Herbal and Dietary Supplements: A Cause of Liver Disease

By: Jose P. Ferrer, Sr.

 The true incidence of drug-induced liver injury in the United States is difficult to discern. The most recent and well-executed population-based studies, however, have estimated an annual incidence of around 20 new cases per 100,000 persons; Herbal and dietary supplements (HDS) are implicated in approximately 16% of these cases.

Herbal and dietary supplements are commonly used by many people, both healthy and with specific ailments, with the perception that HDS are safe and effective. It is estimated that over 40% of the U.S. population uses alternative therapies of some kind, most commonly HDS.

Common Users

Alarmingly, most patients who use HDS do not reveal this to their primary care provider. Users of HDS tend to be Asian, of young age, highly educated, and more health conscious than non-users. The most common reasons for their use include obesity/weight loss, body building, menopausal symptoms, gastrointestinal disorders such as indigestion or constipation, liver disease, and neurological complaints such as headache and migraines.

Side Effects

The hepatotoxic potential of HDS has been recognized for many years and appears to be increasing. As mentioned above, it also seems to be implicated in up to 16% of all cases of drug-induced liver injury.

Many single herbs have been implicated in liver toxicity; however, most currently available HDS comprise a complex mixture of ingredients and although the FDA requires that a product label accurately reflect the contents, reports exist of product contamination and unlabeled ingredients.

Most of the time, the liver injury has a very mild course and it will resolve by stopping the offending supplement. In rare cases, however, the disease will have a more severe course leading up to requiring liver transplantation or even causing death.


Always inform your doctor about the herbal and dietary supplements that you may be taking. In the event of a possible liver injury or abnormal tests, you must cease all supplement use. n

For more information, visit www.livertox.nih.gov


What is Fatty Liver?

Non-alcoholic fatty liver disease (NAFLD) is a disease resembling the damage seen in the liver when there is alcohol abuse, but occurring in patients with little or no alcohol consumption. NAFLD is the most common liverdisorder in the Western world. It is a serious public health problem in the United States where an estimated 90 million Americans are affected.

The spectrum of NAFLD includes fatty liver and non-alcoholic steatohepatitis (NASH). Fatty liver represents the build-up or accumulation of fat (triglycerides) in the liver cells.  In NASH, steato refers to fat and hepatitis means inflammation and damage to the liver. Patients with fatty liver have a relatively benign condition.  By contrast, NASH, due to the ongoing inflammation, can cause scarring and hardening of the liver. When it becomes extensive, it is called cirrhosis.

This condition (cirrhosis) may develop in up to 25% of patients and can lead to complications such as liver cancer, liver failure and liver-related death or the requirement for liver transplantation. In fact, rates of transplantation performed for NASH have increased in the USA over the past 10 years, rising from 0.1% in 1966 to 4.7% in 2007.

Conditions frequently associated with NASH include being overweight or obese, type 2 diabetes mellitus and hyperlipidemia (high blood triglycerides and/or cholesterol). NASH is also closely associated with “metabolic syndrome”, which is a risk factor for cardiovascular disease. Therefore, it is not surprising that cardiovascular disease is a leading cause of death in subjects with NAFLD.

Most people with NASH have no symptoms and it is often discovered during routine laboratory testing when liver enzymes (AST/ALT) are found to be elevated.  Imaging studies like ultrasound and CT scan can assist to evaluate the presence of NASH. Usually a liver biopsy is required to confirm the diagnosis as well as to determine the severity of the disease. This procedure is safely done, under local anesthesia, by an expert radiologist. While guided by an ultrasound machine, the radiologist introduces a slender needle into the liver to obtain a sample that is then examined under a microscope.

Other causes of chronic liver disease (e.g. viral hepatitis B & C, medications, etc.) should also be excluded during the evaluation of these patients.

Treatment is focused on weight loss through exercise and decreased caloric intake; consultation with a nutritionist can help achieve this goal. Also good control of blood sugar in diabetic patients, as well as decreasing blood triglyceride and cholesterol levels when elevated, will help in the treatment of this condition.


Have you had your flu shot

Gastro Health recommends that patients with Crohn’s Disease or Ulcerative Colitis who are taking “immunosuppressant medications” receive a yearly flu vaccination and the pneumonia vaccine every five years.

