Welcome to episode five of the Holy Gut podcast. In this episode, we discuss the liver and liver health with gastroenterologist and liver specialist Dr. Nathan Connelly.
Nick: We’re back with Nathan to talk about the liver and liver health. So, welcome back, Nathan.
Nathan: Oh, thank you, Nick.
Nick: So, let’s begin with the function or functions of the liver. What does this amazing organ do?
Nathan: It is truly amazing. The liver, where it’s situated, is very important for helping you digest your food. Indeed, the food comes into the liver from the gut and very raw, full of toxins and very difficult to process. So, the liver processes at all into more useful food substances, which then gets distributed to the body.
Any toxins and other unwanted parts get excluded out evenly in either the kidneys or in the bile. So, it a very significant detoxifying effect and a very important metabolic function. It also makes lots of proteins for things like blood clotting and albumin, which is the major protein in your body. So, it is absolutely vital to human health.
Nick: Okay. And so we probably need to think that anything we digest be it’s food, drink, drugs, they all ended up going through the liver. Is that right?
Nathan: That is absolutely correct.
Nick: Okay. So we should really respect this organ or think about how we treat it; but, I guess most of us don’t because it’s probably a large percentage of the population, don’t really know what it does, but we now have established that I guess we should discuss how we look after it, and maybe look at how diet, and maybe how things like alcohol affect the liver. So do we want to begin with alcohol?
Nathan: First of all, I’d say, Nick, the reason why people don’t think about the liver is because liver disease doesn’t cause any symptoms until the liver disease is very advanced. So, it’s not like heart disease, where people start to feel short of breath or get chest pain.Or, skin disease where you notice straight away. The liver can get very, very scarred, what we call fibrosis or cirrhosis, until people and people don’t feel any symptoms from it. So, it’s not only often when it’s too late that people will notice they have a liver problem at all.
That’s why it’s important to want to look after to your liver and two, if you suspect there’s a problem, have a test that will tell you whether the liver that has a problem or not. And that’s not easy.
Nick: I see. Okay. So if you go to your GP and he has some concerns about your liver, and then you get some blood tests done and you see a specialist, and they say, “Well look, your liver is severely scarred. It’s too late and there’s nothing much you can do.”
Nathan: Well, to the point where you really sick and you’re turning yellow and losing weight, then it’s too late, ut before then, generally, most forms of liver disease are reversible up to a certain point.
So, to just say that the people listening to the podcast understand, that liver disease, if you’re waiting for to get symptoms before you do something about your liver, you are waiting too long.
Nick: Okay. So we need to be proactive in how we think about the liver and how to treat it, and if we have any concerns, we should get it checked. And there are a number of ways to do that, which we’ll sort of discuss. Okay. I guess there are maybe three areas we can think about. There’s food, there’s probably alcohol, and then this probably medication, which I imagine also can damage the liver.
Alcohol and the Liver
Nick: I guess with Australians, we do drink a lot. We have a sort of a laid back attitude to things. And yeah, we have this culture where we go out and drink often or we drink at home and we don’t really, most of us probably don’t think about what alcohol does to our liver. So, do we want to discuss that?
Nathan: Yeah. So, alcohol’s probably the common toxin, or certainly be the commonest toxin that affects the liver. There is no safe level of drinking for the liver. The general guidelines from the National Health and Medical Research Council for healthy drinking are widely known and widely available.
For me, that would stay two standard drinks of alcohol a day with two alcohol free days a week. Now, undoubtedly from a liver perspective, some people get away with drinking a lot more than that. The consequences of drinking too much are hardly individual, that is true.
Nathan: But, it’s pretty much a continual increase in risks beyond that. So, if you drink five standard drinks, that might increase your risk above two and if you drink 10, that’s above five. So, it’s a continual risk. There’s no cutoff.
Some people drink extraordinarily amounts about high amounts of alcohol and never develop liver disease. That is true, and people always went to that and they’ll, say “Aw, Uncle Dave, he drank, slab a day his whole life and he died at 95,” or something else.
