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Watch our webinar on liver disease: the hidden health risk

Hear from Dr Jayshri Shah, Consultant Hepatologist and Gastroenterologist and Sadie Ridley, Sonographer, as they guide you through the importance of early detection, liver scanning and treatment options.

Please note that any discounts advertised in this video are exclusive to attendees and registrants of the live event.

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Liver disease webinar transcript

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.

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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.

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