Immunosuppressant medications include the following:

  • Prednisone
  • Azathioprine (Imuran, Azasan)
  • 6-Mercaptopurine (6-MP, Purinethol)
  • Methotrexate (Rheumatrex)
  • Infliximab (Remicade); Adalimumab (Humira); Certolizumab Pegol (Cimzia)
  • Natalizumab (Tysabri)

The inactivated influenza vaccine given by an intramuscular shot, as well as the pneumonia vaccine, are both safe for patients taking immunosuppressant medications. However, live vaccinations are not safe if you are taking immunosuppressant medications.  Live vaccinations include:

  • Chickenpox (Varicella Zoster Infection)
  • Measles, Mumps and Rubella (MMR)
  • Yellow Fever
  • Intranasal Flu Vaccine (this is different from the one given by an Intramuscular injection)

If you have ANY questions or concerns, please consult your Gastro Health physician.


What You Might Not Know About Antibiotics

Antibiotics are widely used in the prevention and treatment of infectious diseases. While antibiotics are safe for most people, it has been proven that a common side effect of the treatment is diarrhea. Symptoms can range from mild abdominal discomfort, watery diarrhea, to severe colitis and even death. Sure, the medicine kills the bad bacteria that make us sick, but it also destroys the good bacteria that keep our intestines in-line. Diarrhea is defined by the World Health Organization (WHO, 2008) as the passage of three or more loose or liquid stools per day, or more frequently than is normal for the individual.

According to several studies, diarrhea occurs between 5% and 39% of patients receiving antibiotics, depending on the population and the type of antibiotic. This undesired symptom may result directly from altered gastrointestinal motility (alterations in the contraction or movement of the intestines) or from disruption of the normal bacterial flora of the intestinal tract. However, the major cause of antibiotic-associated diarrhea is infection with Clostridium difficile bacteria.

Clostridium difficile, often called C. difficile, is a bacterium that represents a considerable public health hazard, known to cause symptoms that can even range to life-threatening inflammation of the colon. Illness from C. difficile typically occurs after use of antibiotic medications and has become more frequent, more severe and more difficult to treat. In the United States, it is responsible for more deaths than all other intestinal infections combined. It is suggested that up to 3 million cases of infection occur each year. If these statistics are accurate, it would make C. difficile infection the most common bacterial cause of diarrhea in the United States.

Aside from antibiotic use, the risk factors for C. difficile infection include advanced age, prior hospitalization, treatment with chemotherapy, living in a nursing home and use of proton pump inhibitor (medications used to suppress gastric acidity). Patients suffering from Inflammatory Bowel Disease, both ulcerative colitis and Crohn’s disease, are also particularly vulnerable to C. difficile infection and physicians recommend that their stools be tested whenever disease flares up with significant diarrhea.

Clostridium difficile is a bacteria that can exist in a spore or vegetative forms (a spore is a microorganism in a dormant or resting state).Outside the human colon, it survives in spore form which is resistant to heat, stomach acid and antibiotics. Patients with C. difficile infection shed spores in stools, resulting in contamination of their skin, clothing, bedding and nearby environmental surfaces. Transmission is primarily via the fecal-oral route following transient contamination of the hands of the health care givers.  Once spores are in the colon, they convert to their fully functional and aggressive vegetative form, producing toxins that damage and inflame the lining of the colon resulting in colitis.

The treatment of antibiotic-associated diarrhea consists of several steps:

1- Stopping the antibiotic causing the problem is an important initial step.

2- Administration of probiotics, which are live microorganisms (in most cases bacteria) that are similar to the beneficial microorganisms found in the human gastrointestinal tract. When administered in adequate amounts, they confer a health benefit on the host, in preventing and treating antibiotic-associated diarrhea.

3- If the patient has a stool specimen that tested positive for C. difficile, proper treatment with antibiotics should be started and the patient is advised not to use anti-diarrheal medications (Lomotil, Imodium, etc.) since their use could worsen the illness.

4- Finally, patients are advised to drink large amounts of fluids by mouth to prevent dehydration.

C. difficile infection recurs in up to 25% of the patients even after initial successful treatment, requiring another round of treatment with antibiotics. Due to this high recurrence rate, immunologic approach to the prevention and treatment of recurrence are in development and include the use of immunoglobulins, anti-C. difficile toxin antibodies and active immunization with vaccines. The use of fecal transplant has also shown a high success rate in clinical trials.

Quoting Benjamin Franklin’s axiom that “an ounce of prevention is worth a pound of cure”, the following recommendations shall help in the prevention of antibiotic-associated diarrhea:

1- Do not demand/take antibiotics if your doctor says you don’t need them.

2- Wash your hands thoroughly and frequently.

3- Wear gloves when around a patient who has C. difficile infection.