Prevalence and determinants of biochemical dysfunction of the liver in Atayal Aboriginal community of Taiwan: is betel nut chewing a risk factor?

Acute toxic effects of areca nut on central nervous system and liver: A case report

Areca nut (AN) is an addictive substance widely used in different world regions. There are several side effects associated with the use of AN, which have already been reported. However, the reports on hepatotoxicity of AN are sporadic and non-conclusive. In the present case report, we investigated the hepatotoxicity of AN in a four-year-old Iranian girl who was transferred to our medical center with abdominal pain, vomiting, diarrhea, fever, and other symptoms such as hematuria, decreased mental status, multiple seizure episodes. After a comprehensive evaluation, it was concluded that these signs and symptoms were all attributed to AN consumption, which was given by her mother to control diarrhea. Eventually, the patient medical conditions were managed successfully, and she survived by intense medical care. In conclusion, we suggest AN should be considered a potential hepatotoxic agent.

Systemic effect of arecoline on the gastrointestinal system in oral submucous fibrosis affected wistar rats

Background

The intestine plays an important role in the digestion and absorption of ingested food and the elimination of undigested food, microbes, and microbial products. The functional reliability of the intestinal mucosal epithelial cells depends on the organised regulation of the epithelial cells, mucus layer, the intercellular tight junction, host innate and acquired immune response. The mucus layer of the gastrointestinal tract is the first line of innate host defense, essentially because of the secretory products of intestinal cells.

Aim

Present study was conducted to evaluate the effect of arecoline on the gastrointestinal system due to systemic absorption of the drug during the induction period of oral submucous fibrosis (OSMF) in Wistar rats.

Methods

Oral submucous fibrosis was induced by submucosal injection of arecoline in the buccal mucosa. Arecoline hydrochloride at a dosage of 10 mg/kg was injected into the submucosa of right buccal mucosa in experimental animals over a period of 3 months on every alternate day. After which, right buccal mucosa, gastrointestinal tract organs like stomach, large intestine, small intestine and liver were dissected, subjected to histopathological evaluation of the healthy and experimental Wistar rats were subjected to histopathological evaluation.

Results

On histological evaluation, OSMF was seen to affect Wistar rats showed significant changes in oral mucosa, decrease number of goblet cells in the small intestine as well in the large intestine and deranged hepatocytes. These marked changes indicated a definite effect on the gastro intestinal system by arecoline.

Conclusion

The study has highlighted the effect of arecoline due to systemic absorption during the induction process of OSMF in Wistar rats.

Environmental Exposure to Cyanobacteria Hepatotoxins in a Pacific Island Community: A Cross-Sectional Assessment

(1) Background: Cyanobacteria produce a wide range of secondary metabolites, including tumor-promoting hepatotoxins. We recently reported evidence of an independent association between oral cyanobacteria and hepatocellular carcinoma in a U.S. population. We sought to characterize the nature, sources, and health correlates of cyanotoxin exposure in the U.S. Pacific Island territory of Guam, which has a high incidence of liver cancer. (2) Methods: Seventy-four adult males and females were enrolled in a cross-sectional study to quantify cyanotoxins in saliva, urine, and blood and their correlation with health behaviors, medical history, and environmental exposures. Plant samples were collected from locations throughout the island. Microcystin/nodularin (MC/NOD), cylindrospermopsin (CYN), and anabaenopeptin (AB) were measured in biospecimens and in plant extracts by ELISA. (3) Results: Overall, among study participants MC/NOD were detected in 53.9% of saliva, 7.5% of urine, and 100% of serum.; CYN in 40.0% of saliva, 100.0% of urine, and 70.4% of serum; AB in 30.8% of saliva, 85% of urine, and 92.6% of serum. Salivary MC/NOD levels were significantly higher in individuals using municipal tap water as their primary source of drinking water; both salivary and urinary MC/NOD levels were higher in those not using store-bought/commercial water. Urine MC/NOD levels were highest among individuals consuming fruits and vegetables exclusively from local sources. Urine MC/NOD levels were elevated in individuals with hypertension and hyperlipidemia and salivary MC/NOD in those with recent alcohol consumption. Cyanotoxins were prevalent in plant samples including MC/NOD (46.6%), CYN (35.1%), and AB (51.7%). (4) Conclusions: Our study provides evidence that exposure to cyanobacterial hepatotoxins, including tumor promoters, may be prevalent in Guam and may originate from environmental sources. Population-based epidemiologic studies are needed to investigate the role of cyanotoxins in liver cancer development.

Risk of liver disease in areca nut habitual: A systematic review

Background:

Areca nut (AN) is one of the addictive substances known to cause deleterious effects on oral cavity as well as on various body organs including liver. But, scanty information is available reporting the adverse effects of AN chewing on the liver.

