THE WEEPING LIVER

Most people in her inner circle knew that Sandra was drinking heavily. After golf at the country club, a couple of glasses of wine with lunch, and martinis in the evening. Lots of people drink that heavily. Nobody thought much of it.

Until her belly started to swell.

Within two weeks she looked six months pregnant.

Then, her eyes turned yellow.

There was no sign this was coming. Almost overnight the cirrhosis became apparent. A scarred liver blocks the flow of blood from the massive system of portal veins coming from the entire digestive tract. The liver is engorged and tender. The back pressure causes the liver to ooze fluid into the abdominal cavity. It is called ascites and it makes the belly swell.

It is a sign of a very sick liver.

The fluid built up to the point that she had trouble breathing, and a lot of pain. They tapped her belly with a long needle and took of several liters of a straw-colored fluid. Then she could breathe more easily, for a couple of days.

On Wednesday, Sandra was at Stanford inquiring about a transplant. Mickey Mantle had one didn't he? Why not her?

She has to have counseling first. She has to demonstrate that she can quit. Then they will consider putting her on the list. In the meantime, the toxins and ammonia that the liver normally detoxifies will build up. The coarse tremor Sandra has is from the ammonia. To a county hospital intern it is a "liver flap", and it is the sign of imminent doom.

A transplant could take a while. 

Probably too long a while to save Sandra.

-jh-

HE TOOK A LONG TIME DYING

There was an obituary in the paper yesterday for George Larson. I saw his doc in the hospital last week and he told me he was on hospice. I just couldn't believe it. He had end-stage liver disease for a decade. He even quit for a while but he could never stay quit.

I first met George thirty years ago. he came to see me as a patient. He had some problems with eczema and a few funny moles that needed watching. He was a Cal Poly professor and a nice guy. We were both from southern California and born within a week of each other.

I saw him annually for a skin check. I had no idea of his drinking problem until about fifteen years ago when he was hospitalized for vomiting blood. It was alcoholic gastritis and after discharge, he quit for a while.

Over the years, I watched George grow heavy, then morbidly obese. When we first met, he was on no medications. At last year's check-up, he was on drugs for high blood pressure, diabetes, cholesterol, and acid reflux. Alcohol caused or contributed to all of his medical problems.

Ten years ago, he developed a large ulcer on his protuberant lower abdomen. It was deep with a black crust in the center, and I was worried about infection and possibly even gangrene in a diabetic. The ulcer had irregular, angular edges, not something nature could produce. George was creating it himself, out of some dark alcoholic need that went unspoken. I finally got it healed but at weekly visits he showed up very drunk several times and was rude to my staff and belligerent to me. I considered firing him as a patient but he went to rehab and sent me a letter of apology. I gave in.

Six months later, he had his first bleed from esophageal varices. These huge varicose veins are caused by greatly increased back pressure in the portal vein due to a scarred liver. The mucosa overlying these dilated veins was paper thin and prone to tear easily, especially when a patient vomits, which alcoholics are liable to do when they drink. Once torn, the varice can dump five or six units of blood into the stomach in a matter of minutes, and shock and death rapidly follow.  In the old days, the mortality from bleeding varices was 50%. Now they place bands around them to reinforce them, and often chronic alcoholics survive multiple bleeds.

George just couldn't stay quit, even after a near-death experience with bleeding varices. Little by little the scar tissue built up in his liver and it was less able to detoxify all the waste products in the bloodstream, especially the ammonia resultant from dietary protein break down. George was given a low protein diet but he observed that no better than abstaining from alcohol.

Several months ago, George reached the tipping point. As the liver failed, so went the kidneys. So-called hepatorenal failure is a common end for many alcoholics who used to die of g.i. bleeds.

As the ammonia and other waste products built up, George began a peculiar flapping of his hands at the wrist. This 'liver flap" was accompanied by stupor and severe jaundice. Yellow skin and bright yellow eyes led the way to coma as the liver and kidneys shut down simultaneously.

Within a week, George was dead. 

But George was dying thirty years ago, his fate sealed by the toxic effect of the alcohol and his inability to quit.

One-third of all alcoholics die of their disease. 

It just may take a while.

-jh-