Dr. Nathan Connelly – Hepatologist
In this episode, I speak to Dr. Nathan Connelly, a hepatologist, about what a hepatologist does, fatty liver disease and why it would be worth your while taking a liver with a FIBROSCAN® machine.
Nick: I’m back with Dr. Nathan Connelly. And today we’re talking about the liver. So Nathan as well as being a gastroenterologist. You’re also a hepatologist, which is a liver specialist. Do you want to, Oh, I should say hello. How are you?
Nathan: Thank you, Nick. Yes, I’m a hepatologist as well. Most gastroenterologists are, although some are more interested in the liver than others I would say.
Nick: So what does a hepatologist do?
Nathan: So hepatology is all about the study of and management of diseases of the liver. So it’s all to do with the liver, which is a very important organ indeed, you can’t live without it. And it’s a very special organ because of a number of reasons, but the diseases of the liver are very common. They commonly don’t present with symptoms until the disease is very far advanced. So in some ways, it’s quite similar to the kidneys, which again can be quite damaged before you actually start to get symptoms, whereas with other organs such as the heart and the brain, maybe, sometimes, you know, a bit earlier know that you might have a problem. The liver doesn’t have any symptoms until the disease is very advanced and usually irretrievable in terms of fixing it.
Nick: I see. We did touch on that on the last podcast we did on the liver, which was liver health and the effects of alcohol, diet and medication. So how about today we talk about liver disease. So what’s, what are some of the most common diseases of the liver?
Fatty Liver Disease
Nathan: So, the commonest disease of the liver at the moment that’s causing concern is fatty liver disease. When I was a registrar studying transplantation medicine, so I worked on the transplant unit for a couple of years, by far the commonest reasons for patients to have a liver transplant was hepatitis C. Now, hepatitis C, fortunately, we got such great drugs to treat it these days that 99% or more of people with hepatitis C are curable with treatment. And even quite advanced degrees of scarring can be reversed with the, uh, with the use of antiviral medication. So three to six months of medication will fix most hepatitis C, therefore, patients don’t need a transplant.
Likewise with hepatitis B where you have very good drugs, not to cure the disease but to at least suppress the virus, so again, it doesn’t cause problems with end stage liver failure or tumors. Alcohol is always there – there’s a smattering of patients every year who get a transplant because they drank too much. Um, obviously you have to stop drinking before you get a transplant. But even with that, some people do progress and require a transplant.
And then there’s nonalcoholic fatty liver disease, which is by far the commonest, uh, disease. These guys, which is probably gonna require transplantation in the future. Fatty liver affects anywhere between 20 and 30% of the population depending on which figures you see. And in many ways, it is a disease of Western lifestyle, uh, and the fact that we are getting fatter.
Nick: Okay. It’s, it’s mainly related to what we eat?
Nathan: It’s a complex disease. A lot of it is genetic. A lot of people who have fatty liver disease, and that doesn’t mean everyone with fatty liver disease is fat, by the way. A good 10 to 20% of people with fatty liver have a normal body mass index, which is a way of relating weight to height. So, uh, you can have a fatty liver with normal, uh, body mass index, but most people are overweight. So a lot of it’s genetic and not just the history of fatty liver disease, but a history of what we call metabolic syndrome. So that the archtypical disease of that is diabetes. So often there’s a history of type two diabetes, gout, high lipids, hypertension, all of this fits into polycystic ovarian syndrome. All fits into what we call a metabolic syndrome. And it’s due to what we call insulin resistance.
Nathan: So the body doesn’t respond as well to insulin. And sometimes the first sign of that insulin resistance is having fat in the liver. And in many ways, fatty liver as a harbing or if you like, of a type two diabetes. So the fatty liver first and the type two diabetes, but uh, very much it’s genetic and then there’s lifestyle. So it relates very much to weight, which is probably the next most important factor. The heavier you are, the more likely you are to get fatty liver disease and the more likely you are to have bad fatty liver disease. And that’s a continuum from a BMI, a above the normal range all the way up to people who are morbidly obese. In terms of what people eat, um, that probably isn’t quite as important. People would think, obviously it’s fat, it’s probably more carbohydrates to be honest – sugar than it is fat.