Aim:

To study the risk of liver disease in AN habitual based on the relevant published data.

Methods:

The literature search was performed by an electronic search of the PubMed/Medline, Scopus and Google Scholar databases using proper MESH headings and retrieved the articles published from 1998 to 2021. The eligibility criteria included: Human studies, AN habitual as study participants, use of controls and articles published in English. Data were extracted regarding characteristics of studies, characteristics of AN exposure, effect estimate and outcome of the studies.

Results:

Total 253 articles were identified from various databases and 15 studies were selected that met the inclusion criteria. Among these, thirteen studies showed an association between AN habit and attenuation of risk of liver disease as determined by relative risk/odds ratio/hazard ratio. Eleven studies described additive effect of AN and HBsAg and/or Anti hepatitis C virus status on development of liver disease. However, two of the studies showed opposite results. The heterogeneity in the study designs, exposure characteristics, outcomes and confounders precluded further meta-analysis.

Conclusion:

The association between AN chewing and an increased risk of developing liver disease is noted which necessitates the need for AN cessation campaign.

Serum aflatoxin B1 antibody titer, percent hemolysis and transaminases in oral submucous fibrosis

Introduction

Areca nut is deeply rooted sociocultural habit in India. Areca nut reported to be infested by fungi during the field and storage conditions. Areca nut alkaloids, nitrosamines, tobacco and aflatoxin are cytotoxic, immunotoxic to red blood cell and epithelial cell. Hence, the present study was conducted to assess the serum aflatoxin B₁ (AFB₁) antibody titer, percent hemolysis and transaminases in oral submucous fibrosis (OSMF) patients.

Materials and Methods

In this study, 128 participants of which 88 were suffering from OSMF. Twenty participants were areca nut habitual without OSMF (habitual control) and 20 participants without any habit (healthy control). For the detection of AFB₁ antibody titer, AFB₁ antigen (Sigma) A6636 from Aspergillus flavus was used. Percent hemolysis was estimated as per the procedure described by Mathuria and Verma. Serum Glutamic oxalo acetic transaminase (SGOT) and Serum Glutamic pyruvic transaminase (SGPT) were estimated by the optimized ultraviolet method using the enzyme-linked immunosorbent assay kit.

Results

Mean SGOT, SGPT, percent hemolysis and AFB₁ antibody titer were significantly higher in participants with OSMF than the habitual and healthy controls. AFB₁ antibody titer and % hemolysis in both OSMF and habitual without OSMF were showed significant correlation, i.e., increased AFB₁ antibody titer with increased % hemolysis.

Conclusions

A study result demonstrates that aflatoxin causes increase in serum transaminases which is indicative of liver damage in OSMF. The combined toxic effects of areca nut alkaloids, tobacco and AFB₁ on red blood cell (RBC) cell wall might be responsible for increased percent hemolysis in OSMF and habitual control.

The Association between Metabolic Syndrome and Elevated Alanine Aminotransferase Levels in an Indigenous Population in Northern Taiwan: A Community-Based and Cross-Sectional Study

Our study aims to determine the prevalence of metabolic syndrome (MetS) among the Northern Taiwanese indigenous population and to explore the relationship between MetS and liver enzyme, especially serum alanine transaminase (ALT). This is an observational and cross-sectional study that was conducted in remote villages of an indigenous community in Northern Taiwan between 2010 and 2015. MetS was defined based on the revised NCEP/ATPIII criteria from Taiwan Health Promotion Administration. A total of 454 participants were included in the analysis. There were 277 people with MetS and 177 people without. The prevalence of MetS was 61.01%. The average age was 49.50 years. People with MetS had a significantly higher liver enzyme (ALT) level than those without MetS. In addition, the study showed that participants with higher ALT had a tendency towards a higher prevalence of MetS (76.7% vs. 57.3%, p = 0.001). The adjusted odds ratio (OR) of ALT levels >36 U/L for MetS was 2.79 (95% CI = 1.24–6.27, p = 0.01). The area under the ROC curve (AUC) of the ALT level was 0.63 (95% CI = 0.58–0.68, p < 0.001), which showed that the ALT level was positively associated with MetS. The overall prevalence of MetS was 61.01% in the highland indigenous population in Northern Taiwan; this study indicated that higher serum ALT levels were associated with an increased risk of MetS.

