Events

Damien

Okay, so yeah, good evening, everyone, and thank you for joining us.

Once again we're joined here for another evening webinar at Benenden Hospital this week on diabetes and endocrinology. Now, my name's Damien, and I'm going to be hosting your session this evening, and I'm delighted to be joined by our expert speaker, Dr Sameer Sighakoli a Consultant Endocrinologist.

Now, tonight's session will be a presentation from, Mr Sighakoli, followed by a live Q&A. Now, if you have questions at any point, please feel free to submit them using the Q&A icon at the bottom of your screen.

You're welcome to ask anonymously, or include your name, but just a quick note that the session is being recorded, so any names will be visible in the recording.

So to help us get through as many questions as possible, please try to keep those brief. And if you're interested in booking a consultation, we'll share all the relevant contact details for you at the end of the session.

So I will pass you over to Doctor Sighakoli. Nice to have you.

Dr Sameer Sighakoli

Thank you very much, Damien, and welcome everyone to this webinar. So without any further delay. I'm just going on to the presentation.

So I am a consultant physician in diabetes, general medicine, and technology, and I have nine years’ experience as an NHS consultant, and I joined Benenden this year.

And I do my diabetes and endocrine clinics here in the outpatients.

I have special interest in Type 1 diabetes, diabetes in young adults, incident pump therapy, and diabetes related complications. It also has special interest in other endocrine conditions like thyroid and parathyroid disorders and also review conditions in general endocrinology.

So this is going to be my format where I'll be talking about diabetes in general and go through the different types of diabetes, the common symptoms, the different treatment options in brief, and what happens during consultation, especially with regards to monitoring of glucose.

And towards the end, I'll be talking about living with diabetes and looking forward to the interesting question and answer session.

So diabetes mellitus is the most common endocrine condition. It leads to excess glucose in a blood.

It literally means sweet urine. In the past, historically, that's how it was identified. I'm talking about several hundred years ago.

This is a situation where the body or the cells are not in a position to utilize the glucose. There's enough glucose in the system, but the cells are not able to absorb that.

And this can happen due to either an insufficient insulin production or complete absence of insulin production.

Then a commonly used term is insulin resistance, where the body is not able to make use of the insulin that is around to help in the absorption of glucose.

There are several subtypes of diabetes.

Type 2 diabetes is most common with 90% of cases, followed by Type 1 diabetes, then gestational diabetes, which basically means diabetes in pregnancy.

Then there could be diabetes due to other pancreatic disorders. So if there's any damage to the pancreas due to drugs that can lead to diabetes.

There's some rarer varieties, like monogenic diabetes or LADA, also called latent autoimmune diabetes in adults. It's also called 1.5 diabetes.

Type 2 diabetes is being the most common. I'll talk a bit more in detail about Type 2 diabetes.

Six million people in the UK have diabetes. It's nearly around eight to nine percent of the whole population.

And the incidence is increasing with age irrespective of their ethnicities.

From an ethnicity perspective the South Asian followed by Afro-Caribbean and Hispanic ethnicities are at a high risk to develop Type 2 diabetes.

Again, as I mentioned about gestational diabetes previously which is a diabetes during pregnancy, there's risk of developing Type 2 diabetes after pregnancy, some studies quote the risk could be up to fifty percent in ten years’ time.

And what is important is the annual monitoring and people who are high risk.

The uniqueness about diabetes is that it can present several years even before diagnosis. So people may be relatively feeling well in themselves.

And by the time diagnosis is made, it may be well three to five years down the line.

Important terminology here is about prediabetes and obesity.

Prediabetes is a high-risk factor for developing diabetes.

And people who have obesity are at high risk of developing Type 2 diabetes.

So we need to identify individuals who are at risk so as to Intervene at the right time.

Now, Type 2 diabetes has been increasing in incidence even in younger people.

Overall, the incidence and prevalence is increasing across the population, in fact, across the globe.

Unlike some conditions, Type 2 diabetes has a variable clinical presentation. Starting from no symptoms to severe symptoms.

If untreated, the symptoms can worsen, it could have a major impact on one's life.

Fortunately, there are several classes of medications now available to treat Type 2 diabetes compared to more than twenty years ago. We have options, multiple options.

So with the help of these medications and with assistance from technology we can, a person with diabetes can lead a near normal life.

So what are symptoms of poorly controlled diabetes?

Passing urine even more frequently, especially at night.

Being constantly thirsty or being able to quench the thirst, fatigue is a very common symptom, unintentional weight loss, visual changes.

So I have seen people who were presented to the clinic and mentioned that they had to change the lens in the glasses because the power had to be changed.

And there's also potential history of recurrent infections, for example, foot infection, urinary tract infections, or skin infections.

Now, in terms of diagnosis.

As I said, it can have variable presentation. So during the consultation we go through the symptoms and a simple blood test is done.

Both for screening and diagnosing diabetes there are several tests, like a random blood glucose or a fasting blood glucose.

A popular one is in HbA1c test, which helps understand the duration of poor control of diabetes over the last three months.

These tests are actually cheap, and this can be done in the primary care.

Okay, so during an outpatient consultation in following the assessment.

We can request some standard blood test, and if required, we'll do a urine test to assess the kidney function.

It's an opportunity to assess the risk of other complications which may be associated with diabetes at the time of diagnosis.

If it is mild, we start with standard lifestyle changes.

Give three to six months’ time to see if there's any positive or adequate response to lifestyle changes.

If that doesn't help, we can try tablets.

And if tablets don't help, and if indicated. We can also use those weight loss medications, but at different doses for diabetes.

And in severe cases we can give insulin.

When an assessment is done for complications, and if found to have one, I would refer to the appropriate specialist.

I mentioned about assessing other conditions at the time of initial review for diabetes.

So we would be having a review of history regarding heart disease, kidney disease, any eye problems.

Obviously, we won't, I will not be able to assess the retinal changes in a diabetes clinic that's done by specialist eye services.

Review the possibility of any nerve damage. Some people with diabetes would present with symptoms of numbness and tingling in the toes. That could be the first presentation.

And a very important but less known condition is fatty liver, where there is deposition of fat in the liver.

It may not cause any symptoms, but if persisting or a prolonged period of time, it can cause complications.

There could be other associated conditions with diabetes like thyroid disease or celiac disease.

There's also an association between diabetes and memory impairment like dementia.

So treatment, what do we do? What are we trying to achieve here?

Basically, two things. One, Try to attain and maintain blood glucose levels within safe targets for that particular individual.

Safe targets does not necessarily mean the normal values.

It may differ from person to person depending upon their other health conditions and complications, but we would endeavour to achieve as normal values as possible, but without compromising safety.

The second goal is to prevent or delay any complications, which is very important.

So how do you approach the treatment which I mentioned previously.

We start with lifestyle, but before that, every clinician endeavours to deliver individualized care because the circumstances for every person are different.

When I use the lifestyle in this context of the discussion, it's not a general term, it's a medical term.

It encompasses several aspects of management, it's about healthy eating patterns, not just having certain periods of healthy eating in, but also to have regular physical activity.

So, regular physical activity helps In burning the calories, it can also help in losing weight.

But one may not necessarily achieve significant weight loss, but a combination of changes can help.

There's not much emphasis on sleep, but I would like to emphasize that as well. Good, refreshing, adequate sleep is important.

And very important and crucial is regular medical monitoring, irrespective of what phase of diabetes you are in.

As mentioned before, we have several classes of medications that can be used in the management of Type 2 diabetes.

I will not be going into detail. I've just listed some of the common class of medicines that are used for the treatment of Type 2 diabetes.

I'll just mention briefly about the GLP1- agonist, which is very popular as a weight loss because it's used as weight loss medication.

We can always use insulin in the treatment of diabetes if it is not too, not well controlled.

So with regards to GLP1- agonist, a few points, it's more popular as a weight loss medicine, but it can be used for the treatment of Type 2 diabetes. In fact, it was started as one of the drugs for managing Type 2 diabetes but at different doses.

Basically, it helps reduce our appetite and acts through several mechanisms in the body by acting on the brain and also on the stomach.

It provides additional benefits, It's like an all-rounder. It provides heart protection.

When used on its own, it is unlikely to cause extremely or low dangerous glucose readings.

And it indirectly has a positive impact on the blood pressure and the lipid profile for the cholesterol levels.

These are the commonly known GLP1- agonists, Monjaro, Ozempic, Wegovy.

The ingredient or the chemical in that is a GLP1- agonist.

We have the options of using both injections and oral preparations and there are different doses available.

The most common side effect being bowel related can cause nausea and vomiting. Therefore, it has to be titrated over a period of time and different people can respond differently in terms of efficacy or the side effects.

And it's important to inform the doctor or your primary care physician if you're on this medicine.

Now, as the saying goes, prevention is always better than cure. So what can we do to prevent Type 2 diabetes?

We start by monitoring people who are at high risk. For example, those who are overweight or who would fall in the category of obesity, obese, or have a very strong positive family history of diabetes.

I mentioned about pre-diabetes previously, people who have a diagnosis of prediabetes are at slightly higher risk for heart disease compared to the general population who do not have diabetes.

Again, the same principles of management would be used to the lifestyle interventions which is individualized.

It's vital that we reduce the calories in people who have risk factors or who have prediabetes or Type 2 diabetes.

Different people have different types of meals, some are carb rich, some are fat rich. End of the day, the calories need to be reduced.

A dietitian would have a vital role in signposting to the right type of diet for that person, and also to give some information about the carb content of commonly ingested foods.

Physical activity is always helpful at every phase of diabetes.

Now, people who are obese are at a higher risk of developing Type 2 diabetes, and if the help of lifestyle changes or with the help of medications, there is a weight loss anywhere from five percent or higher.

