As a liver specialist at a hospital in Kerala, I have seen many cases of liver disease and hepatitis. But one patient I had recently, whose was difficult to diagnose, has shed light on how pseudo-scientific health-seeking behavior and unsafe farming practices are leading to newer causes of severe liver disease.

My patient was a 40-year-old man who came to the out-patient department for evaluation of severe jaundice. His bilirubin levels were in excess of 12 mg/dl and his liver enzymes were more than five to eight times the upper limit of normal. His liver tests had all the indications of alcohol use, but the man denied having taken a single drop of alcohol all his life.

He was a pineapple farmer, worked hard for his family, led a healthy life and did not indulge in any substance abuse. He was fit and without a shred of excess fat. So, we went through the same protocol that we have for all patients who present with acute severe jaundice. Every common cause we searched for – viruses, autoimmune hepatitis, use of over the counter medications, herbal medications, painkillers, antibiotics – came up as negative. He said this was first time he had ever fallen sick. Then we started looking at rarer causes like herpes viruses, cytomegalovirus, parvovirus, dengue, typhoid fever and rare cancers. All these blood tests came back negative too.

His jaundice was getting worse by the day and so we had to resort to a test most patients are worried about – the liver biopsy. As physicians, we perform this test because it is not only used to diagnose cancers, but also to identify the cause and understand the severity of liver disease. The man, tired of his ongoing mysterious illness, agreed to a liver biopsy without hesitation.

The biopsy went smoothly and when he got the reports, my pathologist called me and said, “This biopsy is very classical of severe alcoholic hepatitis”. Alcoholic hepatitis strikes the liver of a person who drinks heavily regularly or who binge drinks. I went back to the patient and told him, “See, you might lie about the alcohol, but your liver wont. We have proof that you have been drinking too much and in secret.”

The man almost broke down and told me the same thing he had said before: “Sir, I have not taken a single drop of alcohol in my entire life.”

The Ayurvedic digestive

I thought it was time to bring his family in. You see, I was in my FBI mode. Past experience had taught me that asking fathers about their health and lifestyle behaviours in the presence of their families – especially their daughters – brings out the truth. I thought that he would confess to drinking and could finally plan my treatment for him. But I was stumped. Every family member, including his daughter and son-in-law, vouched for the patient’s version of the story – he never drank. They were always together, ate together and worked the fields together.

But then the man’s wife let something slip. “He eats well and then takes a digestive to reduce the bloating after the meal”.

What digestive?

“Oh, that is nothing,” she said. “It has been in use for so many years.” She called it dashamoolarishtam.

I sat up.

Dashamoolarishtam is an age old Ayurvedic tonic used for supposedly improving digestion and a multitude of other symptoms. It is sometimes the second-most common household item in a Kerala home after the electric mosquito-killer bat. Dashamoolarishtam is made up of more than 30 herbal and other ingredients and has self-generating alcohol due to the presence of extracts from the Woodfordia fruticosa plant that, like grapes, can ferment.

Woodfordia fruticosa flowers. (Photo: Vinayraj/Wikimedia Commons)

In recent times, some practitioners have added baking yeast to speed up the fermentation process and increase alcohol content, which is what gives the feeling of digestion. Other practitioners add alcohol directly in the tonic. This Ayurvedic medicine is so popular in Kerala, that when the government banned alcohol sales in the state, people started overdosing on arishtams to get a high. Some arishtam producers intentionally increased alcohol content in their product to boost sales.

My patient was consuming around four to five ounces of dashamoolarishtam four times a day after every meal. That is almost 38 grams of alcohol every day, considering alcohol content in the arishta to be 8% to 10%. This was what caused his severe alcohol-related liver injury.

Poisoned by pesticide

The pathologist who saw the liver biopsy also reported that a finding not usually seen with alcohol liver injury – necrosis. So even though the man was started on treatment for severe alcoholic liver injury and was improving, I asked him about all of this recent food intake behavior. In the past month, he had been drinking a lot of fresh pineapple juice harvested from his own farm. Unfortunately, he was also dosing his crops with large amounts of pesticides and insecticides like Fenval and Karate.

We then took pineapple samples from his farm and ran them through a strong chemical analyses. We found a host of toxic chemicals such as nickel tetracarbonyl, acetyl pentacarbonyl and carbamic acids in the pineapples tested. My patient also had toxic hepatitis due to these chemicals. We made a final diagnosis of Ayurvedic arishta-related severe alcoholic hepatitis and chemical-induced toxic hepatitis due to excessive pineapple consumption. The patient recovered fully from his disease after treatment.

Cyriac Abby Philips is a liver specialist at the liver unit of Cochin Gastroenterology Group affiliated with Philip Augustine Associates, based at EMC Hospital in Kochi. His findings in this case were published in The American Journal of Gastroenterology.