Betel Chewing and Nonalcoholic Steatohepatitis

Betel chewing is a common social practice in many regions of the world particularly in Southeast Asia and among the Asian immigrant populations in the West. Several studies have shown betel chewing to be associated with increased risk for various health complications including liver cirrhosis and hepatocellular carcinoma. The exact mechanism by which betel causes liver damage has not been elucidated. We present a 31-year-old Asian immigrant in the United States of America (USA) with no family history of the liver disease and non-smoker who was found to have an unexplained persistent mild elevation of liver transaminases. She reported more than 16 kilograms of weight gain over an eight-year period in association with heavy betel chewing. Despite diet and exercise, she was not able to lose weight. Besides, she developed dyslipidemia and gradual worsening of glucose tolerance. Liver biopsy showed severe steatosis with features of nonalcoholic steatohepatitis (NASH). The gradual development and worsening of metabolic syndrome and NASH paralleling betel use are very indicative of the hepatic steatosis being caused by betel.

The risk of cirrhosis in non-alcohol drinkers is greater in female than male betel nut chewers

BACKGROUND AND AIM

The association of betel nut with liver cirrhosis among alcohol drinkers has been clearly shown. However, very few studies have shown such an association among non-alcohol drinkers. The aim of this study was to assess the relationship between betel nut chewing and cirrhosis among non-alcohol drinkers.

MATERIALS AND METHODS

This study retrospectively analyzed data retrieved from the 2012 Adult Preventive Medical Services and the National Health Insurance Research Datasets in Taiwan. Participants' information included physical examination and lifestyle, alongside laboratory tests. Betel nut chewers were grouped into three categories: never, occasional and frequent. Diseases were diagnosed using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Initially, 1573024 adults aged 40 years and above who engaged in the free adult preventive medical services in 2012 were recruited. However, only 1065246 of them were included in the analysis. Chi-square test and logistic regression were used for the analyses.

RESULTS

After multivariable adjustments, there were significant relationships between cirrhosis and betel nut chewing in both sexes (P-trend < 0.0001). The risk of cirrhosis was greater in females than males. The odds ratios of cirrhosis in occasional and frequent female chewers were respectively 2.91; 95% C.I: 1.75-4.83 and 3.06; 95% C.I: 1.69-5. However, they were respectively 1.76; 95% C.I: 1.47-2.10 and 2.32; 95% C.I: 1.90-2.85 in occasional and frequent male chewers.

CONCLUSIONS

This study demonstrated significant relationships between betel nut chewing and cirrhosis in both male and female non-alcohol drinkers. The risk of cirrhosis was greater in female than male chewers.

Early detection of unhealthy behaviors, the prevalence and receipt of antiviral treatment for disabled adult hepatitis B and C carriers

BACKGROUND

Evidence indicates that hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are the leading causes of liver cirrhosis and hepatocellular carcinoma. Antiviral treatments have recently been reported as successful cures. However, the prevalence rates of HBV or HCV infection, unhealthy behaviors and receipt of adequate treatment in disabled adults have not been described. The aim of this study was to examine the prevalence of HBV or HCV carriers, receipt of antiviral treatment, and early detection of unhealthy behaviors in disabled adults in Taiwan.

METHODS

A population-based, cross-sectional study was conducted between July and December 2013 with 845 community-dwelling adults with disabilities aged >20 years. Statistical analyses included descriptive statistics, Chi-squared tests, and stepwise regression analysis.

RESULTS

The prevalence of HBV and HCV infections was 12.9 and 14.1 %, respectively. HCV carriers tended to be older (p < 0.001) and with a lower education (p < 0.001). The majority of HBV/HCV carriers did not know the type of hepatitis infection and did not receive adequate antiviral treatment. After adjusting for potential confounding variables, regression analysis showed that the factors significantly associated with elevated liver function were HCV infection (p < 0.001), HBV infection (p = 0.001), high fasting blood glucose levels (p = 0.001), overweight (p = 0.003), older age (p = 0.027), and alcohol drinking (p = 0.028).

CONCLUSIONS

There was a high prevalence of HCV infection among adults with disabilities; few received adequate antiviral treatment or early detection of unhealthy behaviors for the prevention of liver cancer. Clinicians can provide health education to help the participants and caregivers better understand the relationships between specific risk factors and liver health and can encourage HBV and HCV carriers to undergo annual physical check-ups and receive adequate treatment, as covered by the national health insurance.

