Ramadan is observed religiously across the globe by Muslims. During some seasons and in some regions of the world, the duration of fast may extend from more than 15 hours per day, thereby adding to the stress on bodies of people with physical limitations either due to illness or some other obstacle. Same is the case with liver disease patients.Islam has offered exemption from fasting for those individuals who are unable to bear the weight; such people include pregnant and lactating females, the sick people, the very young and very old/frail people etc. Fasting among individuals with liver disorders is a subject not much touched in literature. Therefore i considered to focus on the issue for my liver patients.
Liver Disorders
There is a huge list of liver disorders, but for the purpose, I have mainly focused on the effects of fasting on patients under the following headings:
Effects of fasting on patients with fatty liver (masld/nafld) with/without diabetes
Metabolic dysfunction associated steatotic liver disease (commonly called fatty liver) refers to liver fat accumulation with atleast one metabolic risk factor (like diabetes, hypertension, obesity etc). Its prevalence is estimated to be upto 30 % worldwide with geographical variations. The essence of treatment for fatty liver lies in weight loss. Ramadan is a blessing for such patients. It is estimated that weight loss upto 5-10 % of body weight can significantly reduce liver fat & even reverse fibrosis to some extent, in addition to improvement in lipid levels, blood pressure & liver enzymes. Hence non diabetic fatty liver patients will benefit from Ramadan fasting .However for diabetic patients supervision of physician is advised. Well-controlled type 2 diabetics can observe the Ramadan fast, but fasting is not recommended for type 1 diabetics, or diabetics who are non-compliant, poorly controlled or pregnant.
Effects of fasting on patients with acute hepatitis with or without liver failure
Patients with acute hepatitis or acute liver failure have markedly deranged liver functions. Most of these have pain in abdomen & are vomiting. Such patients should refrain from fasting, because prolonged durations of fast can prove deleterious to their health owing to already compromised liver status.
Effects of fasting on chronic hepatitis and liver cirrhosis (scarring)
Patients with Chronic hepatitis/Cirrhosis should be under close supervision of gastroenterologists. Liver in addition to pancreas plays a vital role in blood glucose metabolism. Glycogen stores in liver are utilized during fasting phase & prevent hypoglycemia (low blood glucose). But in liver disease patients glycogen stores are depleted and hence such patients are prone to hypoglycemia in particular if they are diabetic. Hence a pre Ramadan assessment of liver disease severity should be done by calculating their risk scores of liver disease like Child Class & MELD scores. In-addition a close historical review about decompensating events like ascites/fluid in belly, gut bleeding and altered sensorium should be carefully sought from history.Chronic Hepatitis B/C & early stage (Child A) liver cirrhosis with no previous history of gut bleeding may tolerate the Ramadan fast if they have a stable liver functions. Hepatitis patients can continue their antiviral medications during Ramadan safely with modification of drug timing. On the otherhand, advanced liver disease (Child C) cirrhotics with previous history of gut bleeding or diabetes should be advised not to fast.
Diet in Cirrhosis
The best diet for cirrhotic patients is one which gives the nutrition body needs and helps manage the symptoms. It is important to get enough calories and protein in your diet each day. Choose low-sodium or salt-free products whenever you can. Read food labels carefully. They show you how much is in a serving. Eat smaller meals more often, including a snack before bedtime. In addition make a habit to check your weight each morning and write down the number in a notebook. This will tell you if you are building up too much fluid in belly.
Special Situations
- Transplant patients: Post liver transplant patients who are stable with normal pre-fasting baseline liver functions may safely fast during Ramadan, but under close supervision of Gastroenterologist/Hepatologist. There are very few studies in post liver transplant patients and the recommendation is extrapolated from post renal transplant patients.
- Gilbert Syndrome: Such patients have mild persistent unconjugated jaundice which is mostly benign. Such patients can fast if baseline liver functions are stable and have no coexisting illness.
Conclusion
Counseling patients before the holy month is essential. A work up should focus on clinical examination, laboratory and ultrasonography assessment and endoscopy if needed. Advice for fasting candidates should include scheduling their medications timing to fit daytime fasting, nutritional advice and probably a daytime PPI (stomach medicine). Another important point is the regular and timely follow up with your doctor/Gastroenterologist.
(The Author is Gastroenterologist at Paras Health Srinagar)