It helps in preventing Type 2 diabetes and I, emphasize the need to have adequate sleep.

Due to the nature of changing work profiles, we now have more sedentary jobs, so we spent more hours sitting at the desk.

So it's important that we remain physically active.

Throughout the day and we're aiming for gradual weight loss because rapid weight loss can also cause complications.

Because I mentioned about obesity in the previous slides, I'll just Let's talk briefly about obesity.

It's now recognized as a disease. It's a chronic, progressive, relapsing, multifactorial and a treatable disease.

Just under one third of the UK population are obese and the most common cause of death in this cohort of people is cardiovascular cause and the worldwide obesity rate has doubled in the last thirty years, and hopefully with the appropriate use of the right medications and change in lifestyle, the rate of increase will hopefully slow down.

Now, obesity is defined based on the BMI and the BMI can change based on the ethnicity as well in terms of the diagnostic criteria.

When there's inadequate response to lifestyle management, if they fulfil the criteria and the conditions.

Pharmacological therapy would be indicated but there's some national guidelines and national criteria for initiating the weight loss medications but regular monitoring is recommended once these medications are started.

There are some situations, not always, where there could be a reason for the weight gain.

And therefore, if that is suspected during the clinical assessment, we would do some basic tests to exclude any hormonal problems related to weight gain.

For example, there might be mild weight gain due to an underactive thyroid gland.

But that can be assessed and investigated in the clinic.

As I mentioned before about lifestyle changes, dietitian input, and pharmacotherapy.

This is an ongoing treatment approach to managing diabetes.

In addition to treating the obesity, an assessment is required for review of other potential cardiovascular risk factors.

And if, for example, we pick up hypertension or high blood pressure during the assessment, we can start the treatment for that.

Now, the management of in the management of Type 2 diabetes, it's essential that we look into their cholesterol levels. A person with diabetes may have high cholesterol, even if that person is not overweight or obese.

Along with the cholesterol, we measure other parameters.

A person may have high cholesterol without having diabetes, for example. So, if high cholesterol is diagnosed, it's good to assess for diabetes by doing a simple screening blood test.

We have treatment options. In fact, statins are the most common class of drugs used for treating high cholesterol.

If intolerant, we have alternative treatment options for high cholesterol.

So I'll talk briefly about Type 1 diabetes.

Now, this can present in any age group but generally presents in the younger age.

It's a very demanding condition and it's a lifelong condition which has impact on the person as well as the family.

A diagnosis, these symptoms may be very severe, requiring hospital admission, unlike in Type 2 diabetes, where people may not necessarily have severe symptoms.

Especially in kids, when they're present, they could be having severe symptoms and rapid progression of the symptoms, requiring hospital admission.

It's an autoimmune condition and therefore the risk of other autoimmune conditions is increased.

But the symptoms are more or less the same. It is symptoms of excessive thirst, passing urine more frequently, weight loss.

Throughout my presentation I'd be emphasizing on the concept of glucose monitoring and it's the same for Type 1 diabetes.

Where it is vital that the glucose levels are monitored regularly, fortunately, with advancement in the technology, we now have sensors or also called continuous glucose monitors.

The treatment is basically giving insulin or taking insulin, and we use a combination of different insulins to achieve optimum control.

As a legal requirement that a person who's on insulin should inform DVLA.

And along with The treatment of diabetes, should be regular screening and monitoring for other potential complications and hence the need for doing regular eye checkups.

Review of their foot and also monitor for the possibility of developing other autoimmune conditions like celiac disease, for example.

And there are several education programs online and in the NHS to educate regarding Type 1 diabetes and Always emphasize on glucose monitoring

It's important because it helps us with the information. It helps us Understand the trend in glucose values and gives a feedback to us, to the person living with diabetes and will help adapt their lifestyle.

This will increase the chances of maintaining or attaining good diabetes control and this will, in turn, prevent or delay the complications related to diabetes.

As a clinician, it also gives the information, the required information that's required to titrate the dose of insulin based on the glucose readings

and during the consultation we would be reviewing the regime and also decide on the titration if required, or if indicated.

I mentioned about the sensors also called continuous glucose monitors. This is just an example of one of the sensors. It's called Dexcom one place. Another popular sensor is Libre sensor, which is available free on the NHS.

This gives us more information, as I mentioned previously, about the patterns of the glucose readings in the body.

The trend whether it's going up or it's going to remain stable or it's going down and what's the percentage of glucose readings within the normal range.

Equally important is it has got this functionality of audible alerts. So if we can set the threshold as say for example, set the glucose threshold as fourteen and if glucose goes above fourteen, it'll bleep and it'll kind of, it lets us know that glucose is rising. So with that information we'll be able to act on it.

These are the traditional glucose meters. I've given some examples here, but this is a finger prick glucose monitor and the readings are accurate.

With regards to treatment for Type 1 diabetes, which I touched base previously, briefly, I also wanted to mention a few other points.

In addition to the insulin injections. We had the option of using a pump device to deliver the insulin instead of the pens.

It really is, it's important that the person with Type 1 diabetes knows how to carb count.

It'll help decide how much insulin needs to be administered after food, or sorry, before food or with food.

I spoke briefly about continuous glucose monitors, and it is free on the NHS.

So with that information, one can decide how much insulin needs to be given.

During every consultation, a cardiovascular risk assessment is done and I would also emphasize the importance of foot care in diabetes, not just Type 1 diabetes and currently there's no cure for Type 1 diabetes.

So I mentioned about insulin pumps in my previous slide, it's a portable device that delivers insulin. This is just an example of one of the pumps.

It is an efficient method of administering the insulin, provides more flexibility and generally gives better control and reduces risk of dangerously low glucose readings.

But this requires a multidiscipline input from the dietitian, from the diabetes specialist nurse, and the doctor.

And it's currently, not recommended for the treatment of Type 2 diabetes in UK.

I had mentioned about this condition in one of my previous slides. It's called LADA, also called 1.5 diabetes.

It occurs in adults as an autoimmune condition, a person with this condition will eventually need insulin, but we cannot predict when the person would end up on insulin.

It's important to recognize this condition early so that the right interventions can be started.

And a person may have features of both Type 2 and Type 1 diabetes, but the principles of treatment are still the same. It's regular monitoring, investigations, and treating.

Diabetes complications. I mentioned that this is the second goal when we are managing a person with diabetes, and that is to prevent or delay the complications.

There are two factors that determine the risk of developing complications. One is the severity of high glucose and second is the duration a person has had high glucose.

I've listed some complications, like the eye, retinopathy, nerves, there could be a problem of neuropathy. Again, with regards to the heart, people can have heart disease.

And, you know foot complications are also common. Every person is different, so we cannot predict who's going to develop the complication.

But we know people who have poor control are at a high risk of developing the complication the rates of progression may differ. For example, someone may have, say, kidney disease, stage one and we can't see when they're going to, when the person would go into stage two or stage three.

But the aim in my care is to provide an individualized treatment regime that's practical and helps prevent and delay complications. In fact, every clinician endeavours to achieve this goal.

Because I mentioned about diabetes, foot. I would like to say a few points about the diabetic foot disease.

So diabetes can affect blood circulation in the in the feet, it can also affect the nerves.

So when there's chronic high glucose, it increases the risk of infection.

And because foot is at a high risk of injuries or trauma or impacts, there could be minor injuries.

In fact, the foot infection is the most frequent complication from diabetes requiring hospitalization.

So I just, I say in my practice, if one does not want to come to hospital. Make sure you take good care of the feet.

And the infection may start with a trivial trigger. It may be just a minor break in the skin, and it can spread superficially or it can go deep down into the bones.

When a person has chest pain or breathlessness, the person goes to the hospital and I would like to emphasize that if a person with diabetes has got any infection or ulcer in the foot, that person should seek medical attention.

So the principles of treatment are quite simple. Actually the time is the essence. Once you seek medical attention.

If infection is suspected, we start the appropriate antibiotics and if required, we do the wound debridement and do the proper dressings and depending upon the severity of the infection, we may have to do offloading.

It's a term that's used to use special footwear and prevent additional pressure on the foot which has got the ulcer or the infection.

That's an opportunity to also assess the blood circulation of the feet, and if there is reduced circulation, we may have to refer to the specialist for further treatment and strongly recommended to stop smoking, as smoking is an independent risk factor for reduced blood circulation in the feet.

And certain tests are requested like simple blood test or taking a swab from the ulcer. And if required, you can do some X-rays or even in an MRI scan.

Again, this is an opportunity to review the blood glucose levels and change the regime if not well controlled.

I keep emphasizing on this point of glucose monitoring, because anytime a person presents with a complication of diabetes, a comprehensive assessment it's ideal to review the glucose levels and titrate the dose of insulin if they're on insulin or review the medications if they're on tablets.

Now, technology has changed the landscape of diabetes and strongly recommended that people who are eligible for sensors or continuous glucose monitors make use of this technology to help manage the diabetes.

Now, finally, living with diabetes is a big challenge.

During the consultation, we may spend anywhere between fifteen to maybe forty-five minutes.

But the rest of the time it is the person with diabetes who's looking after the condition. So, the foundation Of diabetes management is self-care or I would say self-management.

And a person with diabetes needs to know the potential side effects of the medicines they're taking.

And as I mentioned about technology in the previous slides, this can help in managing diabetes.

A person with diabetes needs to inform DVLA if they're taking insulin because it’s illegal.

Can you hear me?

Damien

Yeah, we can hear you. Sorry. Thanks. Thanks, Dr Sighakoli. I think we just missed about thirty seconds. That was all.

Dr Sameer Sighakoli

Okay. Right. Thank you. So I'll be quick. So I was saying about the driving. So people with who are on insulin should inform DVLA and they may have to do some separate paperwork to allow them to drive.

