A man drank 3 liters of rum everyday since age 13. This is what happened to his liver JB is a 27 year old man presenting to the emergency room with “hematemesis”: the vomiting of blood. Breathing fast and heart beating fast, JB quickly falls unconscious just before admission. His younger sister Kristin, in tears, tells the admitting nurse that JB had vomited three times in the past 30 minutes. You see, JB was playing in a band, Mother McCree’s Uptown Jug Champions. He was notorious to bandmates and fans for downing a fifth of rum before each concert which averaged five times a week. He needed to do this. His bandmates couldn’t stand him doing this. This whole thing started from his teenage years. As a 13 year old JB’s irresponsible father introduced him to wine. As JB detested its taste, he enjoyed the feeling that it gave him. The numbness of the cheeks and tongue, the slightly darkened vision on the sides of his eyes, the confidence and euphoria he would feel after finishing what was that first half a bottle of wine. But then it became a whole bottle that he had to steal from his dad every day. Then he moved on to rum and did 15 shots, building up to 35 shots every day. At age 16, JB’s father abandoned the family and three weeks later upon arriving home from school, he found a note left by his mother telling him that she’s leaving for England to live with her new boyfriend. JB dropped out of high school and his only solace was taking care of his little sister, playing in a band and his daily bottles of rum But a fifth of rum doesn’t even begin to describe JB’s current alcohol consumption. Aside from chugging a fifth before the show he would down a whole handle or 35 shots of rum first thing in the morning for breakfast every day. He is also known to drink wine during each concert straight out of the bottle sometimes being so drunk he’d sing the wrong song. The band was trying to stage an intervention, but while on tour there was very little that they could do. At the hospital with Kristin the band mates tell the admitting nurse that two weeks ago they noticed a big change in JB’s physical appearance and mental acuity. His belly had become uncomfortably swollen even though his neck and face had gotten considerably thinner. His skin and eyes had become a brownish yellow color. At times when they thought he was supposed to be sober he was found stumbling over his feet, slurring his words, and presented with an overall confusion. Earlier in the year he fell down the stairs and got a bruise that never seemed to go away. As the nurse takes JB’s blood pressure she reads 62 / 40 (mmHg): a medical emergency and without immediate treatment JB will die in a matter of minutes. Given this past medical history, it’s clear as to what’s going on: most immediately JB is in hypovolemic shock. A drop in blood flow due to low blood volume. The volume loss is simple: he’s vomited more than 20% of his total body fluid. JB is hyperventilating, breathing fast because he doesn’t have enough blood to deliver oxygen to his body and his brain stem detects the sudden drop in oxygen content, it thinks he’s suffocating and demands that he breathes quicker. His heart rate is high because his heart is trying to compensate for the low blood pressure. He falls unconscious because less blood is now reaching the brain. This alone is a medical emergency, Few of his organs are receiving blood now which means no delivery of oxygen. JB’s body will begin to shut down and go into multi-organ failure. He has just minutes to live. So you may think: just replace the blood and he should be okay, right? Well, not by itself and here’s why. Both the mass alcohol abuse described by Kristin and the hematemesis are dead giveaways. JB Is in hypovolemic shock but only because of decompensated cirrhosis. It means his liver is completely unfunctional and scarred. Alcohol, or more formally ethanol is broken down twice in your body, first in your liver by an enzyme called “Alcohol dehydrogenase.” it breaks alcohol into acetaldehyde, Which is similar to the fluid used to embalm mummies. Acetaldehyde make some people red when they drink and it’s partly the cause of hangovers It’s poisonous. It damages the DNA in the liver cells. In small amounts of alcohol consumption which is okay, acetaldehyde quickly becomes acetate which is basically vinegar but in large amounts it wrongly signals to the liver cells to produce fat. It allows the immune cells to attack the liver. When the cells heal they’re covered with collagen. It’s similar to having a scar on your skin after a deep wound. Now everything that JB is suffering from is a result of both liver failure and scarring. The final stage of liver damage is what we call “Cirrhosis”. That word derives from the Greek Word “kirrhos” meaning brownish yellow color. By saying “decompensated” we mean that JB’s body can no longer adapt itself to the liver damage that has occurred. So why is it brownish yellow? Well, let me ask a different question. Why is poop brown? It’s the same reason why JB’s eyes and skin are brownish yellow. Your red blood cells, they only live 120 days and after that they’re destroyed in your spleen and the remnants are sent to your liver to be broken down even more. After the breakdown you get “bilirubin,” the chemical that makes your poop brown. The problem with cirrhosis is that bilirubin is no longer processed. It’s supposed to combine with bile from the gallbladder, something that helps you digest fats and oils, but the liver is not functional at this point, so nothing is being processed by it. The broken down bits of your red blood cells flow freely in your blood and bind to your skin and eyes and make them a brownish yellow color. Instead of brown poop, JB has brownish yellow skin and eyes. Why is JB confused, slurring his words, and stumbling over his feet? It’s because of ammonia in his body. That’s the same chemical in fertilizer, and there’s a lot of it flowing around in his blood in his case. Your liver helps digest the proteins that you eat. Protein contains a lot of nitrogen the most simple form of nitrogen dealt by your