And there are cases like that, but there are also cases of people who drink relatively modest amounts of alcohol and develop significant liver disease. So, there’s genetic factors, there’s other medications people take and they are other liver conditions that may coexist. That means that they’re drinking their level of alcohol, consumption is dangerous.
Nick: Yeah. I just personally, myself, I have looked at my drinking and I do remind myself that alcohol is a toxin. So, it’s probably important to think of alcohol. You read articles where maybe a glass of red’s healthy and all these things, but at its core, alcohol is toxic.
Nathan: Yes. The actually alcohol component, the benefit of drinking red wine probably relates to some of the other volatile chemicals within it, not the alcohol.
Nick: As you have mentioned, depending on maybe on your body type, your age, your health, and some other factors, alcohol will affect your liver differently, depending on each person.
Diet and the Liver
Nick: What about a food? I guess with food, we’re probably talking about aspects of what we eat, maybe how much we weigh, and if we’re developing a fatty liver?
Nathan: Yeah. So, the fatty liver I think is very important. If you had to discuss diet in the liver, you really are talking about fatty liver predominantly. There’s a lot of things out there about detoxifying diets and all this kind of stuff. But from a Western medical perspective, there’s no real evidence for someone with a healthy liver that any sort of dietary intervention is going to make any difference, whether that liver stays healthy or not.
Nathan: If you’ve got a fatty liver, however, it’s different. Because, a fatty live affects 20% of the population. It affects every diabetic. And I mean, just about every diabetic will have fatty liver.
Nathan: It’s what we call an insulin resistance problem. And for most people with fatty liver, the major significance of it is that they have an increased risk compared to the average person developing diabetes. But beyond that, approximately 5-10% of people with fatty liver do develop liver disease. It’s called nonalcoholic steatohepatitis, or NASH.
Diet treatments are very important for trying to reduce the risk of disease progression in people with fatty liver disease. Predominantly, calorie restriction on weight loss, which is by far the most important factor. There were lots of trials being done on medications at the moment to treat fatty liver.
But in the end, the only proven therapy forward is weight loss. It’s an insignificant amounts of weight loss. It’s proven that if a patient loses a significant amount of their excess weight, that their liver disease doesn’t progress, and indeed. It actually regresses.
So, you can have quite a large degree of scarring and it can actually get better if you lose your excess weight. That overall is about calorie reduction. There might be some added benefit to maybe eating more protein, maybe over carbohydrates and fat, although that’s still a bit controversial.
Generally, we just advise people calorie restriction, and course alcohol striction as well. But beyond that, and just the usual general advice, and eating lots of fruit and vegetables and, lean meats, and avoiding processed food, takeaway food, excessive amounts of salt.
Generally, the advice is fairly generic in that it’s advice you give to anyone to live healthily. Calorie reduction is vital for fatty liver.
Nick: I guess we can make it like an educated guess that if someone’s overweight or obese and, they’ve been that way for a significant number of years, it’s likely they have a fatty liver.
Nick: Are there cases where people look healthy, they have good health, they’re at a reasonable weight, but they may have a fatty liver for some dietary reason they haven’t discovered or they don’t know about?
Nathan: You do see fatty liver in people with a normal body weight. Of course, it’s mostly suspected in people who are overweight, but approximately 5%, maybe a fatty liver patients have a body mass index less than 25. Body mass index is a way of relating weight to height. So, yeah. There are what we call skinny fatty liver patients, and they often often have a family history of type two diabetes. So, it’s a genetic thing, it’s predominant.
Sometimes, they have other conditions and other medications that predispose into fatty liver. But just because you have a normal body mass index, it doesn’t mean that you are completely immune from getting fatty liver disease.
The other thing to say, Nick, is if you’re told you have fatty liver because you have abnormal liver test in an ultrasound, which show fat, which is usually have diagnosed, that fat can also be seen in a number of other liver conditions.
For example, Hepatitis C, a virus that affects the liver commonly causes a fatty liver on ultrasound. There are a couple of other liver diseases that do the same. Also, to mention that alcohol does the same thing.
So, to tell the difference in a person between their alcoholic fatty liver disease and nonalcoholic fatty liver disease is all a matter just of questioning the patient. So, just because you’ve got fat doesn’t mean it’s just nonalcoholic fatty liver disease.