It can also impact the work life because people have different shifts. People may have to do different shifts, including night shifts. They may have to take regular breaks to administer insulin.

Family has a crucial role in supporting a person with diabetes. They also need to be aware of the potential risks and complications associated with diabetes.

For example, if somebody were to have a dangerously low glucose and to collapse or pass out, the family would need to know what to do in that situation.

So that brings to the end of my presentation. But I would like to mention that during an endocrinology consultation, a thorough assessment is done of the symptoms, and a comprehensive review is done.

A comprehensive review of your glucose levels is done, and we also take into consideration the potential complications one may develop with diabetes.

So by the time you leave the consultation, you should be Able to go home with a clear plan after reviewing the different treatment options.

Thank you and I'll pass on to Damien.

Damien

Yeah, thank you, Dr Sighacoli, really interesting, much appreciated. Yeah, so if you get answers, if you've got any questions, please pop those into the Q&A box at the bottom of your screens. We've got some coming through now.

We've actually got, Ashok, asking, whether you could give a little bit more information on, on being pre-diabetic?

Perhaps maybe sort of symptoms to look for and well however you interpret that really.

Dr Sameer Sighakoli

Yeah. So that's a very important question because the incidence of prediabetes is also increasing.

People with prediabetes may not necessarily have symptoms.

There is a small possibility that they might have minor symptoms like, for example, they may notice some numbness or tingling, or they could have some change in frequency. Sorry they could. They could be feeling excessively thirsty, but that's less likely with prediabetes is more common with diabetes.

So prediabetes is usually picked up when there is a routine screening test done, or a routine clinical review done, or a blood test, or sometimes when somebody's having some medical procedure and they're having a glucose check or a HbA1c test as part of their assessment for the surgery, for example.

So it's more about being aware of the condition and also having regular reviews.

Damien

Yeah, no, fantastic. Thank you. So we've got George asking. So George is a Type 2 diabetic and asking whether this can be reversed with change of diet and lifestyle alone. George is 47 years old and he has an HbA1c of 98.

But he's not keen on using medications if he can avoid it.

Dr Sameer Sighakoli

Yeah. So short answer is yes. In Type 2 diabetes, we use this term called remission, where if identified early on, and the appropriate changes are made with lifestyle changes where this significant calorie restriction is done, then one can achieve remission in Type 2 diabetes.

But If You have symptoms, if you're not feeling well, then you may have to start treatment first, and once it's controlled, you could consider weaning down the treatment.

So to kickstart the process of achieving good control, you may have to take some medications.

But it's proven in studies, and there's been research on this, so severe calorie restriction can help with remission of Type 2 diabetes, especially in the first few years after diagnosis of Type 2 diabetes.

Damien

Lovely. Well, that actually moves on quite nicely to this next question from an anonymous attendee. If a Type 2 patient reaches the stage where insulin is used, is there any way back from that treatment?

Dr Sameer Sighakoli

Yes, so it's a good question. So if a person with Type 2 diabetes has been on oral medications handle.

Has been on a combination of different class of medications, and if the control is not adequate or suboptimal.

We start insulin and, generally speaking, as we age, as the duration of diabetes increases, the chances of requiring insulin also increases.

But there are situations where, for example, somebody is obese or overweight and diabetes control is poor or inadequate. We might advise starting insulin to make sure the control is good.

But if the person manages to lose weight, then there are situations where we have to cut down on insulin or even stop insulin.

So short answer is yes, we can do that. But it's again depends on the individual circumstance.

Damien

Okay, yeah, grand, thank you.

Next question was, what's your advice for young adults, especially with Type 1 diabetes, regarding diabetes and pregnancy? And typically, is this discussed in primary care or perhaps further consultations, family planning, et cetera?

Dr Sameer Sighakoli

It's very important. So for a person with Type 1 diabetes who's planning pregnancy, it's important to have a review in the secondary care. I mean, obviously, primary care physician needs to be informed as well, but, we have antenatal diabetes service in every hospital in the NHS and in secondary care.

We have dedicated multidisciplinary teams and you'll be eligible for the sensor. You could also be potentially eligible for an insulin pump.

And we have what we call a pre consumption service and before planning pregnancy, the appropriate advice will be given in terms of achieving the target, safe target ranges from a pregnancy perspective.

Damien

Yeah, okay, lovely. Thank you. Yeah, so we've got another anonymous question here, and this is how does insulin resistance present and, I guess, be investigated? This person's struggling with weight. They have gestational, excuse me, diabetes managed with metformin.

And I think their weight was really good, probably the best it's been for a long time.

Alongside sorry, this one's quite a long one.

So yeah, weight's been the best it's been for a long time, and lots of energy, but since weight gone up, really struggling to lose it despite dietary changes and activity alongside fatigue, inflammation, and other conditions.

It sounds like she's tried Wegovy as well.

Dr Sameer Sighakoli

Okay, so you mentioned about insulin resistance, so the risk of insulin resistance is higher in people who are overweight or obese.

There is no specific blood test to measure insulin resistance, but we can calculate insulin resistance by formula, by measuring different parameters.

But if changes in diet and lifestyle modifications have not helped with weight loss.

One might be eligible for the weight loss medications depending upon the criteria that's recommended nationally.

But they're not licensed for the management of Type 1 diabetes. I'm talking about the weight loss medications. But if you had a gestational diabetes, and then, that has and then followed by weight gain.

As I said, if you fulfil the criteria, one could benefit from the weight loss medications and losing weight will help in reducing in managing insulin assistance as well.

Damien

Yeah, lovely, thank you. Janet's got a question here, and, how bad are spikes in glucose readings after eating certain foods? Let me scroll down and see if there's any more to that.

No, that was it. Perhaps maybe, I guess we can interpret that how you wish, but maybe particular foods.

Dr Sameer Sighakoli

Yes. So that's a very good point. So certain food items can lead to glucose spikes. I mean, even in people who don't have diabetes, we can sometimes see what we call as physiological changes after eating certain food items. So that depends on the glucose content or what we call as the glycaemic index.

So, the people who have, a person who has got Type 1 diabetes and has got a sensor or a person who's got a sensor irrespective of the type of diabetes will be able to easily follow the glucose patterns and the trends.

The dietitian will be able to advise on how to avoid that, but just a few points. Having a balanced diet, by which I mean combination of fibre, protein, fat, along with the high glycaemic index foods can help reduce the glucose spikes but when taken on its own, the risk of glucose spikes post-meal is high.

And if a person is on insulin for Type 1 diabetes, then we may have to adjust the dose of insulin based on the carb content of the food.

Damien

Okay, interesting. Yeah, that reminds me of my girlfriend's black bean brownie recipe. Consume some sugar, but higher fibre in the black beans.

We've got David, asking the question here. It seems the common treatment journey is typically pills followed by insulin.

And then he asked them what or what can the patient do?

Dr Sameer Sighakoli

So what happens in the natural history of diabetes? I'm talking about Type 2 diabetes is that by the time diabetes is diagnosed, the body's ability to produce insulin would have come down.

And with time, the insulin that's produced in the body drops further and that's when after, say, maybe 15 or 20 years down the line, the need to support the treatment with insulin increases.

So this is a common scenario where, as you rightly said, you start on medications, but eventually you end up on insulin and that's because of the nature of the disease. Even in spite of the maximum effort you're putting, you might still require insulin to be added to your treatment regime.

Damien

Yeah, okay, lovely, thank you. this next person's actually asking if you can give more details about H01, what it is and how this influences Type 1. I'm not sure if you recognise that one.

Dr Sameer Sighakoli

What is this?

HO-1.

Dr Sameer Sighakoli

I'm not sure. No. I'm not sure what that abbreviation stands for.

Damien

Malakodi, maybe you could, just, give us a little bit more details, in your next question.

We move on to Sandra. Sandra asks, what food should I avoid in pre-diabetics, and I want to get this under control before I go, before I get to Type 2, please.

Dr Sameer Sighakoli

Yes, so that's very important. In fact, when I come across people with pre-diabetes, I advise this.

But it's important to avoid food items such as gut high glyceric index, and we can get the list of those food items online.

This general advice is that have more frequent meals, small portions, rather than having large portions and less frequently.

Anything that's got added sugar, and fortunately, these days, most of the food items that we purchase from the shelves it depicts how much sugar content is there. So anything that's say, for example, shows the glucose is in red means it's got high glucose in that.

And if you still want to have some kind of, if you want to self-treat yourself, then I would recommend you have this high sugar containing food with some other food items like, you know, fibre or protein based.

The best thing is to avoid that, but if you still want to have it, have smaller portions, but more frequently.

The in pre diabetes, the key is if weight is an issue, the key would be to losing weight in losing weight and reducing the waist circumference.

So again, depending upon ethnicities, the recommended base of circumferences are different.

I hope that answers the question.

I think I can't hear you, Damien.

Damien

Sorry, I had a plane go over, and I So we've got David asking, I have an Hba1c of 52, and I'm just about to be prescribed statins, as my glucose is two. Can I reverse the need for statins?

Dr Sameer Sighakoli

You say glucose is two.

Damien

Yeah, that's what it says, yeah. Yeah, I have HBA1C of 52, and I'm just about to be prescribed statins, as my glucose is two.

Dr Sameer Sighakoli

Okay, because glucose of two is extremely low reading, so one may not, one may be very unwell at that value. But going back to the point about statins, so it again depends on the level of the cholesterol in the blood.

With weight loss, we see positive effect on the cholesterol levels as well.

But having said that, if someone has a high risk of developing heart disease, and that is done based on assessment as a whole, taking into account your history of family history of heart disease, or history of high blood pressure.

