Tom Mahl, MD

Chief of gastroenterology at VA discusses liver diseases and the fact that most of those who have hepatitis don’t know they have the disease

By Chris Motola

Tom MahlQ: Give us an overview of your specialty.

A: I am a board-certified gastroenterologist and also a board- certified internist. I’ve been here at the Buffalo VA for 26 years and on the faculty of the University of Buffalo for as many years. I’m currently a clinical professor of medicine at UB.

Q: I understand you’ve been particularly involved with treating liver disease.

A: My academic interest has been liver disease. So hepatitis, cirrhosis, fatty liver, other disorders of the liver. But I do also take care of Crohn’s, celiac disease, ulcers, heart burn, what we call ‘luminal disorders.”

Q: The liver has the reputation of being one of the body’s most resilient organs, what has to go wrong for it to fail?

A: That’s a very good question. There are two important topics in liver disease right now. One is discovering people who have hepatitis C who don’t know they have it. Many people aren’t receiving regular health care, who only get treated when there’s a crisis: many are not being treated for hepatitis C. About one-third to one-half of all people with the disease don’t know they have it. The reason that’s important is that we can cure upwards of 95 percent of patients with hepatitis C. In the past, it didn’t matter as much because we didn’t have too much to offer them. But in the last two years, things have changed dramatically. We can actually eradicate the virus, but it’s really best that we do it before it’s too late and they’ve already developed long-term complications. And though the liver is a resilient organ that can repair itself, it can develop scar tissue if it’s pushed too far. If you have a lot of it, we call that cirrhosis. Many people think that if you have cirrhosis that means it’s alcohol-related. It can actually be caused by a number of things, including viruses.

Q: I know I have a hard time keeping track of which hepatitis is which. Can you remind us?

A: Most laypeople think of it as a viral disease, but to a liver doctor, hepatitis means irritation of the liver. It can be from anything from viruses, to alcohol, to autoimmune diseases, to toxins. But within viral hepatitis, there are three major, completely different viruses. Hepatitis A, or “infectious hepatitis,” is transmitted through the fecal-oral route, so it’s transmitted by the ingestion of fecal matter. That’s why you see signs in restaurants that employees must wash their hands before returning to work. It’s very common in the third world. About 99 percent of people get over it and are immune for the rest of their life. It’s most dangerous to elderly people who weren’t exposed to it at an early age, but even that is a little unusual.

Hepatitis B, or “serum hepatitis,” is transmitted by blood and body fluids. It used to be a problem with transfusions. We’ve been screening it out for the past 30 years, and it’s almost never transmitted that way anymore. So it’s more often spread by sexual transmission. But we do have a wonderful vaccine for that, so the incidences are plummeting. The biggest risk groups we’ve noticed are immigrants from Asia and men who have sex with men. We have drugs that can suppress it, but not eradicate it. So you’ll have to be on medication the rest of your life, but it’s pretty much just taking a pill a day.

Until 25 years ago, we weren’t exactly sure what hepatitis C was. Before that, we would test hepatitis patients for A and B, and if they were negative, we’d call it “non-A, non-B.” It’s transmitted mostly by blood and less so by sexual transmission. So if you had a transfusion a long time ago or you’ve been sharing needles, then you’re more at risk. So we’re looking to screen baby boomers in particular, as well as anyone with anyone with signs of liver irritation, especially since we can completely cure it in nearly all patients.

Q: How about the other important topic in liver disease right now?

A: The other topic is what we call non-alcoholic fatty liver disease. It looks just like alcoholic fatty liver disease in a biopsy. It consists of fat deposited in the liver. In some people, that fat can promote inflammation and scar tissue. I probably put my kids through college on the number of patients I’ve seen with alcohol-related fatty liver disease, but this is unrelated. It’s related to insulin resistance. It’s a very common problem that tons of people don’t know they have. It typically occurs in overweight people. What’s happening is the body isn’t responding as well to insulin, which lowers blood sugar. But insulin does a lot of other things too. If you’re not responding to it, you see high blood pressure, lipids in the blood, a predisposition to atherosclerosis and fatty liver disease. You can actually see a globule of fat within the liver cell. Many people tolerate that well, but a percentage will go on to get more progressive liver disease, including cirrhosis. With obesity as common as it is, as much as 25 percent of the population may have fatty liver. Many will do fine with regard to their liver, but if even 10 or 20 percent of them get cirrhosis, we’re talking about millions of people with cirrhosis.

Q: Are there warning signs that you can notice, outside of testing?

A: You really have no nerve endings in the liver, and you won’t see jaundice until you have significant cirrhosis. If you’re seeing your doctor regularly, normal blood tests can usually detect general liver abnormalities, which then can let us know that you need further, more specific testing.

Q: And I take it alcohol can make all these situations worse. How much is too much?

A: We know there’s a bit of a double-whammy with hepatitis C. By itself, the virus isn’t necessarily a death sentence — maybe 20 percent or less — but you add alcohol and the combo-platter has at least an additive and possibly a multiplicative effect on liver disease. You’d be surprised how many people drink a case of beer a day. I saw a 20-year-old who drank a liter of vodka a day. The threshold for alcohol-related liver problems seems to be around six drinks a day.


Name: Thomas C. Mahl, M.D.
Position: Chief of Gastroenterology at VA Western New York Healthcare System; Clinical Professor and Interim Chief of Gastroenterology, Hepatology and Nutrition at University of Buffalo
Hometown: Tonawanda, NY
Education: Fellowship-Yale; Residency-University of Connecticut; MD-University of Buffalo; BS-SUNY Oswego
Affiliations: Veterans Health Administration (local and telemedicine); Buffalo General; Erie County Medical Center
Family: Two sons
Hobbies: Kayaking, biking