Medication and the Liver
Nick: Okay. Alright. So we’ve touched on alcohol and on diet. What about medication? If you’re taking antibiotics or other medication, that’s obviously going to affect the liver too.
Nathan: So, drugs in the liver is a fascinating area. The vast majority of drugs that cause liver tests to be abnormal probably are pretty harmless. They’re doing what’s called enzyme induction. So, lots of drugs make the liver make enzymes. A lot of antiepileptic drugs do that. Some of the cholesterol pills do that. Alcohol does that.
So ,there’s lots of medications that make the liver tests go up, but there are also some medications that can cause severe liver damage; mostly acute, meaning that it all happens suddenly. There’s a number of antibiotics out there that can cause that.
We see that commonly. People rarely die from it. I haven’t, I’ve seen cases but, I was involved with the transplant unit. So, you kind of do see those cases; but generally, most people recover from a drug induced liver injury. But, some drugs can also cause chronic liver damage as well.
So, that has to be taken into account when having patients on these medications. It’s quite a specialized area. It’s certainly worthwhile; if you’re worried about your medications and your liver talking to, initially a local doctor or maybe a specialist about whether the medications you take might be affecting your liver.
Nick: Okay. I know a lot of people do Google things like, when I did my research for this podcast, you’ll see things like liver cleanse or kombucha. So, can people treat unhealthy liver or a scarred limit with kombucha or can they do a liver cleanse?
Is that sort of just nonsense?
Nathan: I’m very careful, Nick, with this topic, not to use the word ‘nonsense.’
Nathan: I would rather use the word ‘unproven.’
Nathan: Yeah. Has been some alternative/herbal/naturopathic, whichever way you want to use them. Preparations that had been tested in treating liver diseases. For example, they are in China; there’s a number of herbal preparations. If they’ve actually tested to see whether they work, they don’t seem to, based on the studies they’ve done. Neither did that cause harm.
All the other things, I think a lot of it, because it’s untestable, you can get away with saying a lot of things about it and you can’t disprove it. Therefore, they hide behind that and say they were of benefit. So, I’d say unproven is a kind word to use.
But, do I think they work? No, I don’t.
Nick: Alright. I think the general idea, I now believe, that the liver, you either have a healthy one or an unhealthy one. It’s going to be pretty hard to live with an unhealthy liver.
Nathan: Not really. I mean the liver, you talk about the natural age of organs, like how old you have to get for your heart gives out, and your kidneys give out, and you brain gives out. The liver is actually quite robust.
It does quite well with acute injury, it recovers nearly always, unless you really, really push it too far. Even with degrees of scarring and fibrosis, if you stop the injury, whether it be alcohol or a virus, or fat or whatever is injuring the liver, it will generally bounce back.
The other point is, is that most people, as I said previously, don’t know that they’ve got a problem with the liver. Therefore, it’s all just a case of not being picked up quick enough. So, I think it’s more accurate to say that most people do have a healthy liver.
Most people who have an unhealthy liver, if they attend to their unhealthy liver, they will get better. That’s not like kidney disease, where if you push the kidneys a little bit too far, they will gradually deteriorate, regardless of what you do.
To some degree, the heart, it’s similar liver. The liver tends to be a little bit more tolerance of being abused to some degree.
Nick: I see.
Nathan: Whatever that process might be. So, it’s never too late. What people really need to know, I guess, is whether they got a problem with the liver at all, and that isn’t as easy as it sounds to know that.
Nick: Now that you’ve said that, there’s talk about liver testing. So, I think there are four ways to test that. The liver, obviously, can get a blood test. You could do an ultrasound, do a FIBROSCAN®, or a needle biopsy.
Nathan: It’s a pretty good way of putting it there. The main tests we do.
Nick: Okay. So, let’s discuss each of those and maybe the accuracy of each, or what they reveal.
Liver Fuction Test
Nathan: Yes. Starting with liver tests. The liver function tests are interesting. They’re not really tests of liver function. They’re actually tests of liver enzymes, and that’s different.
