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Liver health: prevention and treatment

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Liver health: prevention and treatment

  1. 1. Yap Chin Kong Gastroenterology & Liver Clinic Liver health:Prevention & Treatment Dr Yap Chin Kong Consultant Gastroenterologist Hepatologist & Clinic Director MBBS, MMed, MRCP, FRCP @ Mount Elizabeth Medical Centre, Singapore www.gastroliver.com.sg
  2. 2. An ounce of prevention is worth a pound of cure Henry de BractonYap Chin Kong Gastroenterology & Liver ClinicFor Digestive, Colorectal, Liver & Pancreatic Health
  3. 3. Is life worth living? It alldepends on the liver William James Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
  4. 4. Hepatic artery Hepatic vein Liver cells Bile ductPortal vein
  5. 5. Liver cells Blood vessels Text
  6. 6. Liver disease may be caused by❖ Injury to the liver cell • viruses: hepatitis A, B, C, D, E, CMV, EBV • toxins (alcohol, poison mushroom) • fat (non-alcohol fatty liver disease) • auto-antibodies (auto-immune hepatitis)❖ Injury to the bile ducts❖ Injury to the liver blood vesselsYap Chin Kong Gastroenterology & Liver ClinicFor Digestive, Colorectal, Liver & Pancreatic Health
  7. 7. Liver injurySpontaneous resolution Chronic liver diseaseAcute virus hepatitis A,B,C Chronic hepatitis B,CAcute drug injury Fatty liverAcute EBV, CMV Alcohol Primary biliary cirrhosis Primary sclerosing cholangitis Acute liver failure Acute virus hepatitis A,B,C Acute drug injury Wilson’s disease Autoimmune hepatitis
  8. 8. Liver injury: Prevention Prevention Avoid hepatitis viruses Good water and food hygiene Sexual transmission: B Blood transmission: B & C Dirty needles, tattoo, dental: B & C Vaccination: A & B Drugs only when needed Tuberculosis, thyroid medication Avoid “health” supplementsYap Chin Kong Gastroenterology & Liver ClinicFor Digestive, Colorectal, Liver & Pancreatic Health
  9. 9. “Slim-10” and liver failure
  10. 10. Health supplements: side effects Adverse events associated with health supplements Palmer et al, Lancet 2003;361:101
  11. 11. Health supplements: liver side effects 2% is not a negligible problem Adverse events associated with health supplements Palmer et al, Lancet 2003;361:101
  12. 12. Liver injury Prevention Prevention Alcohol: avoid Limit to 40 g alcohol a day for males Maintain healthy BMI: weight/height2 <23 Healthy diet and exerciseYap Chin Kong Gastroenterology & Liver ClinicFor Digestive, Colorectal, Liver & Pancreatic Health
  13. 13. Hepatitis B follow upHepatitis BLiver function (SGPT)HBe antigenAFPHBV DNA AimUltrasound liver To identify silent inflammation that isLiver biopsy in selected cases the window of opportunity forEndoscopy in selected cases to treatmentdiagnose and treat varices To screen for liver cancer at an earlyEvery 4-6 months stage, especially with cirrhosisALTAFPUltrasound scan Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
  14. 14. Normal Varices
  15. 15. Bleeding from esophageal varicesYap Chin Kong Gastroenterology & Liver ClinicFor Digestive, Colorectal, Liver & Pancreatic Health
  16. 16. Ultrasound scan showing cancerDiagnose cancer early, as small as possible
  17. 17. Hepatitis B: risk of liver cancer
  18. 18. Yap Chin Kong Gastroenterology & Liver ClinicFor Digestive, Colorectal, Liver & Pancreatic Health
  19. 19. Radio-Frequency Ablation RFA Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
  20. 20. Trans-arterial chemo-embolization TACEYap Chin Kong Gastroenterology & Liver ClinicFor Digestive, Colorectal, Liver & Pancreatic Health
  21. 21. Hepatitis C follow up Hepatitis C ALT (SGPT) AFP HCV RNA Ultrasound liver Fibroscan Liver biopsy in selected cases Endoscopy in selected cases to diagnose and treat varices Every 4-6 months: ALT AFP Ultrasound scanYap Chin Kong Gastroenterology & Liver ClinicFor Digestive, Colorectal, Liver & Pancreatic Health
  22. 22. Hepatitis B: TreatmentCurrently, there is no ideal treatment, so treatmentis advised for patients who fulfill certain criteriaand in whom benefits outweigh the risks Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
  23. 23. Phases of chronic hepatitis B
  24. 24. Hepatitis B treatment: considerationsVirus Liver PatientHBe Ag/Ab ALT CostHBV DNA Cirrhosis ComplianceMutations Varices Coexistent medical problems Cancer Pregnancy plans Tolerance to side effects Preference Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