liver is ammonia whereas water contained the central oxygen, ammonia contains a central nitrogen. That ammonia is typically processed in the liver to become something that we call more water-soluble meaning that you can urinate it out. But since JB’s liver is failing the ammonia flows in his blood crosses into the brain and disrupts his brain cells. This is called hepatic encephalopathy: disorder of the brain because of the liver. His brain cannot function because the chemicals the liver are supposed to handle are disrupting it. Finally why is JB vomiting blood? The last point here is that the liver synthesizes blood clotting factors. When you get cut they come together to help you stop your bleed. The bruise that JB got after falling is his muscles bleeding underneath the skin. They’ll keep bleeding for a long time because he doesn’t have the clotting factors to stop it. Because the liver’s failing, clotting factors are hardly produced. But now here’s the twist: because the liver is scarred blood also doesn’t flow easily through his liver. You see the hepatic portal system is a major blood circulating pathway where nutrients are absorbed and reabsorbed through your stomach and small intestines. Everything that you swallow goes through your stomach, absorbed into your intestines, and it’s processed in your liver. Oral medicines in tablets and capsules famously go through something called first pass metabolism. You take the medicine by mouth, it goes into your stomach, and goes into your liver where it gets broken down If you took 220 milligrams there might only be 22 milligrams left after first pass. But if a drug is injected, it doesn’t go through the liver first and that’s why oral drug dosing is always higher than injecting the drug. For example, these morphine tablets which are supposed to be taken orally are always at a higher dose than morphine injection. Everything that you swallow goes through the liver. Now, this is important because the hepatic portal vein flows almost directly into the lower part of your heart. When the liver is cirrhosed, blood flow is blocked. It backs up into the veins of the stomach and the esophagus. These are called “Varices”: where the blood is circulating against the valves of each vein. As the liver becomes less and less functional and more and more like scar tissue, the varices build up more and more pressure until they burst. What’s happening to JB’s stomach and esophagus is the veins have burst, and the stomach is now filling with blood. It’s called variceal hemorrhage and if left untreated, he will bleed to death into his stomach. The most immediate treatment required here is to stop the bleed and transfuse blood into JB. Stopping the blood flow would be done with rubber band ligation. They’re sent down the throat through a tube and the bands are tied, to temporarily stop bleeding. A drug known as octreotide is infused into JB intravenously to decrease blood flow to the abdominal organs. Finally, allowing the portal vein to bypass the liver through this shunt to short-circuit blood flow through the liver decreases the pressure back up in the stomach. It’s a little newer of a technique and a little risky. It’s transjugular meaning that they enter from your neck. Intrahepatic means that it goes through your liver, and portosystemic meaning connecting portal vein to systemic vein. In the old days, they would have used this balloon tamponade, where balloons were sent down your throat and inflated just at the top of your stomach but this had a chance for you to breathe in the contents of your stomach or perforate your esophagus. These are only temporary solutions to keep JB alive until his liver is replaced, these problems won’t go away. Without liver transplantation, JB cannot survive this medical emergency. We can temporarily stop the blood flow backing up with bands, medicines, and shunts. We can treat his encephalopathy with lactulose, but without transplant, JB has a 70% mortality rate in three months. In 90 days, it’s more than likely he won’t be alive. But obtaining a liver for transplant would mean we need to find a matching donor. And in the United States, in 2016, the average waiting time was 149 days for a donor organ, down from 349 in 2006. Neither of those are less than 3 months. You need to be on a waiting list to get a transplant. There simply isn’t a large quantity of livers available. We can’t harvest humans for organs. We can’t grow livers magically. If someone passes away, their liver may not be suitable for transplantation even if they mark themselves as an organ donor. With how difficult it is to obtain a matching donor for a liver, the fate of JB is up to the caregivers for monitoring him and waiting for a liver to become available. The outcomes of alcoholic cirrhosis are not glamorous. No more than 1 to 2 shots per day, without rollover, of hard liquor or equivalent before age 65, and, no more than one afterwards is the recommendation. No matter the medicines, surgical procedures, genetic engineering and whatever technology that may be available at any point in time, alcoholism is a human problem that will always be best solved from the support of other humans. Luckily for JB, after some time in long-term care, an organ donor was found, and his 27 year old body was able to accept the transplant. With social support from his little sister Kristin, his band and with newfound wisdom of the dangers of mass alcohol consumption, he was able to live his life to the fullest. This story is based on Ron Pigpen McKernan of the Grateful Dead. The only similarities here were Mother McCree’s Uptown Jug Champions, the age of 27, and the cirrhosis. He was a counterculture icon said to have cursed the keyboard seat of the Grateful Dead as every other full-time keyboardist of the band after him died by accident. Pigpen himself died of variceal hemorrhage in 1973 a time when octreotide wasn’t available and the transjugular intrahepatic portosystemic shunt was merely a conjecture. Pigpen was and is now forever one of the Grateful Dead. Thank you so much for watching. Take care of yourself and be well.