So, the test of liver function or actually things like the aluminum level in your blood, the bilirubin level, which is a toxin, and the way your clotting works in your blood, they’re true liver tests.
The liver test that most people get done at their local doctor are actually liver enzyme tests. And all All they do is indicate whether there may be a liver disease or not. They’re very poor at telling us how bad the liver disease is.
They are prone to false negatives and positives, which means sometimes liver tests can be completely normal and there is a problem and sometimes a little bit test quite abnormal and there’s actually no problem at all. So they suffer a lot from accuracy problems. So, they’re only really an initial test and a screening tests, if you like.
Nick: So, this is a blood test you’re talking about?
Nathan: Yes, these are the liver enzyme tests of the liver. They’re commonly called liver function test, but that’s a misnomer.
Nathan: A very unfortunate one that we’re trying to get rid of. It’s just a blood test. It can be repeated several occasions, and often the trend of what they’re doing is more important than the absolute numbers.
The ultrasound has positives and negatives. The ultrasound is an imaging test of the liver, there’s no radiation involved. So, it’s very safe.
It will tell you if you have a very diseased liver. So if you have a liver which has got cirrhosis and has shrunken and irregular, it will tell you that. It will tell you if you have a fatty liver, most of the time if it’s significant. It will tell you whether, usually there’s any problem with the gallbladder or the bile ducts, which can cause liver disease as well.
So, it’s a very useful initial test. And I think anyone who has persistently abnormal liver function tests, should have an ultrasound as the next test. Most people would agree with that.
Nick: Well that’s what happened to myself, which we might discuss after you explain each test as a case study. Okay. So, normally you’d probably get a blood test and if there are elevated results, and your GP saying, “Okay, the next step is to get an ultrasound.” Then, if that doesn’t reveal anything, but you still have concern or there’s still evidence to say there’s something wrong with the liver.
I guess the next step could be a needle biopsy or a FIBROSCAN®?
Nathan: It’d be fast for both of those. Basically, the next thing one would do- So, first of all, the first thing to say is, you’d have a one-off, which is normal. Don’t panic, get another test a month or two later and see what it’s doing.
That’s the first point because often it’s transient; so, lots of viruses in it will give you a transitly abnormal liver function test.
Nathan: So, what we do is repeat them in a month or two. The ultrasound I would usually combined with a whole bunch of blood tests to look for the reason why the liver tests are abnormal. So, a number of liver diseases give you a specific blood test markers.
For example, Hepatitis C and Hepatitis B, you can do a blood test for them. You can do a blood test for iron overload, which is another cause of abnormal liver function tests.
So, that will be combined with the ultrasound. If your ultrasound was normal and your blood tests didn’t reveal a cause for your liver, the test being abnormal, and you still didn’t know what’s going on, and the liver tests were getting worse, then yes. You would want to do another test to both either diagnosed the cause of liver function test abnormality, or at least to tell you how bad it is in terms of scarring.
A liver biopsy is definitely an option. It is commonly used in people who are very worried about their liver. The problem with the liver biopsies is, it’s invasive. You have to stick a needle in your liver, you have often have some sedation for it. It can be painful.
There can be complications such as bleeding. Now, that’s not to say if your doctor says you should have one, you shouldn’t have one because you almost certainly need one.
It just means that there’s a useful to have other options available when trying to assess how bad the liver disease is. That’s where FIBROSCAN® comes in.
So, a FIBROSCAN® is a relatively new test, has been around for about 10 years, and the FIBROSCAN® uses ultrasound waves, which will bounce through the liver to test how stiff the liver is. So, the stiffer the liver, the more scarring there is. We come up with what’s called the liver stiffness score.
That correlates with most liver diseases to a degree of scarring or fibrosis. That’s a good aid to diagnosis because of the person that has fairly, mildly abnormal liver test and you don’t know why, but they’re FIBROSCAN® score is low, then you can afford to take a wait and see approach.
Maybe assess a bit more carefully for fatty liver, advise them to lose weight and to do some exercise, and hope or liver function tests down.
If, however, the FIBROSCAN® score is very bad, then that is a patient you could recommend these as a biopsy or some other further evaluation. So, the FIBROSCAN®’s very good at what’s called stratifying patients risk.
