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Moderator: The purpose of these chats is to provide general information, and they are in no way intended to be construed as medical advice for any visitor's specific disease or condition. The intent is to increase a participant's knowledge about a general disease or condition. For treatment of your specific condition, please see your personal physician. This forum is not intended to be used in emergency situations. If you are uncertain of the urgency of your problem or condition, contact your personal physician or the nearest
hospital for assistance. Welcome to all. Our special guest for today, Dr. Joseph S. Galati, is President of Liver Specialists of Texas, and Medical Director of the Center for Liver Disease and Transplantation at The Methodist Hospital.
Welcome Dr. Galati!

Dr Galati: Thanks for having me.

Roberta: What is hepatitis?

Dr Galati: Hepatitis is any inflammation of the liver. Most people think that hepatitis means viral hepatitis which could be contagious, but that is not necessarily true. Hepatitis can be a drug-induced hepatitis from medicine, alcoholic hepatitis, or you could even get hepatitis from heat stroke. So the key thing to remember is that it is inflammation of the liver, and there are probably 50 different causes, one of which is viral hepatitis.

Sheila: What is the difference between Hepatitis A, B & C?

Dr Galati: They are different as far as how they are contracted, and they're different in whether or not they can develop into a chronic hepatitis. The key thing is different risk factors. Hepatitis A is predominantly spread by fecal/oral contamination, and this is usually from poor sanitary conditions. Very few people die from Hepatitis A; usually the very young or the very old. Hepatitis B is spread through sexual transmission, and through intravenous drug use. Fifteen percent of those who contract Hepatitis B will become chronic carriers. This has to be contrasted with Hepatitis C, where 85 percent of those infected become chronic carriers. This 85 percent chronic carrier rate is the big problem with Hepatitis C. Vaccines are available for Hepatitis A and B, although none are developed yet for Hepatitis C.

GG: Is hepatitis contracted at any age, or is there a more predominant age?

Dr Galati: You're at risk for viral hepatitis at any age, depending on the risk factor. The risk factors for Hepatitis B are people who are sexually promiscuous and intravenous drug users, whereas Hepatitis A is more of a problem with travelers. This might be a good time to review risk factors for Hepatitis C, which include blood transfusions before 1992, intravenous drug use, even if done once, tattoos and body piercing, sexual promiscuity, and children born from Hepatitis C positive mothers.

Chat: Are there early signs of Hepatitis C to alert the patient?

Dr Galati: In many cases, there are no early signs, but the majority of patients will complain of fatigue. Because many people are fatigued for other reasons, this is an overlooked symptom.

Noelle: Can someone living in the same house with someone with Hepatitis C also contract hepatitis?

Dr Galati: The intra-household transmission of Hepatitis C is quite low, on the order of 2 percent. Sexual partners run a risk of approximately 4 percent. There is a large 1000 couple study that's ongoing in California, which is very carefully looking at sexual transmission for Hepatitis C. Hopefully, this will shed additional light and give us the real risk of transmission. In general, we tell all of our patients to avoid the sharing of toothbrushes and razor blades, to cover cuts, and not leave soiled Band-Aids around. There had been some data suggesting that women with Hepatitis C who were menstruating were at higher rate of sexually spreading it to their partners, so it was suggested to avoid intercourse during menstruation.

Fun E Lady: How do the treatments vary between the different types of hepatitis?

Dr Galati: Hepatitis A essentially requires no treatment, other than supportive care, hydration if necessary, and a high-protein diet. Hepatitis B, because only 15 percent become chronic carriers, usually resolves spontaneously. For those who need treatment, there are a few drugs that are effective, including interferon, lamivudine (EPIVIR) and adefovir dipivoxil (HEPSERA). With Hepatitis C, the standard of care today is interferon and ribavirin. The latest developments with this family of drugs are the new pegalayted interferons (PEG-INTRON AND PEGASYS), which are long acting, once weekly injections.

Herbert: What is interferon?

Dr Galati: Interferon is a natural part of our immune system that stimulates the immune system to fight viral infections. The pharmaceutical companies have been able to very closely reproduce various interferons exactly as they appear in the body, and we give that to patients in very large doses in an effort to overwhelm the virus. The well-known side effect of interferon, i.e. flu-like symptoms, is due to the stimulation of the immune system. Keep in mind that when you have the flu, you feel sick because of your own levels of interferon that are raised.

Arthur: What is Ribavirin?

Dr Galati: Ribavirin is an anti-viral antibiotic that originally was used as an aerosol medication for children with respiratory viral infections. More recently, it was compounded into a tablet form and tested in conjunction with interferon. No one really knows how Ribavirin works with Hepatitis C, but when used alone, it works very poorly against Hepatitis C. When used with interferon, the effects of the two together are better than either one alone.

Geraldine: My sister has Hepatitis C and was diagnosed with it six years ago now. What should a person with this do to maintain their health and stay on top of it? Can she lead a normal life?

Dr Galati: Many people with Hepatitis C do lead normal lives. The main thing that the person has to do is to properly be worked up to determine what stage the Hepatitis C is at. If it's in the early stage, with minimal inflammation and minimal scar tissue, then chances are you'll do relatively well. If it were more advanced, with the early stages of cirrhosis or even established cirrhosis, then the long-term prognosis would not be as positive.