And based on that, there's a scoring system, and based on that, if the risk is high, statins are prescribed by physicians. So, in your case, if you have high risk, then statins would be beneficial, but if the risk is low, then I say this, the risk is low, and if there is room for losing weight, then yes, we can improve the cholesterol levels in blood.

Damien

Yeah, yeah, no, okay, fantastic.

I've got Amanda here. I'm on type there's a few, questions that are sort of repeating themselves, so I'll just mention that to some of the attendees.

So look back, and this will be recorded so you can listen back.

But we've got Amanda here. I'm Type 2 on insulin, initially from diagnosed. It's now on now I'm on medication only, metformin, with new diet, now gaining weight.

So her HBA1C is 8.5

So yes, I think that's she's been prescribed metformin, but now she's gaining weight.

Dr Sameer Sighakoli

Okay, alright. So HbA1c of 8.5 percent needs to be treated. And if you've just been prescribed metformin, then please continue that.

In fact if I, if I just been start on metformin, it needs to be assessed within three months whether that has helped.

Now, metformin does not normally cause weight gain. It's considered beneficial from that perspective.

If you're having weight-related issues, it's good to assess your thyroid function, for example and if that is normal, then you'd benefit from a dietitian review.

And again, as I said about the principle of calorie restriction, if, let us say, you're still gaining weight and you've reached the threshold where you might benefit from some weight loss medications, then that's a discussion you will need to have with your physician.

But Hba1c, of 8.5% definitely needs treatment.

Damien

Okay, yeah, thank you. We've got another anonymous one here. In your experience, this is a good one actually, does stress play a significant role in Type 2 diabetes?

I have a stressful job and wonder if this might have played a part. I wear a monitor and do see that glucose levels rise during stressful meetings or days.

Dr Sameer Sighakoli

Short answer is yes. Stress has an impact on the blood glucose readings.

And I have seen few people who for some reason change their jobs and they were less stressed and the doses had to be reduced.

Now, there's a concept called stress hyperglycaemia, which means that in stress situations, in terms of physical stress, it can lead to high glucose during and if you suspect that the stress is causing the high blood glucose, it's important to realize whether that is leading to a need for higher dose of insulin.

So I'm not sure what regime you're on, but if you're on insulin, then that needs to be addressed as well. But the changes and fluctuations related to stress are generally mild to moderate, not severe.

But short answer is yes, stress can lead to high blood glucose.

Damien

Yeah, okay, thank you. This one's following on from, Janet's question. What would be classed as a spike?

My continuous glucose monitor shows that my time in range is 100%, but sometimes I'm right at the top of the green band on my monitor.

Dr Sameer Sighakoli

Well, then I would say you're probably having a physiological spike. I mean, that's probably within the normal limits.

So I would not be worried. If your timing range is 100%, then that spikes are probably post meal, maybe in the first one after a standard meal.

So I will not, I would I would say you don't need any treatment for that.

Damien

Fantastic. Okay, good stuff. And another one, quite simply, how can I improve my fatty liver?

Dr Sameer Sighakoli

Okay, so the fatty liver is basically deposition of fat in the liver, and it's being deposited in the wrong part of the body, and that's because of the excess fat.

So if you have, you're overweight or obese, losing weight will definitely help. It could be either through diet or physical activity or weight loss medications, but it will help.

And we see few people with diabetes in my practice where when they have managed to lose weight, the fatty liver has also improved.

Damien

Okay. Yeah. Fantastic. Fantastic.

Next question. So if there is a strong family history of MODY, I'm not sure if you're familiar with that. Good. Can it actually stop diabetes, prediabetes, or insulin resistance?

Dr Sameer Sighakoli

No, if there's a strong family history of MODY, then there is always a risk of the person developing MODY as well. So say for example, one of the parents has got Modi, the different subtypes of MODY.

So if there is a risk or if you feel that you have or if you have been told that you have borderline high glucose readings or abnormal glucose readings, then you would need to have MODY testing.

But it has no link to insulin resistance. I mean, for example, a person with MODY may also have weight-related issues, and they may be obese or overweight, and they could have insulin resistance because of that, and not necessarily because of MODY.

Damien

Yeah. Okay. Interesting. Now, this is an interesting one. I think this is the last one we've got. Another anonymous question.

Can LDL cholesterol rise after weight loss? I've lost I've lost 12.5 stone over the past 10 years. All bloods are really good, but LDL cholesterol is a little high. I've heard bad things about statins, so reluctant to go on them.

Dr Sameer Sighakoli

So generally speaking, weight loss leads to an improvement in all the parameters of lipid profile.

If, I mean, it's, it's a remarkable achievement that you managed to lose 12. Is it 12.5 stone?

Damien

Yeah, 12.5 stone over 10 years.

Dr Sameer Sighakoli

That's a remarkable achievement. So the indication for starting statin treatment would depend upon whether you have diabetes and whether on the scoring system you still have a higher risk of heart problems.

So if that is the case, statins would be advised. Now, if you don't have diabetes, if you only have a mild rise in LDL cholesterol, then that can be supervised and monitored and addition can be made on further subsequent reviews.

Damien

Okay, yeah, fantastic. Yeah, and in fact, I think, this person has also added, that they're 80 years old, normal weight, normal height.

Lost weight once started taking insulin and they happen to be Southeast Asian or South Asian.

I don't know if that has role to play.

Dr Sameer Sighakoli

Yeah. So, I mean, I would still say, I mean, I don't have the exact values, but if your LDL cholesterol is raised, it's important that we continue to monitor that. But given the information that you are showing a positive response in your health parameters, like the weight loss, etc.

You're likely to notice positive effects in LDL cholesterol values as well. But, as I said, we need to look at the specific measurements.

Damien

Yeah, absolutely. Okay, grand. Well, I think that's our questions for this evening. If we move over to the last slide, Dr Sugakoli, that'd be great.

Dr Sameer Sighakoli

Sure.

Damien

Right, so thanks again for all those questions and being part of this evening's session.

Now we'd like to say as a thank you for attending, we're actually pleased to offer 50% off the value of your consultation, a callback from your dedicated Private Patient Advisor. You'll receive an email with a recording of this session, treatment information as well as loyalty reward points and updates on future events.

We'd really appreciate it if you could take a moment to complete the short survey at the end of the session. It helps us to improve and tailor future webinars to your needs.

Now, if you'd like to speak to someone to book your consultation, our private patient team is available until 8.30pm this evening and from eight am until six pm, Monday to Friday. And you'll find the contact number on your screen.

We also have upcoming webinars on a range of topics, including urology and orthopaedics and you can sign up for these on our website.

So finally, a thank you from all of us here at Benenden, as well as Dr Sighakoli and we'll see you again soon. Thank you, doctor.

Sadie Ridley

Good evening, everyone, and thank you for joining us. We'll just give it another moment or two to allow everyone to get settled.

Once again, good evening, and a very warm welcome to our webinar on liver disease. My name is Sadie, and I'm an advanced practice sonographer here at Benenden Hospital. I'm delighted to be joined by our expert speaker, Dr Shah, who is a Consultant Hepatologist and Gastroenterologist.

Tonight's session will begin with a presentation from us, followed by a live Q&A session.

If you have any questions at any point, please feel free to submit them using the Q&A icon at the bottom of your screen. You're welcome to ask anonymously, or include your name, if you'd like to.

Just a quick note that the session is being recorded, so any names shared might be visible in the recording. And to help us get through as many as possible, please keep the questions as brief as you can.

If you're interested in booking a consultation, we'll share the relevant contact details at the end of the session. So to get started, I'll hand you over to Dr Shah, who will talk you through liver disease. Dr Shah, over to you.

Dr Jayshri Shah

Yeah, thank you, Sadie, and I would like to welcome everyone to this very important, session, you know, on liver disease.

I come with a huge amount of experience in liver disease and feel very passionate about this very important, remarkable organ of the body, which performs 500 functions every day, every single day, until it starts failing.

So, the objective today is to kind of demystify some of the aspects of liver.

Which will help, to diagnose this disease early.

Next slide, please, Sadie. Thank you.

So, this session will include aspects of symptoms, what kind of symptoms one can experience if they have liver disease, how it can progress. We will touch upon a very common condition, particularly when there is fat in the liver, how we can go about diagnosing liver ailments.

We will also, I will then hand over to Sadie, who will talk about the liver ultrasound service, and we will discuss some treatment options, followed by a question-and-answer session,

Next slide, please.

So, liver disease is, like, currently the most, you know, important, you know in the statistics, we find that it is ignored organ, really, and actually, there is a triple ticking time bomb that you can see in this triangle here, or three common liver conditions that we are facing in our practice today.

And this is very concerning because, most of most of the time, no symptoms. So what are these three conditions? You can see on the top of this triangle is the non-alcohol fatty liver disease. Now, this is how it was traditionally, called.

As the name suggests, there is fat in the liver, which is not alcohol related. That means, what is causing that fat? Now, it's invariably related to, conditions such as being overweight.

Obesity, diabetes, dyslipidaemia, that's a medical term. I will simplify that for you. If you've got an altered cholesterol profile, high cholesterol or triglycerides in the blood, underactive thyroid, and invariably, these are the four conditions which can continue to deposit fat in the liver and damage the liver. Now, this has been renamed as

Medically, as a metabolic liver disease, because as you know, all of these conditions are related to how the body metabolizes the calories that you take, and how the fat, therefore, builds up.

At the bottom, you see that there is alcohol. Now, almost in the past, it is stigmatized, isn't it? Anybody tells you that I've got a liver problem, and the next thing that somebody will think, oh, it might be because of alcohol. Yes, it is one of the very, very important causes of liver disease, but we've already discussed that there could be non-alcohol-related fatty liver disease as well.