So, low FIBROSCAN® score, you can take a relaxed approach. High FIBROSCAN® score, you need to be a little bit more concerned. That’s particularly important with common liver diseases like fatty liver; because, Nick, fatty liver affects 20% of the population.
You can’t biopsy them all to figure out which of the hundreds of thousands of people in Australia with fatty liver have bad liver disease, and which ones have fairly mild liver disease; because most of them, actually, are going to be alright.
It’s not only a relatively small percentage, 5-10%; they might run into trouble. So, it’s important to try and find those cases and to concentrate your efforts at weight loss and other therapies on that group.
Nick: I understand. With these tests, as you know, towards the end of, I think the middle of last year, I just went and had some blood work done just to check up on my health. I came back with all these elevated levels for ALT, and AST, and ALP, and GGT. I really still don’t understand all that, but my GP couldn’t really explain anything other than “Okay, they’re high and it means it could be something wrong with your liver.”
And then, he recommended that I take an ultrasound and that didn’t really reveal anything. Like, it sort of revealed there’s nothing wrong with your liver; but then I decided to take a FIBROSCAN® with you guys. So, I sort of have one question.
Could you skip the ultrasound? Because, what I understand is, the FIBROSCAN® seems to be a more advanced version than an ultrasound, and it goes deeper and, provides sort of better data. Does that make sense?
Nathan: It does, it does. The only issue, I guess, your particular liver test abnormalities, what we call a mixed liver test abnormality. Looking at your liver tests that you tell me, basically the ALT and the AST, tests that measure liver cell damage themselves. The other two, the alkaline phosphatase and the gamma GT, or gamma-glutamyl transferase, generally our enzymes involved with the bile ducts.
They look for what’s called, cholestatic liver disease. So, disease that affects the bile ducts and the liver. When both are elevated, either problem could be going on, or both.
Therefore, sometimes the FibroScan can give you a lot more information than the ultrasound does, but it doesn’t give you one piece of information, which is sometimes important, which is are the bile ducts and the gallbladder normal?
So, that’s why they kind of go together. But, a FibroScan- if you know, for example, you’ve got a fatty liver, the FIBROSCAN® will actually tell you whether you have any scouring or not.
Nathan: Whereas, the ultrasound won’t, not unless you’ve got very, very, very severe scarring or cirrhosis. So, you’re true, yet you sort of right in one way and not right in the other.
Nick: Okay. Let’s say someone doesn’t like their blood being taken or, they’re only concerned about their liver. Let’s say I think they’re healthy in general, and I know they drink a lot. Can they just take a liver, a FibroScan?
Nathan: Yeah. Snapshot FibroScan, at a point in time, is a pretty good test for exclusion of significant liver disease. So, if you drink too much or you have a fatty liver, or you have whatever the cause of your liver problem is, and you have a FirboScan, which suggests that your scarring level is normal, then a FibroScan is very reassuring.
That doesn’t mean you should go off and drink more. Alcohol can affect other organs and it’s not good for you. So don’t get me wrong, but if you’re specifically worried about “Is my liver scarred, is my liver damaged?” A FibroScan is a pretty good test for reassuring the patient that it’s not that. That is absolutely true.
Nick: Okay. And how often would you recommend someone get a liver scan?
Nathan: It depends on what their result is, Nick. If they have a very, very normal score and I have no reason to have ongoing liver damage, you might just do one. If on the other hand, they have ongoing risk, like a fatty liver, or the use of certain drugs, which we know affect liver function, then we might do them every two or three years.
For example, there’s a drug called- as an example if I can use, there’s a drug called methotrexate, which is commonly used in rheumatology to treat rheumatoid arthritis and those kinds of conditions. We commonly do FirbroScans every two or three years in patients from methotrexate to see whether it’s safe for them to continue taking the medication.
Nathan: So, that’s a situation where serial FibroScans can be useful in preventing the patients in the liver biopsies because it used to be, that it was protocol; these patients had a biopsy every five years. Patients don’t want to have-
You can get patients to have one liver biopsy, but getting them to have more than one is difficult because they’re not very enjoyable. Basically, it can be repeated.
