten years or so. It is the context of one, maybe two decades, where this research has made us aware of certain elements. This is why it is so important not only to think holistically about the liver in the context of the hepatocyte itself and probably hepato-protection, but also precisely to relieve the burden on the liver in the context of those detoxification areas that it has to do, which include this ammonia and hepatic encephalopathy, so ornithine aspartate. Why is this so important? Because we already know that a malfunctioning liver is such a mutually driving vicious circle mechanism. A damaged liver will accelerate insulin resistance and the development of diabetes will accelerate hypertension, will accelerate atherosclerosis. These diseases, as they begin to accelerate, begin to fuel liver damage. The circle closes for us. The result is an increased risk of strokes, heart attacks, complications, diabetes and so on. It is precisely the aggravation of intermittent hepatic encephalopathy. So something we can easily define as such an element. And well that's how this patient ages, well maybe less favourably, right?

Jarosław Drobnik
And it's such a drop in mood, maybe depressive, maybe demented. Not always the best example. I experienced hepatic encephalopathy many, many years ago. It was so incredibly revealing to me, because I also do palliative medicine and pain management. And I remember many, many years ago, I consulted an elderly lady who was just a bit slow, a bit demented. She was in her eighties. Anyway, she had a bit of a history of illness, because she had once had hepatitis and so on. But that may not have been important in this context, because at the time I was clearly being asked for a context related to proper pain management. He was not being properly managed, overused NSAIDs and so on and so forth. So I modified it, of course, but I also looked at the lady, and I said maybe there is this encephalopathy, this mythical encephalopathy, because it's already going into a coma and so on. These are obvious things, we can see that. But the parents were also very responsible, because they also tried to treat and depression, and so on. Well, it wasn't working, so I had this premise, I just looked at it and she was not hydrating properly, et cetera, et cetera, so we determined the ammonia was discreetly, discreetly elevated.

Jarosław Drobnik
Imagine that the family later resented me a little bit in inverted commas, of course. You moved out coolly in terms of the context of pain management, but what did I want to say? The patient revived after a month and a half, started to rule and it turned out that indeed this context of ammonia and this encephalopathy slowed her down so much. Such a discrete abnormality she was just a bit, as they said, lethargic. And now the grandmother has come to her senses, as she said, Well, and she's putting us to rights. I had a lot of pleasure, by the way, because I had a bit of contact with this patient for a couple of years, it really changed in my eyes. So it's really not a contrived, purely theoretical clinical problem. And then, as I sometimes tell these patients, by a kind of mental shortcut, because I don't want to explain anymore, I don't have time, what this encephalopathy is, It's too complicated. I say please detoxify your liver and just introduce this ornithine aspartate at least 3 g or sometimes 6 g with medication and so on. If I didn't see an effect after a month, that means it wasn't necessarily the issue.

Jarosław Drobnik
On the other hand, very often these effects, not always spectacular, but nevertheless, could be seen to improve this patient's mentality. They just happened. You can see that. So as I say, this is a real problem.

Monika Rachtan
And I think that encephalopathy still has very big consequences, precisely social consequences, because we have talked about this driving, but also, as it were, when we have nice, cheerful seniors, fit, with a will to live with vigour. It's probably a bit better for all of us to live in such a society, which is simply healthier and has a will to live. Because when such symptoms appear, which the professor mentioned, when we see that from one day to the next our organism starts to change, and we become infirm, although we still have strength in our heads and we are, as it were, at full strength, and something blocks, something does not allow, it is difficult. And such people are probably a little bit angry, a little bit pissed off, a little bit behaving differently. This affects not only their wellbeing, but the health of the whole family and the health of the whole society de facto.

Jarosław Drobnik
Without a doubt, you know, it's a great pleasure when you can see that the patient improves, we say also starts to cooperate with us. And of course, as I say, it varies in level. Sometimes it's really very spectacular results, sometimes it's just a little bit better, but it's just a little bit that he's trying, that he's trying, that he's more active, that he's making contact with relatives and so on and so forth. You know, there is nothing more dramatic in my opinion than ours, the loved ones that we have a lot of contact with. A big reduction in contact, it's true, because it's so dull, because it's putting to sleep precisely the kind of person who doesn't want to go out for a walk, who wants to lock himself in that chair, in those four walls and so on. But on the other hand, it is also extremely important to keep an eye on our seniors, for example in the context of driving. I'm really going to come back to this, because it's less about names, but there was such a consultation recently, an eighty-something year old patient anyway. With medicine strongly associated with such a person and how much time I had to spend to make this person aware that this is the end, right?

Jarosław Drobnik
And there was an area when we were still helping, when we had these features of encephalopathy as well, in my opinion, we managed to prolong this period a little bit, but there comes a point when you have to say basta. On the other hand, these people try to cross this, to stretch this boundary, but sometimes it is possible if you define the problem correctly. If we have an obviously depressive area, well, you just have to treat it. We clearly have a dementia area. Sometimes things can be improved, sometimes not, but if we have features of encephalopathy, then we can really help this patient here. And sometimes I say it's not just the context of we see a disease, a diseased liver, so elevated enzymes, bilirubin, something there, something there, right? The ultrasound will show us this steatosis and so on. It's enough that it's a bit of that already tired liver, of life. And in addition to that, it's the constipation that's the hydration, the elements, so frequent infections and it's like, we have this sinusoid of better, worse, better, Worse. Just worse as in either bad, as in this worse. The patient is still trying to drive, because it's really the slowing down of that reaction is really similar to after alcohol.

Jarosław Drobnik
Here's research on that.

Monika Rachtan
I think, however, that systemic solutions concerning the testing of drivers in general after a certain age should be a solution introduced by either the Ministry of Health or the Ministry of Transport. This is, however, a responsibility for the health of all of us, and I hope that they will appear at some point, because I think they are very much needed, and there are really various conditions, not just encephalopathy, which simply exclude these patients from being able to drive. Sure everyone wants to be mobile, fit, young and believe that they are. It is just that sometimes this belief is not enough, because health does not allow this vehicle to be driven. Professor, I thought to myself that I would like every Pole, every senior citizen in Poland, to have a family doctor like you, Professor, who cares about the patient, who is inquisitive, who looks for the cause, who does not leave the patient without answers. And I think that's what I wish our viewers at the end of the episode. But I also thank you very much Professor for the work that you do, both the scientific work and the work in many surgeries, because you can really see this enormous commitment.

Monika Rachtan
Also, when you talk about professional burnout, it is not the professor here who is absolutely not affected by it.

Jarosław Drobnik
Thank you for these compliments. Above all, I wish our listeners, those who are watching good health and that they sometimes think that this liver does not have to hurt, but it can be ill and that sometimes we can have the features of encephalopathy. We can counteract it by just using ornithine aspartate properly and appropriately. And in general, that we just try to go through this life so normally, especially in old age, but also try to solve problems.

Monika Rachtan
Well, and these problems can be solved for us primarily by the primary care physician. If there is a need, he or she will cooperate with other specialists. But whether it is encephalopathy or many other conditions, it is worth turning to these primary care doctors, cooperating with them and, above all, being honest with your doctor and talking about your symptoms. Ladies and gentlemen, today my guest, but above all your guest, was Professor Jarosław Drobnik. Thank you very much, Professor, for our meeting today, and thank you very much for your attention. Thank you for being with the programme every week. First of all, Patient. I invite you to subscribe to our social media channels. We're on YouTube and wherever you can listen to the podcasts. Thank you very much, good health and see you next week.