And then the third very important cause of liver disease is hepatitis, which is usually I'm talking about viral hepatitis. Now, what does hepatitis mean to you? If I had to simplify this, HEPA means liver.

And itis means inflammation in the liver. So you can get one can get inflammation on the liver because of a variety of conditions, but

Viruses are some of the common causes of inflammation in the liver. Medicines. Many times we, you know, we take medicines, antibiotics, or some herbal Chinese products, something over the counter or online, and, and you know, these can all sometimes be responsible, for inflammation in the liver.

There are some other uncommon causes as well. We'll touch upon those in some of the subsequent slides. But the triple-ticking time bomb is these three conditions, and very, very common in practice. I'm seeing it almost every day.

Next slide, please.

Now what is the prevalence? Why are we focusing so much on the liver? You know,

The British Liver Trust is a very is a charitable foundation, and they have had a variety of input in this particular, you know, liver disease field. They have a number of information leaflets. If you go on their website, you will find a huge amount of resource related to liver.

And, this prevalence is captured from their site, and you would find that one in five people actually have fatty liver.

Now, that is 12% of the adults, and there is a risk that this fatty liver will progress, and my subsequent slides will show you how this can progress.

So it is clearly a problem. It is very much prevalent in our society because of alcohol consumption, because of diet, because of some of the medicines. Lifestyle is the key.

How much you exercise, how much calories one consumes, are we able to have a negative deficit status, or are we continuously building up positive caloric intake in the body?

All of that matters. Do we have a sedentary lifestyle? Are we walking those seven,000, 10,000, that magic figure every day? You know, how much do we stand? Do we have a desk job? All of that matters in how this condition will evolve and shape up.

Next slide, please.

Obviously, there are things when it comes to any medical condition which is out of your control, and that is your genetics, and there are certain autoimmune conditions, there are certain metabolic conditions, like alpha-one antitrypsin, there are, you know, iron overload disorders such as hemochromatosis.

These are all medical terms, but to simplify for you that there are a good set of conditions which may be genetic, but fortunately, that they are not as common.

Copper, you know, deficiency, metabolic effects related to that, but they are all very uncommon compared to the three conditions that we talked about. Fatty liver, non-alcohol related as well as alcohol-related, and the hepatitis infections.

Now, although on the slide it says, outside your control is A, B, and C, I would like to dwell a little bit on that.

Now, hepatitis A is actually a virus which is spread through food and water, and a majority of the times, you will have no symptoms, and only a small proportion of people will feel sick with it, and it can spontaneously resolve.

Many people will not know that they had the condition. It has no bearing with chronic liver damage but, E is another virus which is also spread through food and water and has the effect of chronicity in the body.

The chance of that happening is small, less than one%. Again, doesn't produce many symptoms most of the time. If your one is pregnant and acquires this virus through, the faecal oral route, then they can get symptoms of acute hepatitis, jaundice, feel very unwell. But by and large, no symptoms with A&E.

But B and C are the ones where some of the people who have been transfused before these viruses were possible to check in the blood, that's where I would say that it is outside your control, because some people have acquired these infections without actually knowing about it, because we were not testing for these viruses routinely.

We didn't have methods to check them before 1952. So, so, so many people who've had transfusions or dialysis or, you know, inadvertently got these infections because we were not able to screen the blood for all of these at the time.

But otherwise, they are very much within our control. These are spread through blood, blood products, sexual route, and there's actually a vaccine available for hepatitis B and I would recommend that any members who are having hepatitis B infection, their family should be screened, and they should all be offered a vaccine if they did not have the infection.

So, if you've already got the infection, then there is no point of having the vaccine. The vaccine is meant for people who have not been infected. There is no vaccine for hepatitis C, however.

But it's easily, you know, treatable with a finite duration of treatment, and totally curable.

Now, what is within our control?

Obviously, we talked about some of those factors already when I touched upon fatty liver disease, alcohol and non-alcohol related, but just to emphasize the importance that your physical activity, your diet, you know, you are what you eat.

I'm sure many of us have heard this quote, is extremely important, and has a huge impact on whether one will develop fatty liver disease or not and alcohol consumption.

Now, what is the safe alcohol limit? So, the NICE, which is the National Institute of Clinical Excellence, recommends a certain allowance which they find is safe. Now, for women, it is a bit lower compared to men, approximately 10 to 14 units, and for men, it is 18 to 21 units.

Having said that, if one has got underlying liver disease, even these safe limits of alcohol may not apply, and there will be a time when people say no level of alcohol consumption would be safe for the liver. This is in people who do not have any liver conditions.

So, you can see at the bottom, the British Liver Trust emphasizes, again, if you put alcohol, excess body weight, which is obesity, and I would add the diabetes, you know, and some of the other factors which cause fatty liver, and viral hepatitis are responsible for nine out of 10 cases of liver disease, which goes down to the fact that the uncommon conditions are quite uncommon.

That is, one in 10 will have those, and not these three common conditions responsible for silent liver disease. Now, I've used the word silent, and I will touch more about it in the subsequent slides.

Next one, please. Thank you, Sadie.

So, when I, broach the word silent, I mean liver disease, by and large, is actually,

doesn't produce symptoms. So one, can be walking around having a very damaged liver, and not even know about it, because liver is a very, very resilient organ. It is, has a potential to regenerate and grow, like the hair and the, and the nails.

You know, only three organs of the body can regrow and therefore it does not produce symptoms unless Ivan is in a very advanced stage of liver disease, or there's acute inflammation from the liver, like I described from some of the viruses.

So, some of the symptoms that one can observe when the liver is very, very damaged is jaundice. I'm sure many of you are familiar with that term. There is a yellow tinge to the eyes, or the skin, and the urine will become quite high coloured.

Sometimes, when the liver disease is very advanced, people can vomit blood, or they can pass blood in the stool, because the blood supply to the liver is kind of blocked because of a scarred liver, and the veins then find alternate channels, and the blood then goes into the food pipe, and big, big veins develop in the food pipe or stomach, which can suddenly burst and then the first presentation many times in my practice for an underlying liver ailment that I have seen very, very frequently is vomiting blood and blood and stalls.

Waterlogging can happen in the body, which we call a cystitis, or outside your lungs, and which can cause difficulty in breathing. That's why that has been mentioned.

The liver, as I mentioned earlier, it performs 500 important functions, and some of the functions include removing all the toxins from the body.

Which means that if the liver is now not functioning very well, these toxins are building up and if they are building up, that means that kind of affects the ability to function neurologically. The brain is confused because these toxins then flow through the blood-brain barrier and result in confusion, irritability, drowsiness, reversal of sleep patterns, and, really, people at this stage should not be driving, and are at risk of a variety of complications as a result of that.

Next slide, please.

Now, what are the early symptoms? So, I already said that most of the time, you might have liver disease with no symptoms, okay? And the set of symptoms I started off were the red flags, which means if you've got complications from an advanced liver disease. Now, what might happen before you've developed those life-threatening complications that we talked about would be that sometimes people just generally feel unwell, they feel tired, not rest even when they have rested, fatigue, they have, small, red patches which might develop in the palms, in the upper part of the chest, or, you know, at the back, upper part of the back, and these are called spider angiomas, as you can tell.

What is seen in the palms in the picture depicted there, are also some of these, new kind of vessels that open up as a result of liver disease, commonly seen in people, actually, who have alcohol-related liver disease.

You might also find there is a contracture in your ring finger, which you can see, actually, on this picture in the left hand, in the ring finger, there is a slight contracture there and that we call as Lupiter's contracture.

Again, I won't bore you with medical terms, but it suffice to know that these are some of the symptoms.

If you find some kind of abnormal red patches appearing in your palm, in your chest, or any red patches appearing anywhere in the skin, it may actually be an indirect sign of liver disease.

Next slide, please.

We've talked about some of the later symptoms, which I covered, in the first slide when there were the red flags, but this is summarizing it, in a, in a much more, you know, I think, user-friendly way, from your point of view.

Jaundice, itchy skin, because when you're yellow, and you've got, an altered skin colour, you find that the skin can become quite dry, and that can cause itchiness.

The nail colour can change, muscle cramps can develop because of the water imbalance in the body. The liver can't handle salt and water the same way when it has failed, and therefore the water starts building up in the legs and in the tummy.

Then, with use of water tablets, or in proportionate use of salt and water, one can experience these cramps. So, a variety of reasons for that.

Now, there is hormonal imbalance. The liver plays a huge role in the sexual hormones of the body, and therefore sexual dysfunction can be one of the symptoms of liver disease.

Next slide, please.

Now, what are the stages? So, a healthy liver is what we all want, and that's the objective of all this, you know, discussion and education. But, invariably, we have noted, that one in five people are having this fatty liver.

And this fatty liver can progress through various stages to inflammation, which is hepatitis, we talked about that, scarring, which is called fibrosis medically, and cirrhosis.

Now, cirrhosis is a rock-hard liver. You know, normal livers are supposed to be soft, and you can see in the diagram depicted here on the left-hand side, where it says healthy liver.

To these nodules which develop, and that means from a soft tennis ball, this liver is becoming hard like a cricket ball. Now, let me take you through some of the stages in the subsequent slides. You know, this is a broad picture, but we'll talk about each of these stages.

So, the first stage, which is when, you know, touching upon the common conditions, that is, fatty liver, irrespective of alcohol or non-alcohol factors.

Fat starts building inside the liver cells, so you can see that the orange colour because of the fat building up in the liver. Now, normal livers will have less than 5% or less than 5-10% of fat, anything more than that is a fatty liver.

And we have a variety of tests which can pick up the fat and I will talk about that in the investigations that will be conducted to help assess the fat in your liver.

But at this stage, which is the first stage, there is no liver damage, and we can tell that from a variety of investigations that we can conduct, and actually stratify the stage of liver disease, which is the beauty.