Nathan: Uh, certainly highly processed carbs like white bread and white pasta, they’re just like sugar. These, these, uh, are just long chains of, uh, of sugar molecules connected together and they’re broken down very quickly and act like sugar. So when you wait white bread, you basically sugar. Uh, and I was not quite as bad as sugar, but it almost is. Uh, so that’s the major dietary thing, but calories overall and weight, sedentary lifestyle, uh, all of these factors play in as well. And then, of course, you also think about co-injurious agents like alcohol causes exactly the same finding as the non alcohol, which is why we call it non alcohol. And on biopsy you actually can’t tell the difference between the two. It’s only on the patient’s history of alcohol that you can tell the difference. So people with fatty liver often say, “Well, I don’t drink doctor. Why have I got this problem? ” Well, it’s mostly genetic and lifestyle.
Nick: So, so with a scarred liver, let’s say from excessive alcohol, that’s obviously irreversible.
Nathan: No, no, it’s not irreversible.
Nick: Okay. So I guess my question is going to be the difference between a scarred liver and a fatty liver. I’ve had the impression if you, if you’re, if you scarred, you’ll liver, too greatly, you’re in serious trouble.
Nathan: So which point is it? Irreversible is what you’re asking.
Nick: Yeah, probably. And how is it different too? Or how is fat or fatty liver different to a scarred liver? Or are they both scared?
Nathan: With all forms of liver disease, um, it’s all the same things. So they’ll feed into the same pathway. It’s what’s called the fibrosis pathway. So you don’t get a scared liver from having an acute liver injury. Say, for example, you take too much Panadol and you end up with what’s called paracetamal hepatotoxicity, you will either get better or you will die. And there’s no in between. You don’t get scarring. The liver gets better or it doesn’t. You knock off vast waves of liver cells, but then they recover. Fibrosis and its end point, which is cirrhosis. And everyone would know the term cirrhosis, which everyone equates to drinking, but it’s caused by any form of liver disease. Cirrhosis is the end stage of a progressive scarring of the liver. And that scarring occurs because of ongoing damaged, chronic day in, day out inflammation. And then the scarring comes on top of that.
Nathan: We call it fibrosis, but scarring is just as good a word. And that will happen over, in most cases, years or even decades. So it doesn’t happen overnight. It takes years and decades for it to happen, but a causes absolutely no symptoms. And you might not even have much in the way of abnormal liver tests either. So if you say, well, why can’t you just do liver tests? Um, liver tests don’t tell you everything. You see people who can become cirrhotic with minimally elevated liver function tests. And you can see some people with very elevated liver function tests, who don’t have any scarring at all. So the liver function tests, which are the blood tests you get at the local pathology, are a very imperfect way of monitoring your liver health.
Getting a Liver Scan
Nick: I understand. So we’ll probably touch on this later, but it’s probably worthwhile getting a liver scan and there are two ways to do that, with an ultrasound or with a FIBROSCAN®.
Nathan: Yeah. So a routine standard ultrasound as we have done over the years, doesn’t really tell you much about liver scarring unless it’s right at the end. So at the end of the process, you end up with this shrunken knobbly, uh, abnormal looking liver, which you can be on an ultrasound, but that’s it. That’s done. If you’ve got that kind of scarring, you can’t do anything about it. So at that point, the disease has, um, has finished .
Nick: Or finished you really?
Nathan: Well. Yeah. So that, that point, the disease has run its course and you’re left with cirrhosis. You might stay clinically stable for many years, so in no way am I saying if you’re diagnosed with cirrhosis, you’re going to die tomorrow, but your liver scarring has progressed as far as it can. The question then is one, when are you going to develop signs and symptoms of chronic liver disease? And that can be you know, months, two years down the track, but you can’t actually fix that kind of scarring. Once you’ve got cirrhosis is visible on an ultrasound, you can’t fix that.
Nick: I see.
Nathan: Um, you can’t fix that with medication to, to change the disease process. Uh, you can’t fix it with white loss. Once you get that appearance on an ultrasound, the liver fibrosis problem has gone past that point. So what you want to be able to do is to pick milder forms of fibrosis. And there are a number of ways of doing that. The way we used to do it ,10 years ago is do biopsy. So if you are really worried about someone’s live about 10 years ago I’d do a biopsy, basically stick a needle in the liver and take a sample, which is obviously invasive. It hurts. And there’s a pretty significant risk of complications such as bleeding or bile leak. In more recent years, we have developed ultrasound based or sound wave based techniques to do that, one of which is a fiber scan, which is probably the best known where we bounce ultrasound waves to the liver to see how stiff deliveries.