Ruby: Is there a simple test to see if your fatigue is in fact Hepatitis?

Dr Galati: First, check to see if your liver tests--ALT, AST, Alkaline Phosphatase, GGTP, and bilirubin--are normal or abnormal. Then, if you have risk factors for liver disease, these should be explored with your physician. As you know, there are many causes of fatigue. Hepatitis/chronic liver disease is just one of many causes. As a physician facing this every single day, it becomes very frustrating for both the physician and patient to sort out where the fatigue is coming from. A specific antibody test will determine if you do have Hepatitis C.

Sylvia: Is Hepatitis C fatal?

Dr Galati: In select cases, it can be. Hepatitis C is the leading cause of liver disease ultimately requiring liver transplantation. Alcohol and Hepatitis C are a bad combination, and chances are greater that both cirrhosis and liver cancer will develop in these particular patients that have Hepatitis C. Like anything else, early diagnosis and intervention are helpful.

Shirley: When a baby is born and has to be put under the bilirubin lights, will this have any bearing on whether they will get hepatitis in the future?

Dr Galati: The bilirubin elevated at birth is very different from bilirubin elevated in people with chronic liver disease. Usually jaundice as a new-born does not indicate future risk for liver disease.

Dawn: Is alcohol the only cause of cirrhosis?

Dr Galati: No, no, no! This is probably the most popular misconception that I have to answer on a daily basis. Alcohol accounts for about 50 percent of all cases of cirrhosis. The other 50 percent is due to viral hepatitis, hereditary forms of liver disease, and various acquired illnesses. A lot of people feel that the only type of alcoholic beverage that causes cirrhosis is "hard liquor." Whether you drink beer, wine, or vodka, you're putting yourself at equal risk for liver disease. 1.5 ounces of spirits, 6 ounces of wine, or 8 ounces of beer have exactly the same amount of alcohol. The other item of key importance is that women are much more sensitive to the effects of alcohol on the liver, so less alcohol is required to cause significant liver disease in women. According to recommendations, excessive alcohol consumption in women is greater than one beverage per day, and in men, it is two alcoholic beverages per day. You do not have to be an
'alcoholic' to be at risk for liver disease. We see many heavy social drinkers on a daily basis who have very severe liver disease, and are in need of transplants.

Walter R: What is cirrhosis?

Dr Galati: Cirrhosis is a pathologic term to describe the scar tissue we see in the liver under a microscope. Again, not everyone that has cirrhosis is an alcoholic.

Karenna: How long can you live after a liver transplant?

Dr Galati: We do not have any predetermined length of time for survival. The vast majority of patients, after recovering from the surgery, goes back to lead productive lives, and may eventually die of complications unrelated to their liver, i.e. heart disease, stroke, cancer, accidents, etc.

Sonya: How long does a transplanted liver usually last?

Dr Galati: There is no predetermined life span on a transplanted liver. It's interesting to note that donor livers from older patients put into younger patients, surprisingly, do very well.

Archie: Are alcoholics given the same priority as non-alcoholics for liver transplant?

Dr Galati: Yes, with one exception. Nationally, most liver transplant programs follow the 'six-month rule.' This is where we would want someone to be abstinent for at least six months prior to the transplant. Most programs require patients and their families to participate in ongoing alcohol rehabilitation, and any deviation from this, i.e. resumption of alcohol use, or non-compliance with the sobriety contract, could be grounds for removal from the transplant list. The reason most programs are very strict in this area is because of the lack of available donors. The same goes for any kind of other drug abusers. Staying sober from drugs or alcohol is a very good indicator that they will be compliant with the very rigorous follow-up required after any sort of organ transplant.

Wendy: Why would someone need to have a liver transplant?

Dr Galati: There are many diseases of the liver that require transplant. The patient would have to be very sick, with an failing liver. In most cases, the patients that undergo transplant have under one year to survive without it, so this truly is a lifesaving surgery. Most people take organ donation for granted, until they themselves are confronted with a tragedy. Then, when they're in a position that they're waiting months and months for a donor, they always wonder why there aren't more organs available. Most Americans take a very laissez-faire approach towards transplants because it seems so foreign to them. But when it hits either directly in their community or in their family, they realize the problems that we in transplant face every day. The best way to become a donor is to talk with your family. Even if someone carries an organ donor card, the next of kin can refuse that person being a donor. It is estimated that many thousands of potential organ donors are lost every year. But, even without a donor card, if an individual discussed his intentions to be an organ donor with family members, that usually is enough for the families and loved ones to come forward, expressing a particular person's desire to be an organ donor. A single donor can help up to ten individuals. While most concentrate on heart, liver, kidneys and lungs, tissue donors (involving cornea, skin which would be used for burn victims, and bone for severely traumatized patients) are equally important. So a single person can touch many, many lives.

Millie: When the disease becomes bad enough for a liver transplant, does that totally cure the person, or are other organs damaged as well?