At this stage, everything is reversible. You will find that you have no symptoms, none of the stuff that I mentioned in those slides with symptoms you would experience if you just had

A simple fatty liver, but no inflammation or scarring.

Okay, next slide, please.

In the next stage, which is inflammation, sometimes you will find that, a blood test, which is done, incidentally picks up that your liver enzymes are raised, and your liver blood tests are raised, and your doctor might say, oh, you've got an inflamed liver, we need to find out what the causes are.

Now, I've already mentioned that commonest causes is viruses, medicines, drugs, invariably, and some of the, you know, uncommon causes are autoimmune liver conditions, genetic issues, and stuff like that.

But fatty liver and viruses and drugs are the commonest causes of inflammation in the liver. And you may or may not experience symptoms depending upon the degree of inflammation in the liver. So, mild inflamed liver, one will experience no symptoms, and therefore, at this stage, even.

One can have silent liver disease, and can be picked up through a blood test, and again, scanning.

Next slide.

Now, what happens anytime you've got a wound, think about, you've injured your hand. It starts bleeding, there is a cut, and then the cut heals with some, inflammation around it, so it appears red.

After the clot is formed, when the bleeding stops, and then after a period of time, depending upon the intensity of that cut, you will find that it heals with or without scarring.

So superficial cuts, you will have no scarring, you'll find that there is no residue, nothing left. But, if there is deep and repetitive injury in the same area, you will find that the scar tissue builds up after the inflammation has resolved.

Now, this is exactly what happens in the liver, whether it's because of alcohol-related fat or non-alcohol-related fat, or viruses, or a variety of other causes. The inflammation results in scarring.

Liver is very, very regenerative, we talked about that. It kind of heals itself but if the insult is repetitive the process of healing lags behind, the scar tissue starts building up and then comes a time that there is an imbalance in that scale of the insult versus healing.

Then inflammation, resulting in ongoing scarring, scar tissue building up, scarring is fibrosis, and even at this stage, one may not experience any symptoms.

And going on to the last stage, which is cirrhosis, which is what we talked about, where you've got to rock our liver. At this point, one is at risk of having complications. Now, even at this stage if many people have normal liver function tests.

If you do their blood test, because at that point in time, the liver is scarred, but there's no active inflammation at that time, but the scar tissue has built up, so you will find that some of the liver blood tests are completely normal, and sometimes a regular ultrasound can actually miss cirrhosis.

So, that's why it's important to understand the availability of some of the sophisticated equipment that we have, and Sadie will touch a lot on it in her aspect of the presentation, but for now, to let you know that people can be walking with cirrhosis and not know about it because they have no symptoms, and have and feel very well.

So, it's like, people go for routine health checks, and sometimes there is a growth sitting in the body, and it's very small, and you don't notice it because you have no symptoms, but the scan incidentally picks it up. So yes, there's a lot of incidental diagnosis of cirrhosis that I get to see in clinic.

Next slide, please.

So how then should we be looking at diagnosing this very important condition before one reaches the point of those complications, the advanced stage, where we talked about vomiting blood, swelling of one's feet, logging of water in the tummy, confusion, and all of that, you know, nodules in the liver and the cirrhosis can result in liver cancer.

I haven't talked much about it, but yes, one of the commonest causes of liver cancer is having liver cirrhosis.

So, we can do a lot by starting early, even if one has no symptoms, but if you identify yourself as having any of these risk factors, which we talked about.

Obesity, diabetes, cholesterol profile being off, overweight, you don't have to be fully obese, even overweight, alcohol intake, previous blood transfusions, history of hepatitis B, C.

Where there is a preponderance or risk of any of these blood-borne virus infections.

You should try and get yourself assessed, even if you feel well and have no symptoms and we are able to do blood tests, we are able to do special scans, and these include ultrasound.

I wouldn't start doing a CT, MRI, and DEXA. The initial assessment for any patient with liver disease would be a simple ultrasound.

And I'm sure all of you will know about ultrasound. It's very, very easy. It's jelly, painless, non-invasive, like the babies when one's having the pregnancy scanned. So that's how you will feel no discomfort when it is done.

Now, what is important is that the ultrasound sees the outside of the liver part, the elastography techniques that we have available, see the inside of the liver and we are able to understand the degree of fibrosis, which is the scar tissue buildup.

With a number of non-invasive tests, which allow us to see the level of scarring, these tests can be blood tests, and they can be scans. And there's a limitation with blood tests, and therefore we have to resort to the elastography techniques, and these are fully approved by NICE, but I will let Sadie talk more in depth about this special scan that we do have at Benenden.

But many times, to completely assess the liver, if we found some areas in the liver which are not, of, you know, identify very well on ultrasound. We would do a CT scan or MRI.

These are cross-sectional imaging, which give you a better perspective of any growths or incidental areas in the liver which we don't understand very well on ultrasound.

And why is endoscopy and liver biopsy put in there? Those will be at the stage when one is worried about complications of liver disease, we are worried about those veins building up from which one can bleed, and therefore, we would recommend an endoscopy, which is a camera test, which goes from the mouth into the food pipe and stomach, to look for these veins from which one can lose blood silently, and sometimes overtly, with actual vomiting.

Biopsy is one of the, you know, something that we used to do very, very frequently, but now we have reduced this because of having these sophisticated elastography techniques. It is used to understand the cause of liver disease when it is not apparent, and stage the liver disease, or if the elastography techniques have failed to help us know where the stage of liver disease is.

Next slide, please.

I will hand over to Sadie, who's our Sonographer, a very advanced, you know, comes with a breadth of experience across Kent, Sussex, and Bristol.

And she is currently been in Benenden Hospital for three years, very passionate about, research and innovation, and she will take you through the, ultrasound elastography, and, over to you, Sadie. Thank you.

Sadie Ridley

Thank you, Dr Shah, for that nice introduction. So, a little bit about, the results that we hope to achieve with the elastography. I'll talk you through the technique in a minute, just to explain how we do it. But as Dr Shah explained, a healthy liver is nice and soft.

When it becomes stiff, that means there's a risk of scarring and damage, and we measure the stiffness with elastography in kilopascals, which is a unit of pressure.

So when we get the results back, a normal liver is five kilopascals or less. Less than nine means that you're not likely to have serious liver disease, but it's above the normal range.

Between nine and 13, it means that there's more tests required, and you are at risk of serious liver disease.

And over 13, you are in the range of serious liver disease, and as the results go up, you're going to get, the reverse blood flow in your, main blood vessels, as Dr Shah was explaining earlier, known as portal hypertension, and this causes serious problems.

So, looking at the fat in the liver, because we measured two things, the stiffness, which, is the texture, and we also measure the percentage of fat in the liver, which can lead to the inflammation, as Dr Shah explained.

So, less than five% fat is normal, five or less. Up to 10% fat we class as mild fatty liver.

15% is moderate, and over this, we start to get into the more severe range of fatty buildup, which can cause inflammation and further problems.

So, elastography, or shear wave elastography, is an ultrasound technique that is a new specialized technique that's available to measure, the stiffness of the liver.

Here at Benenden, the advantage we have is that it's part of the conventional ultrasound system. So we can look at the liver first, and look for any lesions, any abnormalities, look at the contour of the liver, look at the texture. We also have a look at the gallbladder to see if you've got any gallstones.

And then we will do some measurements. As you can see with the box on the screen, we put the measurement boxes right in the middle of the liver.

So that we're getting the most accurate results we can, and we take multiple measurements, and that will bring, us some really good results on the stiffness and the fatty infiltration, which we can analyse.

And these, as Dr Shah mentioned, this information can mean that you don't have to go and have a liver biopsy, which can be quite painful.

So, elastography looks at how stiff your liver is. So, because the stiffer your liver gets, the it's quicker for the sound waves to travel through, just because of the texture of your liver. So, a normal liver would look like the water on the left, where the sound waves

It's not stiff, and it's quite liquid, and then as your liver gets more damaged, it becomes a bit stiffer, and the speed which it travels through changes, and that's how we can identify when there is damage to the liver tissue.

It's also the same for the fat in the liver. It changes the speed, so when we get the results back, it will automatically calculate how much fat there is throughout the liver tissue.

So we have, Siemens machines here. They're about a year old. They're top of the range, and they come with a specialized shear wave elastography liver package, so that we can look through your liver with normal ultrasound, and then we can go ahead and take some measurements with elastography to get those more advanced measurements to look inside the liver tissue to try and analyse whether you've got fibrosis or, fatty deposits.

So, when you come for your scan, we ask you not to eat for six hours beforehand, because this can change, how the liver looks with elastography.

It's best to wear comfortable clothes so that they're loose and we can access your liver quite easily, as you can see on the screen. We just need to put some jelly on your skin and the probe there, so that we can actually go through the skin and have a look at your liver and take some measurements.

If you have questions about the scan, it's probably better to contact the private patients team beforehand so that they can answer your questions in case you need to change anything before you come. We can answer questions on the day, but, always best to answer them beforehand if we can.

And once you arrive, we'll take you into the ultrasound room. Depending on whether you're having your whole abdomen scanned, or just your liver for elastography, the scan can take 20 to 40 minutes, and we always look through your liver, gallbladder, portal vein.

First of all, find the best part of the liver between the ribs and then we'll take several measurements through the best part of the liver tissue to look at the results and analyse the results and these are reported on the same day and sent straight to your consultant for the follow-up appointment, which will be in person or by telephone.

So, as Dr Shah mentioned, the National Institute for Health and Care Excellence, NICE, they give the guidelines on what we do in healthcare.

And in 2023, they issued landmark guidance, stating that liver scanning ultrasound elastography is one of the best techniques for assessing and detecting early liver disease.