Nathan: So when the liver stiffness goes up, it equates to scarring. So therefore you’ve got, we’ve got these tables and these ways of equating the two to each other. So for example, a liver stiffness score of over 15 kilopascals pretty much universally means you have, um, quite severe fibrosis bordering on cirrhosis even before you see a single thing on a, on a visible ultrasound. So a score under five is universally normal. Anything over 15 pretty much is universally cirrhotic already. In between there, there’s various stages of fibrosis determined by various charts and data we have. Um, but the, uh, the fiber scan over time will tell you what’s happening with the liver. So, for example, I’ve had patients with fatty liver who are found to have a score of 12 or 13 which means they’ve got it what’s called F3 fibrosis, which is just before cirrhosis and there’d been morbidly obese and we’ve gone get them to lose weight.
Nathan: And some of my patients have lost 20 or 30 kilograms, which whatever way they do it, and then you re-fiber scan them a couple of years down the track and this score is six or eight. So they’ve actually the reverse their fibrosis with weight loss.
Nick: Okay. So we need to this perception that once you’ve damaged your liver, it can’t be repaired or can’t become healthy is false.
Nathan: It’s absolutely false. So whether you do that, you just need to remove the injurious agent. So obviously it was viral hepatitis, you suppress or eradicate the virus. If it’s alcohol, you stopped drinking. And if it’s fatty liver, the only proven therapy for fatty liver is significant weight loss. And what I mean significant, I don’t mean a kilo or two. You probably need to lose maybe 20 or 30% at least of your excess weight. So you need to lose five, 10, 15, 20 kilograms to make a difference.
Nathan: But weight loss is still the only proven therapy for fatty liver disease. Um, and I know that because of studies they did with patients having gastric banding procedures. This was done about 15 years ago. So, and that was done with paired biopsies. But you can do the same thing with fiber scan and you’ll see the numbers improve. And we’ve seen the numbers improve our patients, if they lose significant amounts of weight. It might be a little bit more subtle in that may be visceral fat’s more important than weight. Uh, I have had patients recently have improved this goals with not losing much weight, maybe only two, three or five kilos, but they’ve lost a lot of visceral fat by exercising in the gym and putting on muscle and losing fat. And it might be more visceral fat that counts. But it’s hard to measure visceral fat. Um, that’s the fat inside your abdominal cavity, basically. It’s a hard thing to measure. So it might be a little bit more subtle, but basically it’s, it’s weight loss.
Nick: I believe you’re only clinic in Victoria to have one of theseFIBROSCAN® machines.
Nathan: It’s he only private clinic.
Nick: Private clinic.
Nathan: Most public hospitals have one. Um, it’s the question is when you should have a fiber scan. I’ve got some rules for my patients. I think, I think any diabetic should have one. 97% of diabetics have a fatty liver. If you’re a young diabeteic and you’ve got type two diabetic, and you’ve just been diagnosed as highly likely to go to fatty liver. You almost certainly got a fatty liver. Um, and if you have a fiber scan it will tell you, um, what stage that fatty liver is that. If you have a fatty liver with a minimal fibrosis score, then it’s okay to keep doing what you’re doing and to sort of gradually lose some weight and be healthy, but you don’t have to panic. If you have a fiber scan, and the scores 15, you’ve got a problem. And that happens not infrequently.
Nathan: The estimate is that probably five to 10% of people with a fatty liver will develop significant fibrosis. and cirrhosis, but that might not seem like a lot, but when you’re talking about five to 10% of 20 to 30% of the population, it’s a huge number of people, which is what’s got everyone worried about this epidemic of obesity. It tends to not be a problem that you see commonly in people under the age of 50, but over the age of 50, you start to see this landslide of people who turn up with cirrhosis, uh, on the background of either having diabetes or being significantly overweight. So I think if you are diabetic, um, you should think about it. I think if you have abnormal liver tests, um, you should definitely think about it. Uh, and I think if you’ve got a body mass index over 35, you, you’d think about it. Um, and they’re the sort of groups I would recommend having one, having normal liver function test is no guarantee either, by the way.
