The Resilient Liver Deserves More Respect

The liver is seemingly an organ without any facility for "self promotion". Unlike the large bowel, it lacks an orifice that allows for early presentation of disease and dysfunction. Instead, like the kidney, a massive loss of function is required before symptoms of liver disease develop, and those symptoms are typically non-specific. Unlike the kidney, however, for which simple blood tests often give an indication of overall renal function, most so-called "liver function tests" do not measure function at all. This combination of factors results in liver disease often going undiagnosed until late in its course. In particular, infectious hepatitis can be contracted early in life, but may have its major deleterious effects only once the individual is much older.

The liver also gets little respect from geriatricians. We are continuously concerned about renal changes with aging and how to prescribe medications properly to accommodate those changes. However, the effects of an aging liver on drug disposition are less predictable, so we tend to ignore them, except in the presence of overt liver dysfunction. I certainly have had patients presenting with "drug-induced falls" who really had occult but severe liver disease with abnormal drug metabolism as the cause of their problems.

Hence, I think an issue with a focus on liver disease in the elderly is timely. From Drs. David Stell and William Wall, we have an excellent article in our Biology of Aging series on the impact of aging on the liver, which will help us understand the cumulative effects of aging on disease presentation. Dr. Robert Fingerote discusses primary biliary cirrhosis, another disease in which major, serious manifestations present after many years of disease progression. This issue presents articles on acute viral hepatitis by Dr. D'Arcy Little, portal hypertension and its complications in elderly patients with liver cirrhosis by Drs. Faisal Sanai and Cameron Ghent, and the diagnosis and management of gallstones in the elderly by Drs. Bao Tang and David Urbach. As the field of organ transplantation matures, an increasing number of elderly patients are being transplanted, and Drs. Douglas Thorburn and Paul Marotta review the indications and outcomes of liver transplantation in the elderly. To cap off this topic, our For Your Patient column comes from the Canadian Liver Foundation.

In other articles, Dr. Ron Keren discusses the relationships between alcohol and dementia, Drs. Ernane Reis and Nicholas Morrissey review the diagnosis of peripheral arterial disease in the elderly, Drs. Simpson and Ulanski II examine ocular malignancies, while Dr. Margda Wærn writes about physical illness and suicide. In a special article, one of Canada's most eminent and respected geriatricians and Program Director of the Regional Geriatric Program of Toronto, Professor Rory Fisher, reviews the implications of the Romanow Report for health care of the elderly.

Enjoy this issue.