So, as well as visualizing the liver tissue and the surrounding organs, so we can, analyse the pancreas and the spleen as well while we're there, we can provide you with an accurate assessment of the density of your liver and look for any signs of liver disease.

So I'll hand you back over to Dr Shah, who is going to talk to you about some treatment options.

Dr Shah, I'll hand over to you.

Dr Jayshri Shah

Thank you, Sadie. So, the good news is that liver disease is treatable, depending upon the stage, right? Now, we also mentioned earlier that liver is a regenerative organ, it's very resilient, it likes to fight back, and therefore you do not see any symptoms until it's too late.

So, in spite of, reaching a point of cirrhosis, which is a very, very scarred liver, we have seen that that can reverse to a certain extent one takes away what is causing the damage.

So, it's like you've got a fire somewhere, and you know, you've taken away the cause of the fire, you've, you know, you can add water as much as you want, but if you keep putting oil to the fire, X amount of water will not be sufficient.

So, similarly with liver disease, if one were to continue to take alcohol after knowing that they've got alcohol-related liver disease, no amount of medication is going to help this liver. It's going to worsen, irrespective of all medical interventions.

If one has got fatty liver because of obesity, diabetes, and if these factors are not under control, the liver disease will continue to progress. So, the take-home message about treatment is treat the cause.

Treating the cause, taking away the cause, will help the liver regenerate. Now, many times in the hospital environment, obviously where I'm working, and we see very, very sick patients.

The situation reaches a point that it is so advanced that people have developed portal hypertension. You heard that term from Sadie.

I was trying to simplify it by saying those big veins in the food pipe, that is portal hypertension. Portal being used because that is the one of the veins which supplies blood to the liver, and these veins build up. Now, these are life-threatening conditions, and many people sometimes require, because of these life-threatening complications, to be considered for liver transplant. So we stage the liver cirrhosis into A, B, and C.

A, most of the time do not have any symptoms, but B will have symptoms, and C are in the last end-stage liver disease. And we start talking about liver transplant when somebody has got, into the stage B or C.

We have different scoring systems that we use to understand the severity of cirrhosis and, direct access, to, you know, discussions with liver transplant centres.

Now, obviously, we do not wish that people reach that point, and hence, accessing, the services early is the key to, treatment.

So, if, if, for example through a routine health check, one was to find that, in spite of normal LFTs, the ultrasound elastography had a score of 17 kilopascals.

That means there is cirrhosis, but you feel very well. That means you're at a very good stage of treatment, because we will just try and understand what is causing that stiffness in the liver through a breadth of investigations, including blood tests and variety of assessments, which will tell us what is the actual cause, what is driving that stiffness in the liver.

Treating those causes will help that reversal of liver disease. So, all is not over, and that's why it's worth, identifying liver disease early.

I would sum up by saying, hit hard, hit early, because if we detect liver disease early, one doesn't need to have any of those complications or worries of cirrhosis-related cancer.

You know, you can cure the condition. But, if it is left unattended, waiting for symptoms to happen, many times we are talking liver transplant, or many people who are not even fit for a liver transplant because they are so sick by the time they come to us.

Avoid over the counter, so do's and don'ts. Avoid over-the-counter medications without prescription. Do not take medicines online without being, you know, consulting your doctor. Stay within the limits of alcohol intake.

Diet, diet, diet, very important. Having a balanced diet, and if you have any of the risk factors, such as diabetes, cholesterol, underactive thyroid, overweight, all of these need to be, hypertension, all of these need to be monitored and treated.

And if there is any family history of liver conditions, please see your doctor, because you might want to verify if you are at risk because of any genetic inhabitants.

So, obviously, we opened up our seminar to questions. We tried to cover as much as we could, but we want to leave time for interaction and questions. So, over to you, Sadie. We can go through the chat box and see if there are any, questions, and address them.

Sadie Ridley

Okay, thank you, Dr Shah. So we're really pleased to have so many with, so many of you with us today, and while we may not be able to answer all your questions, we'll try and cover as many as you can.

So let's have a look, see what questions we've got.

Okay, so I've got the first question is, I also get right upper quadrant pain, Dr Shah, is that a common reason, would you like to answer that one?

Dr Jayshri Shah

Yeah, yeah. So, there are multiple reasons for right upper quadrant pain. Liver disease in the early stages will not cause right upper quadrant pain unless there's a lot of fat deposited in the liver, and it's stretching the capsule of the liver. So, one of the causes of fatty you know, one of the causes of right upper quadrant pain could be a very fatty liver or liver disease.

But many times it is quite silent, and people will not have a lot of symptoms. Gallbladder stones, on the other hand, are more common causes of right upper quadrant pain, and it also depends upon whether the pain is associated with meals, or irrespective of meals.

So, if one is experiencing that, should see the doctor to get themselves assessed, for sure.

Sadie Ridley

Okay, thank you, Dr Shah. Another question I have, I have Gilbert's, syndrome, which I understand is a benign liver condition.

Is this likely to progress to something more serious, or likely to remain benign?

Dr Jayshri Shah

So, yes, it is a very it's quite common, we see, you know, this condition. It is genetic, it is benign, as you have put it in the question.

No risk of chronic liver disease. Absolutely nothing to be done about this diagnosis, except that you should be aware that you have it.

Because it matters for insurance purposes that you do not have a life-threatening or a progressive liver condition, because it can affect your travel insurance. Many times, individuals will turn yellow.

And they will start worrying, oh my god, what's happened? And therefore, it's important to know whether you've got it.

Stress, sometimes infections, low blood sugars, all of that can be associated with, you know, driving this bilirubin, higher, and it is dynamic, and the level of bilirubin will fluctuate from time to time, but

To answer the question, no fear of long-term liver damage or getting cirrhosis or a scarred liver from this condition.

Sadie Ridley

That's good, thank you, Dr Shah. I have a couple of questions, asking the same thing. Is elastography the same as a FibroScan?

Dr Jayshri Shah

Yeah, so, they do this they give us the same information, let's put it that way. They are two separate machines, but the objective of that is to tell us if the liver is scarred or not. Now, having said that, these are, you know, the way they are done, you've heard Sadie explain how simple how simple it is to do an ultrasound elastography.

FibroScan was also done in a similar way, but the equipment is different.

10 different readings are taken, and an average of those readings gives you the score in kilopascals. The interpretation of the scores and the cutoffs are different depending upon the machine that one is using, so you heard some cut-offs from Sadie.

Those cutoffs will be different when one is using the FibroScan, to answer the question of scarring.

Now, both of these tests are phenomenal in telling us about a scarred liver, but they also, one must remember, interpretation.

Not everyone with that high score has got liver cirrhosis, or fibrosis, because many times if one's liver is inflamed, you can get these scores going up and once the inflammation settles down, then, the scores can go lower.

Now, liver disease can be at a point where there is inflammation and scarring happening at the same time, and therefore, interpreting all of this with over a period of time.

Clinical correlation, cause of liver disease is extremely important, and there are different cutoffs set up as per guidelines for both the machines.

Sadie Ridley

Thank you. Can I just add that, the difference between us and FibroScan is also that we can see the liver to place the measurement boxes.

So it's just, yeah, it's a different technique.

Okay, so, I've got one here. What does a below range in serum album level mean? Is this something that requires follow-up action?

Dr Jayshri Shah

So, albumin is a protein, and it has a half-life of 21 days, you know, produced by our liver, and therefore, if one's albumin is low, you're worried that there is an underlying liver disease, but it can also be low because of leaking kidneys.

You know, one can lose a lot of protein if they've got a kidney problem. So, a low albumin is not synonymous to liver disease. You have to get checked for it. It could be just nutritional, it could be that you're losing a lot of protein, or you're not generating enough because you've got liver disease. And additionally, if it is measured during an active infection, you will find that it is paradoxically on the lower side, because it

It's the body's response to inflammation anywhere in the body.

Sadie Ridley

How good is it to follow cookbooks that claim to give you a good liver diet recipes?

Dr Shah?

Dr Jayshri Shah

Oh, I want to but it's a difficult one. You've got a Google there for me, yeah? Because it's not straightforward, it depends upon the recommendations. I would run this past nutritionists and dietitians. I might not be best placed to answer this, but what I would like to sum up is that body needs everything, okay?

And when I say that I know there's a lot of fad about keto diets, and this type of diet, only eating one type of nutrient, only protein, or low carbohydrate, or, you know, you want to go into prolonged fasting, and there's so much out there, and there are obviously those cookbooks.

It is important to run past all of that with a certified nutritionist or dietitian to actually marry in what your expectations or requirements are for your body's health, with what is being put in that cookbook.

From a liver point of view, to avoid this very common epidemic of fatty liver, one has to realize that the body weight needs to be you know, appropriate.

Your body mass index, your BMI, should be within normal range, and, you know, along with that, not taking alcohol. So, so diets which are very rich in fat, processed foods, you know, too much red meat.

Sugary stuff, all of that are, you know, the drinks, such as Coke, how much of sugar there is in one can of Coke. You need to start looking at all of those, to make those choices.

I hope I've answered that question and not answered that question.

Sadie Ridley

You tried.

I've got another question for you. Following, elastography, what does borderline fibrosis four score mean?

The following was that with a FibroScan.

Dr Jayshri Shah

Borderline fibrosis low score or F4?

Sadie Ridley

F4 score.

Dr Jayshri Shah

Full, F, F4? Does it say F4?

Sadie Ridley

I guess it's an F4 score, yeah.

Dr Jayshri Shah

F4. So, F4 means that there is advanced fibrosis, heading towards I'd use it as cirrhosis, F4 means cirrhosis, F3 is advanced fibrosis, and that's why I said that the cut-offs are different, and we can use the word F3 for the same score, depending on the liver condition that we're talking about.