A review of the systemic adverse effects of areca nut or betel nut

Areca nut is widely consumed by all ages groups in many parts of the world, especially south-east Asia. The objective of this review is to systematically review and collate all the published data that are related to the systemic effects of areca nut. The literature search was performed by an electronic search of the Pubmed and Cochrane databases using keywords and included articles published till October 2012. We selected studies that covered the effect of areca nut on metabolism, and a total of 62 studies met the criteria. There is substantial evidence for carcinogenicity of areca nut in cancers of the mouth and esophagus. Areca nut affects almost all organs of the human body, including the brain, heart, lungs, gastrointestinal tract and reproductive organs. It causes or aggravates pre-existing conditions such as neuronal injury, myocardial infarction, cardiac arrhythmias, hepatotoxicity, asthma, central obesity, type II diabetes, hyperlipidemia, metabolic syndrome, etc. Areca nut affects the endocrine system, leading to hypothyroidism, prostate hyperplasia and infertility. It affects the immune system leading to suppression of T-cell activity and decreased release of cytokines. It has harmful effects on the fetus when used during pregnancy. Thus, areca nut is not a harmless substance as often perceived and proclaimed by the manufacturers of areca nut products such as Pan Masala, Supari Mix, Betel quid, etc. There is an urgent need to recognize areca nut as a harmful food substance by the policy makers and prohibit its glamorization as a mouth freshener. Strict laws are necessary to regulate the production of commercial preparations of areca nut.

Impact of chronic hepatitis B and hepatitis C on adverse hepatic fibrosis in hepatocellular carcinoma related to betel quid chewing

The pathogenesis of hepatocellular carcinoma (HCC) related to habitual betel quid (BQ) chewing is unclear. Risk of HCCis increased with adverse hepatic fibrosis. This study aimed to assess the impact of chronic viral hepatitis on adverse hepatic fibrosis in HCC related to BQ chewing. This hospital-based case-control study enrolled 200 pairs of age- and gender-matched patients with HCC and unrelated healthy controls. Serologic hepatitis B surface antigen (HBsAg), antibodies to hepatitis C virus (anti-HCV), α-fetoprotein (AFP), and surrogate markers for significant hepatic fibrosis were measured. Information on substance-use habits was obtained with a questionnaire. By analysis of surrogate markers for hepatic fibrosis, the prevalence of significant hepatic fibrosis in patients chewing BQ was between 45.8% and 91.7%, whereas that for patients without BQ chewing was between 18.4% and 57.9%. The difference was significant (P <0.05 for each surrogate marker). Multivariate analysis indicated that cirrhosis with Child-Pugh C (odds ratio (OR) = 3.28; 95% confidence interval (CI), 1.29- 8.37), thrombocytopenia (OR = 3.92, 95% CI, 1.77-8.68), AFP >400 mg/L (OR = 2.21, 95% CI, 1.05-4.66) and male gender (OR = 4.06, 95% CI, 1.29-12.77) were independent factors associated with habitual BQ chewing. In conclusion, adverse hepatic fibrosis and severe liver damage play important roles in the pathogenesis of BQ- related HCC, which could be aggravated by chronic hepatitis B and hepatitis C. BQ-cessation programs and prevention of chronic HBV/HCV infection are needed to prevent HCC related to BQ chewing.

Alcohol, metabolic risk and elevated serum gamma-glutamyl transferase (GGT) in Indigenous Australians

BACKGROUND

The interaction between overweight/obesity and alcohol intake on liver enzyme concentrations have been demonstrated. No studies have yet examined the interaction between metabolic syndrome or multiple metabolic risk factors and alcohol intake on liver enzymes. The aim of this study was to examine if alcohol consumption modifies the effect of metabolic risk on elevated serum GGT in Indigenous Australians.

METHODS

Data were from N = 2609 Indigenous Australians who participated in a health screening program in rural far north Queensland in 1999-2000 (44.5% response rate). The individual and interactive effects of metabolic risk and alcohol drinking on elevated serum GGT concentrations (>or=50 U/L) were analyzed using logistic regression.

RESULTS

Overall, 26% of the population had GGT>or=50 U/L. Elevated GGT was associated with alcohol drinking (moderate drinking: OR 2.3 [95%CI 1.6 - 3.2]; risky drinking: OR 6.0 [4.4 - 8.2]), and with abdominal obesity (OR 3.7 [2.5 - 5.6]), adverse metabolic risk cluster profile (OR 3.4 [2.6 - 4.3]) and metabolic syndrome (OR 2.7 [2.1 - 3.5]) after adjustment for age, sex, ethnicity, smoking, physical activity and BMI. The associations of obesity and metabolic syndrome with elevated GGT were similar across alcohol drinking strata, but the association of an adverse metabolic risk cluster profile with elevated GGT was larger in risky drinkers (OR 4.9 [3.7 - 6.7]) than in moderate drinkers (OR 2.8 [1.6 - 4.9]) and abstainers (OR 1.6 [0.9 - 2.8]).

CONCLUSIONS

In this Indigenous population, an adverse metabolic profile conferred three times the risk of elevated GGT in risky drinkers compared with abstainers, independent of sex and ethnicity. Community interventions need to target both determinants of the population's metabolic status and alcohol consumption to reduce the risk of elevated GGT.