Nick: Well, that’s, that’s what happened to me. Um, I had to live a function test. I just had a regular blood test, I think. And then there were elevated levels in the results related to the, I guess the function of my liver
Nathan: What they tell you, they don’t tell you liver function at all. I must say, sorry to cut in, liver function tests for the vast majority of them are a misnomer. They’re actually live that enzyme tests. They don’t tell you how the liver functions. They tell you whether you might have a problem with your liver, particularly inflammation, the inflammation of the liver cells or inflammation of the bile ducts that carry the bile away from the liver or blockage of the bile ducts will present as abnormal liver tests, but they don’t tell you anything about the function. The albumin test does. The Billy Reuben does, the coagulation studies do, but not the other liver function tests.
Nick: I mean, it was quite, it was quite a frustrating process me because my GP recommended I take a an ultrasound and that didn’t reveal any problem, but the, the levels in my function tests was so high. There was some concern and then I went to see you guys and had theFIBROSCAN® and that sort of revealed no problem.
Nick: Yeah, it’s very important in people who have that process. So the standard approach for an abnormal liver test is pretty simple. Um, if you kind of me with abnormal liver tests and you’re otherwise, well I would take a history of how much you drink, how, how much you weigh, medical problems, medications you take. I would then wait at least a month and repeat them because sometimes a one off liver test abnormality can be due to a virus or some other intercurrent illness that just goes away. So I don’t panic after the first one. If they’re repeatedly abnormal, then I would do an ultrasound and you’re doing an ultrasound predominantly to make sure that you don’t have a blocked bile duct because that will make you liver test abnormal and that you don’t have any focal lesions in your liver like a tumor or something that could make your liver tests go up and that you’re not obviously got cirrhosis.
Nathan: The next thing we do with that, it’s not the case. So you liver a test is normal. We do what’s called a liver screen. So we test you for liver viruses, uh, on overload, copper overload, those kinds of things to see whether there’s an obvious reason for why you got abnormal liver tests. And if we don’t find any reason for it, then a fiber scan is useful in that setting to make sure you don’t need to do a biopsy. So if you do a fiber scan on someone with slightly abnormal liver test, no cause found, um, one the fibroscan might say, well hang on, this is fatty liver cause you’ve got a high what’s called attenuator parameter school, but more so it will say, okay, you got slightly abnormal liver tests but your fibrosis score is normal. Therefore you can afford to wait, repeat the liver tests in six or 12 months and not panic. If on the other hand the score comes back as a 15, then really you’ve got significant liver disease and you probably should have a biopsy. So cause that’s the end in game. That’s the sort of last thing we do is liver biopsy and some people need to have that. So that’s the other situation where it’s as useful as people with abnormal liver tests and no idea why because that’s not an uncommon problem.
Nick: So with a Livescan if, if someone is listening and they are a diabetic or they are concerned with their weight or that they just would like to get a scan, they don’t require a referral, do they?
Nathan: No. So fiber scans and non-Medicare rebated, um, the, we, there have been several attempts to get a Medicare rebate for patients with diabetes, patients with hepatitis C, but no, no, no luck. So, uh, it’s got nothing to do with Medicare therefore you don’t need a referral. Might be a good idea to let your GP know that you need a fibroscan. But, um, we would always send a copy to the GP if the patient was happy. But generally speaking, you don’t need to refer. He’s walking and have one.
Nick: Okay. So if you have been drinking for let’s say 20 years and maybe having a typical Australian diet with lots of meat and let’s say you binge drink occasionally on the weekends and you don’t want to go to GP just to get a referral or recommendation, someone could just call you guys and say, Hey look, I’m interested in getting aFIBROSCAN®.
Nathan: Yeah, you can just book in and have it. Very interesting about alcohol. Um, we do get those people coming. They come in and say, listen, I’ve been drinking a bottle of red wine a day for the last 30 years. Um, I want to keep drinking my bottle of wine a day for the next 30 years. Um, I say to those patients, first point. Um, if I tell you your liver is quite bad, will you stop drinking? If they say yes, then I think a FIBROSCAN®is very reasonable. Um, I also tell them if their FIBROSCAN® is a, okay, I have one of these recently, a guy who drinks bottle and a half to two bowls of red a day , he has done so for 40 years and he’s FIBROSCAN® score was six, which is barely above normal. And I said to him, listen, you can keep drinking for your liver but the rest of you is not going to be very happy.