Dr Galati: In the very late stages of liver disease, unfortunately, other organs may become involved, most notably the kidneys and the lungs. Patients may become too ill to undergo transplantation. Again, we always appreciate early referrals to our liver transplant program before many of these end-stage problems develop. In many cases, the underlying disease that causes cirrhosis is still present, even after the transplant. Hepatitis C recurs 100 percent in the transplanted liver, but luckily, only 15-20 percent of the patients develop significant problems over time. Many of the other hereditary forms of liver disease can recur at various rates.

Chat: With the limited amounts of livers available for transplanting, have any inroads been made with mechanical and/or man-made replacements?

Dr Galati: A number of people are at work world-wide, but it is the complexity of the liver with over 200 vital biologic functions that makes it nearly impossible to reproduce. We have worked with both bio-artificial livers as well as pig livers, but we're still very far from being able to use them as a replacement for transplant. One exciting area is in hepatocyte transplant, where liver cells are grown and then transfused back into the patient with the hope that these new liver cells could 'repopulate' the liver. Many times the livers are grown from donated livers that are only partially used. Of course, the ethical dilemma comes with the use of fetal livers, which may also be used to cultivate large banks of liver cells. Within the next ten years, I would anticipate meaningful inroads. As you can imagine, this is expensive research, and the availability of research limits how far we can go.

Martin: The cost for a liver transplant must be very high. What do you tell those folks who are on waiting lists for years? What percentage actually gets a liver in time?

Dr Galati: Over the past ten years, the number of people waiting for liver transplantation has steadily grown, but unfortunately the number of donor organs is a relatively flat curve. Across the country, roughly 20 percent of all patients waiting for liver transplants die while waiting. The cost of transplant is expensive, and in a majority of cases is covered under health insurance. The cost of transplant is higher in a patient who is critically ill in the intensive care unit than in a patient who is sick and able to stay at home. So again, it's early diagnosis, early intervention, and early referral.

William: I am not sure I understand transplants exactly. Does one liver equal one patient, or can it be shared among several patients?

Dr Galati: In some circumstances, one liver can equal two patients. This would be what we call a split liver transplant. The larger portion of the split typically goes to an adult, and the smaller lobe goes to a child or small adult.

Chuck: When you have a liver transplant, do you have to have the same blood type as the donor?

Dr Galati: Yes, blood type and size of the donor liver are the limiting factors. In heart and kidney transplants, there is much more advanced typing that is required.

Fran: Is a donor required for a hepatocyte transplant, or can the cells be taken from the patient?

Dr Galati: I believe that right now, the majority of hepatocyte transplants are taken from donor organs. But in the future, the hope would be to take a portion of one's own liver, and either grow the liver in a laboratory and reinfuse those liver cells, or somehow genetically alter the liver to correct any underlying problem the liver may have.

Tommie: I remember hearing about a liver 'cleanse' that involved drinking large quantities of olive oil. Does the liver need to be cleansed periodically, and if so, would this method actually work?

Dr Galati: A lot of patients come with information on various herbal remedies. Whether or not they work probably still needs to be proven. There's no doubt that olive oil is good for you, especially on garlic bread! But its anti-oxidant effects may be one of the mechanisms by which it works.

Milton: Is there a special diet for those individuals with liver disease?

Dr Galati: For the most part, I do not recommend any particular diet other than a hearthealthy diet. The vast majority of people with some form of liver disease do not have a fatal form of liver disease, and are at risk, like the rest of us, for coronary artery disease. In the more advanced stages of liver disease, where there is cirrhosis and portal hypertension, it may be required to limit the amount of dietary protein and salt intake.

Marissa: How is a liver biopsy performed?

Dr Galati: A liver biopsy is regularly performed now as an outpatient procedure. The patient will receive intravenous conscious sedation, with a local anesthesia around the area of the biopsy to deaden the skin. A needle is used to aspirate the liver biopsy. This is generally a safe procedure, with less than one in a thousand complications reported.

Lynne: I've been diagnosed with Gilbert's syndrome. Would milk thistle help with this condition?

Dr Galati: Probably not. Gilbert's syndrome is a completely benign disorder, and does not ever progress to more serious liver damage. Milk thistle is a weak antioxidant, felt to be equivalent to 80 international units of Vitamin E. Milk thistle is the latest craze for those with liver disease, and some studies have shown that it may be helpful through its antioxidant effects. Vitamin E and Vitamin C are probably cheaper than milk thistle.

Rhonda: What is the best way to make sure you avoid liver disease? Is there a way?

Dr Galati: Number one, know your risk factors. Number two, limit alcohol consumption. Number three, know your family history, because many forms of liver disease can be hereditary. Number four, if you have any abnormal liver functions noted, they should be meticulously evaluated.

Moderator: Dr. Galati, thank you for a most informative chat tonight  Is there anything else you would like to say before we close tonight?

Dr Galati: Thank you for inviting me. This was wonderful. Closing thoughts-number one, seriously consider becoming an organ donor. Number two, limit alcohol consumption. Number three, have a physical examination at least every year, with appropriate blood work. If you know anyone with liver disease, encourage them to get evaluated.

Moderator: We thank you, our great audience, and a very special thank you to our guest,
Dr. Galati.