So, I would be very careful when we are using those terminologies, F3, F4, but the take-home message is, whether it's an F3 or an F4, the, you know, the alert bells are ringing.

One has got to take the liver disease seriously at this point.

They should not be, you know, discharged back to the doctor in primary care. They should be under a liver specialist being followed up in hospital if they had F3 or F4, because of whatever liver condition, whatever be the cause causing that state of scarring.

Sadie Ridley

Thank you.

Another question I've got here is, is milk thistle okay to take regularly?

Dr Jayshri Shah

Yeah, I think there's a lot of evidence that it is a good antioxidant, and, you know, we've not shown any harm done to the liver. There's a lot of evidence about caffeine, similarly, and its beneficial effects as an anti-inflammatory on the liver.

So, yes, I'm not giving a prescription, because these are not all FDA approved, but yes, I haven't heard any harm done to the liver from milk thistle or caffeine from whatever data is available.

But I can't prescribe that, you know, because it's not an FDA-approved drug.

Sadie Ridley

Thank you. Another one here, can we have an initial blood test at the GP surgery?

Dr Jayshri Shah

Can you have your initial blood test and the GP surgery? Of course you should have, you know, you have to see your doctor. I mean, if you are worried about your liver, you should see your doctor, you know, if you've got membership with Benenden, now you know you can contact, you know, the Benenden Helpline, and, you know, use your membership to access the help. But alternatively, if you don't, you must see your GP if you come under any of the risk factors that I've mentioned and request initial assessment.

Not everybody will be referred for a FibroScan or ultrasound elastography, but there are clear-cut, guidelines available for primary care at, based on some scores and blood assessment, simple blood work and ultrasound.

And then, depending on the results of those tests, onboard referral for this special scan, including ultrasound elastography.

Sadie Ridley

Thank you. Another one I have here, is raised ALT a sign of liver disease?

Dr Jayshri Shah

It can be. ALT is a liver enzyme, and it is a marker of inflammation in the liver, and sometimes one can have this, you know, intermittently, you know, fluctuating. It's just telling us that the level of inflammation is varying. It can be from a variety of conditions that we've talked about, fat.

Because of alcohol or non-alcohol drugs, medicines, infections elsewhere in the body or within the liver, autoimmune liver conditions. So yes, if one has got to raise ALT, we will need to find out why.

Sadie Ridley

Okay, thank you. Another one here. How important is lowering blood pressure and cholesterol levels for the liver?

Dr Jayshri Shah

If, as mentioned, that we have got these are defined risk factors for fat deposition in the liver, and invariably, I get referrals from the GP saying, that somebody's on a statin. Quite a lot of people are on statins to lower their cholesterol, and their liver enzymes are slightly up, so they stop the statin, and then we're actually causing more harm to the liver because the fat levels are building up.

So, yes, statins can cause the ALT to go up, so if somebody has had, you know, high cholesterol and the statin has just started, and the liver enzymes worsen, then yes, the drug is causing it.

But if somebody's been on statin for several years, and now suddenly the ALT goes up, it could be because of a variety of causes, and one of them could be that the fat levels are not under control. But it needs assessment.

Sadie Ridley

Thank you. I have another one here. What is the difference between fatty liver and polycystic liver?

Dr Jayshri Shah

Okay, so they're two separate conditions, completely separate. Fatty liver, as the name suggests, is fat deposited inside the liver cells, and the liver cells are hepatocytes, HEPA meaning liver.

And, polycystic, or poly means many, and cyst is like a fluid-filled cavity. So if you've got plenty of these fluid-filled cavities in the liver, it is polycystic liver disease.

There is a genetic, you know, component to that, and sometimes people, along with plenty of cysts in the liver, may have plenty of cysts in the kidney, and we call this a polycystic liver and kidney disease, but they can occur separately as well.

That needs to be addressed, so if you've got that condition, then you must see your doctor. And there will be a kind of annual monitoring and surveillance offered.

Sadie Ridley

Thank you. I have another question here. How do you seek a review of your medication to ensure it's not causing or impacting liver disease?

I'm concerned that my medication plan for chronic pain is not being comprehensively reviewed.

Dr Jayshri Shah

I think you must see your doctor and address that you know, in detail, you have right to information, medicines that are being consumed, and what is the impact of that on the liver.

Almost all medicines can cause some form of, you know, irritation in the liver. However, there are certain types of liver medicines that we will completely avoid in liver disease.

And I'm sure your doctor will get a red alert for that if you are known to have liver disease and are on a medicine that is contraindicated if you have underlying liver disease.

But having said that, you know, it's important, if you have any doubt that this has not been reviewed, that you arrange to see a doctor to do that.

Sadie Ridley

Thank you. I have another one here, the patient's saying they have an unexplained enlarged liver with raised liver enzymes in the past, and more recently, focal nodular hyperplasia and an intolerance to alcohol.

Their enzymes are not currently raised, but would it be worth exploring this with a scan to look at their, liver stiffness?

Dr Jayshri Shah

So, a focal nodular I'm going to separate this out. Focal nodular hyperplasia will invariably not cause your liver enzymes to go up.

This is a condition which causes some kind of a focal liver lesion, an area in the liver which is, you know, just focal, as the name suggests.

It does not require ongoing surveillance or monitoring. There is no risk of cancer with focal nodular hyperplasia. If we are absolutely confident that this is focal nodular hyperplasia, it does not require surveillance scans.

The problem lies if there is a doubt, because if it is any other condition, then some of the other focal liver lesions can be having risk of, you know, growth and risk of cancer.

Therefore, it is very important that if somebody has got this lesion, that we have discussed this, reviewed the scans carefully, and made that diagnosis for sure.

So if that diagnosis has been given to you, then there's no follow-up required for that, unless it's absolutely a very, very big, growth in the liver and causing symptoms from pressure, which is not very, very common.

Now, if your liver enzymes are raised, that requires a separate set of investigations and you will require a non-invasive liver screen, which is a breath or blood test to be absolutely sure what is causing these.

If fat is the cause, and alcohol is one of the commonest causes of fat deposition in the liver.

I would say that you cannot take alcohol, or you must not take alcohol, because the fat will continue to build up.

Whether you tolerate alcohol or not, if you've got elevated liver enzymes, I would recommend stopping alcohol and understanding through investigations, what is the cause of those liver enzymes, so you should see your doctor, and if the doctor is not able to understand that you should be seen by a liver specialist.

Sadie Ridley

Thank you. I have another one here, which I think you've probably answered, but just, I'll ask you anyway. What should we eat to cleanse the liver, or particular food to avoid to keep the liver healthy?

Dr Jayshri Shah

Okay, another diet dietetic one.

I would say, avoid too much fatty foods. When I say so there's healthy fat, but there is there is a lot of processed food, there's a lot of preservatives in in, you know, food, which is, you know, frozen, sauces, you know, we take a pack of crisps, you should look at the salt content and the fat content.

I would avoid all of these, on a regular basis. Of course, you can, you know, take it, depending upon your condition, as and when, after you've, assessed yourself, but on a daily basis, if one was to take burgers, for example, a lot of bacon, a lot of red meat, you know, those are a strict no-no, and a recipe for building up fat in your liver.

On the other hand, salmon has got fat, you know, there's oil in that fish, but it's healthy fat.

So, I cannot say don't take fatty foods, and that's why I sway away from going into dietetics advice, and I would recommend that people see a dietitian, because advice relating to diet can be quite descriptive and lengthy, and it has to be tailor-made for individual needs.

But by and large, you know, the don'ts are frizzy drinks, too much of alcohol, too much of, you know, sugary foods, processed foods, fatty foods, you know, which are burgers and, you know, sausage rolls and stuff like that, yeah, red meat.

Sadie Ridley

Thank you. Just got one last question, and then we will, finish the session as we're running out of time. Does autoimmune hepatitis lead to fibrosis and, cirrhosis?

Dr Jayshri Shah

Yes, it does. Like, other causes of, you know, liver disease I mentioned, the disease starts with inflammation and then the inflamed tissue goes on getting scarred. But autoimmune hepatitis, can be treated.

There are effective medications available for it, so that from the inflamed stage, one does not reach the point of cirrhosis.

The objective is with autoimmune hepatitis, that we silence the immune system with the right cocktail of immunosuppressive medication.

To prevent cirrhosis from, happening. But patients with autoimmune hepatitis will require to definitely be with a liver specialist and be monitored regularly.

If they are on immunosuppressants, then they will need, every three months to be checked for their dosages, because these may change, the requirement of the immune medication may change from time to time.

Sadie Ridley

Thank you. Thank you again for your questions, and for being part of this evening's session.

Thank you, Dr Shah, for answering those all so eloquently. If we haven't answered your question, because we've run out of time, you'll and you've provided your name, we'll follow up, with you via an email.

As a thank you for attending, we're pleased to offer 50% off the value of a consultation for a limited time.

A callback from your dedicated private patient advisor, an email with a recording of this session, treatment information and loyalty reward points and updates on future events and health news.

We'd really appreciate it if you could take a moment to complete the short survey at the end of this session if you have time. It helps us to improve and tailor future webinars to your needs.

If you'd like to speak with someone or book your consultation, our private patients team is available until eight o'clock this evening, and from 8am to 6pm, Monday to Friday, you'll find the contact number on your screen.

We also have upcoming webinars on a range of topics, including knee and hip surgery and gynaecology, if you're interested in those.

You can sign up for those on our website. On behalf of Dr Shah and myself, and all of us here at Benenden Hospital, thank you once again for joining us. Hope it's been informative and helpful to you.

We hope to hear from you soon. Take care and goodbye.

Dr Jayshri Shah

Thank you.