Nathan: So you know, alcohol does more than just affect the liver, it causes heart failure it causes, it causes atrial fibrillation, which is an abnormal rhythm of the heart. It causes lots of problems, increases risk of multiple forms of cancer. So it’s not just about the liver, but I did say you specifically asked me about your liver and your liver is fine and it probably will continue to be fine giving you 75 years old and you’ve been doing this for the last 30 years. Um, but the rest of you really should significantly reduce your alcohol intake for those reasons. What he did. I don’t know, but that’s not an uncommon scenario for people to come in and ask, you know, a might be a patient who’s overweight and their parent had, you know, a severe fatty liver disease and died from it or had um, or needed a liver transplant and they might come in and says I’m overweight as well.
Nathan: Um, I’ve got bad genetics. You know, I want to know what my liver is doing. You know, we’ve had that situation multiple times, sometimes the results good. And I tell him to go and lose weight cause I should lose weight cause it’d be good for them to lose weight. Other times, it’s really bad. And I said, listen, you really, really need to lose weight. Sometimes that can be the difference between opting for ongoing attempts at diet and exercise versus suggesting more extreme forms of the weight loss like bariatric surgery, which I have sent multiple patients for because of their very bad fatty liver. In the end their fatty liver aren’t going to be helped by losing weight. There are drugs in development but they’re still in phase two and three study. So, and they’re probably not gonna be as effective as weight loss. Anyway, by the looks of it.
Nick: I see. So, so with the liver, and this might sound like a stupid question, obviously the, there’s preventative care, just, just don’t drink too much and be careful with your diet. And then if you have, you’ve killed your liver, basically your only chance is replacement and it’s obviously it’s not an organ where you can do any sort of surgery on.
Nathan: No. So there’s no, there’s no, what you have to do with the liver, you have to stop the injury to the liver before you have irreversible fibrosis. So identify and stop before irreversible fibrosis and therefore cirrhosis occurs. The next phase if it has already happened, is to support the patient. So to look out for the complications of cirrhosis and the ultimate treatment is an orthotopic liver transplant or a liver transplant, which um, is needed because there’s no dialysis for the liver. They’ve been attempts that things, Mars machines and stuff, but they don’t really work very well. So really it’s a liver transplant or you die in the end. And it’s basically two ways how people die with liver disease. I either develop jaundice and liver failure and bleeding and all those kind of problems. Or they get a tumor in their liver, what’s called a hepatocellular carcinoma or a hepatoma, uh, and that, that kills a, a good proportion of patients who have, um, who have end stage liver disease.
Nathan: So, unlike the kidneys, you can live on dialysis, uh, for many years, the washing machine as they call it. You can even have an artificial heart put in, but there’s no artificial liver. It’s someone else’s or, or that’s it. The good news is, the liver has an amazing capacity to regenerate and if the liver disease is recognized early enough. It is reversible. So things like FIBROSCAN® are there to go right You’ve got abnormal liver tests, but not only do you have abnormal liver tests, you have evidence of progressive liver damage and fibrosis. Therefore we need to find out what’s causing it and we need to stop it. That’s the point. 90% of people with fatty liver have fat, but they have no scarring or insignificant scarring. Therefore we don’t have to worry about them so much. Yeah, they need to lose weight for their diabetic risk and other reasons, but it’s not specifically for their liver they need to do that which marks them is a different group of patients.
Nick: I see. Well I actually, as I mentioned before, I had a liverscan with you guys and it was um, pretty much like taking an ultrasound, um, and it only took about five, five minutes and the good thing you get the results immediately and then there’s your elf to explain what they mean.
Nick: Did we give you a diagnosis?
Nick: Oh no, not a diagnosis. You just said, okay, you’ve got a score of 4.3, so you’re fine or something.
Nathan: then I diagnosis, but you don’t need a biopsy. That’s not uncommon. I mean the liver tests, the liver tests are interesting. They, they go up and down with the seasons. Sometimes they go up and down for reasons we don’t understand. And that’s all fine. As long as you don’t have progressive scarring. So not everyone who has abnormal liver test absolutely requires a reason as to why. And we do see quite often no reason. And that’s fine. We just repeat the fiber scan every five years. So otherwise you need a biopsy and, and it’s amazing how often the biopsy itself doesn’t provide an answer. So you really, you really want to avoid biopsing people if you don’t have to. That’s why it’s a great test.
Nick: Well, I recommend it. I also recommend you guys – professional, very caring, and I know you care for your patients. So on that note, I guess we’ll, we’ll end this podcast episode. Thank you for your time.
Nathan: Okay, thanks. Thanks, Nick.