  25. 25. Simplified guideline No treatment Treatment? Treatment Inflammation ALT normal ALT normal ALT ↑↑ DNA not between 1,000 to DNA>10,000 HBV DNA detected 9,999 copies/mL copies/mLAmerican Association for Study of Liver Diseases (AASLD)European Association for the Study of Liver (EASL)Asia Pacific Association for the Study of Liver (APASL)
  26. 26. The perfect treatment ....❖ Easily administered e.g. tablet or injection❖ Eliminates the virus from the liver❖ Fixed duration of treatment❖ No side effects❖ Affordable Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
  27. 27. The perfect treatment ....❖ Easily administered e.g. tablet or injection❖ Eliminates the virus from the liver❖ Fixed duration of treatment❖ No side effects❖ Affordable .... is not yet available. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
  28. 28. The reality with tablets ...❖ Easily administered tablets available: lamivudine, adefovir, entecavir, telbivudine, clevudine, tenofovir❖ Suppresses but does not eliminate virus❖ Indefinite duration of treatment, for life perhaps❖ Virus mutation a potential problem❖ No side effects❖ Moderate cost Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
  29. 29. The reality with injections ...❖ Some inconvenience: once a week PEG-interferon, or 3 times a week interferon❖ Chance ≈ 30% to eliminate virus❖ Fixed duration of treatment 1 year❖ Virus mutation not a problem❖ Mild to moderate side effects❖ Expensive Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
  30. 30. Hepatitis C treatment Virus Liver Patient Genotype ALT Cost Viral load Cirrhosis Compliance Varices Coexistent medical problems Cancer Pregnancy plansMedications Tolerance to side effectsTablets Preference ribavirinInjections PEG interferon Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
  31. 31. Fatty liver treatment Patient habits Healthy life-style habits Exercise Diet Discipline & complianceYap Chin Kong Gastroenterology & Liver ClinicFor Digestive, Colorectal, Liver & Pancreatic Health
  32. 32. Excessive calories
  33. 33. Insufficient exercise
  34. 34. E 2 t - ! F6:i ; * i : ! i* E s ; 5 ;.5r9 a3 3 E. E F EE..:g ! ;gs 6E! E fe - :6F! i ts.- < Ef E i :!;: g >EG e j 1 !!^E J!95 6: # I E& gei E EE, s_i 9 -t uo i ,E r- =Er = E i ;iE fi:E BJ!E :: Y iE.q sieslc gE ts{ x P 6 :I*E H;g . rr{ a ct) -; s d €.8 3.t? E:-Es s; iB;; "E :?e* 5ii .Fl r-{ c) -E 9-3 E F o O JE =: fJ O F{ =g tsF =_rE ; As:u g6 ;E i J a a;{ Et ;--: o o s c =&e €EH u) 0u HHI E t ? *E Ei jFr F=+ ; r-B;. ;tr= ;it9 F F"EE .2, 11 ;5sE B a 5 E P.. S;d 503 l----r F{ n ; F:u. r . 8 i E.= ^t:ii -{ Fi :;F E €* E:g t i 9 9 > I 6 y ; E ic -EeHs :i* 3 6io- =Pi 6 E ; €Bz = 6 - fi ; t-33a iiP! EI"E ; E J*eE * E * =!*; =E: F d n
  35. 35. Fatty liver treatmentPatient habits Coexisting medical problemsHealthy life-style habits DiabetesExercise HypertensionDiet Cholesterol, triglyceridesDiscipline & compliance Sleep apnea Heart diseaseMedications Bariatric surgeryReductil Gastric bypassMetformin Gastric “lap band” Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
  36. 36. End-stage liver disease: what can we do?❖ Cirrhosis (child A, B, C) severity❖ No alcohol, traditional medicines, supplements❖ Vaccinate against hepatitis A❖ Treat underlying cause e.g. hepatitis B, C❖ Prevent bleeding by ligation of varices❖ Treat ascites, mental confusion (encephalopathy)❖ Be vigilant to infections, kidney problems❖ Anticipate liver transplantation Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
  37. 37. Take home messages❖ To prevent hepatitis A and B, effective vaccination is available❖ Avoid alcohol, traditional medicines, “health” supplements❖ Maintain a healthy body weight through diet and exercise❖ Screen for hepatitis B, C, liver function tests❖ Treat hepatitis B and C where appropriate Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
  38. 38. Take home messages❖ Diagnose and treat liver diseases early: primary biliary cirrhosis, autoimmune hepatitis, hemochromatosis, Wilson’s disease❖ Regular follow up to detect early liver cancer Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
  39. 39. Take home messagesAn ounce of prevention is worth a pound of cure Henry de BractonYap Chin Kong Gastroenterology & Liver ClinicFor Digestive, Colorectal, Liver & Pancreatic Health
  40. 40. Thank you for your attention www.gastroliver.com.sg Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health

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