For someone with fatty liver, we often will say, depending on their score. If they had a borderline score of like an 8 or a 10, we might say, “Come back in three years and have one.” If they’ve got a score of 5 or 6, we might say, “5 years,” that kind of thing, depending on the form of liver disease and how bad their initial score is.
Nick: I understand. Okay. Well we’ve been going for almost half an hour, so let’s maybe wrap things up. So, I think we’ve established that the liver is, obviously, it’s an amazing and vital organ. We probably don’t appreciate it and treat it with the care that we should.
And so, we need to factor in what we eat and perhaps our level of health or how much we weigh. And if we are overweight, we probably want to think about reducing our calories, and obviously eat a healthy diet.
If we are drinking, we really want to monitor out drinking and maybe cut back. And if we have some concerns about if we’ve damaged our liver, let’s say due to alcohol, or if we think we have a fatty liver, be worthwhile getting a FIBROSCAN®.
Nathan: Yeah, just a little point. There are FibroScan machine test available. We have one here in Moonee Valley Specialist Centre. It’s a point of care test, Nick.
Patients can walk in, we’ll do the FibroScan. Only thing they need to do is fast. And, we’ll give them an answer on the day, as well as an explanation. A basic explanation and what it all means.
Nick: Yes. And since you know I went through one. So, into it, it was just peace of mind because I was pretty sure there wasn’t anything wrong; but at the same time when you have a blood test and you see all these elevated levels, then you thinking, “Ah, I think I had these elevated levels eight years ago and I’m not sure why.”
Nathan: Are they still on that level?
Nick: No. I dropped down a little on the blood test I had after that. But, I’m probably due for another test..
Nathan: Some people, the reasons we don’t understand, and I’ve seen this a lot of times, will have a very quite abnormal liver test and no cause. Of course, eventually, a lot of them do end up having a biopsy, even with a relatively benign FibroScan.
Just because we just don’t want to miss anything, and if you’re running ALT and IST is 200 or 300, and it’s quite odd and you don’t know why. There’s no fat and there’s no drugs involved, and the screens are negative, when you biopsy people with that, often you don’t find much.
So, there are some people who have quite abnormal liver tests, but no apparent reason. And it’s a benign process. You do see that from time to time. So, just because the doctor in the end, even when the biopsy can’t work out why the liver tests are abnormal, it doesn’t necessarily mean that you have a massive problem.
Nick: I understand, but it’s obviously it’s worth the peace of mind of getting your liver checked.
Nick: And making sure that at least there’s no scarring.
Nathan: That’s the people who have all the tests done. I’m not talking about your average person who just walks into the GP, does a test and they’re abnormal. Most people like that will have a problem.
Nick: Yeah. Okay. Which was my case. They were sort of triple, sort of a standard rating. So there’s a bit of a concern. But, that was worthwhile for me getting the test. It sort of gave me some peace of mind and I knew there was nothing sort of really wrong.
Then I think that the following blood test levels had come down significantly. I think we discussed a few things when we were doing the test. I think it was one of those things where I was pretty stressed at the time where I took the first blood test, and maybe that was the problem.
I was probably thinking, “Oh man, I’m really stressed. I should go and get my health checked.” Which might’ve had some, I mean I have no idea if that influences blood work, but, yeah. I’m certainly glad I came in. I had the test and sort of view. “Okay. Yeah. I don’t have a scarred liver.”
Nathan: Yeah. It’s certainly true that people worry a lot when that first test comes back abnormal. So, the FibroScan is good in providing that reassurance that you’re not developing scarring of the liver; because, that’s what it’s all about in the end, in terms of your liver.
Nick: I agree. All right. Well let’s wrap up this podcast. Thank you very much for your time, Nathan.
Nathan: Thanks, Nick.
Nick: This episode was brought to you by the Moonee Valley and Specialist Centre and LiverScan Australia. To learn more about the liver FibroScan or to make a booking, please visit liverscanaustralia.com.au.
Moonee Valley Specialist Centre is Victoria’s only private LiverScan facility. There is no waiting list and no referral required. Go to liverscanaustralia.com.au to book your liver scan.