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Melanie Cole (Host): The liver disease program at Our Lady of Lourdes Medical Center is staffed by hepatologists, liver transplant surgeons and interventional radiologists who all work collaboratively in this comprehensive program. My guest today is Dr. Hisham ElGenaidi. He’s a liver disease specialist at Lourdes Health System. Welcome to the show, Dr. ElGenaidi. what conditions constitute liver disease? What are we talking about here?

Dr. Hisham ElGenaidi (Guest): What we’ve been hearing a lot about, lately, in liver disease is hepatitis C. So, we are getting a lot of information from the CDC regarding the importance of screening for hepatitis C, because now, more than ever, this is a curable disease. So, hepatitis C is definitely one of the most important diseases that we should screen for in the baby boomer population because 1 in 30 baby boomers actually has hepatitis C regardless of the risk factors that they reveal to you. And, the other liver disease which is probably even more common that hepatitis C that we don’t hear much about is fatty liver disease. Fatty liver disease is actually two types. You have the alcohol fatty liver disease which is brought on by people just consuming too much alcohol--and that would be about, for a male, more than 30 grams a day of alcohol, and for a woman about greater than 20 grams a day of alcohol. But, the other fatty liver disease which is the non-alcoholic fatty liver disease is really attributed more to what we call “metabolic syndrome”. So, it’s really anyone that’s overweight, that maybe has high cholesterol, has high blood pressure, diabetes or is at risk for diabetes. That’s probably the most common liver disease today in the United States. We’ve heard that diabetes is on the rise. Well, so is fatty liver disease and we think up to 30 million Americans actually have fatty liver disease and don’t know it. Some of them, they have what we call “steatohepatitis” which is actual scar tissue building up in the liver over time leading to liver cirrhosis. People get shocked when they hear liver cirrhosis because they think you have to be an alcoholic to get liver cirrhosis. But, you can get liver cirrhosis from non-alcohol fatty liver disease. So, all diabetics, people with high cholesterol, high blood pressure, really should be screened by their healthcare provider--just checking liver function tests and maybe even doing an ultrasound to look to see if there’s any fat on the liver. But, there are other types of liver diseases. Some of them are autoimmune related and usually people that have one autoimmune disease may have another so if they’re not sure, maybe someone with thyroid disease, for example, if they’re hypothyroid, they really should check liver donation tests on those patients as well. And, then there are genetic diseases like increased iron overload states like hemochromatosis. So, there are a variety of liver diseases much less common than the first two I talked about, which are the fatty liver and hepatitis C, but when someone comes to my office with elevated liver function tests, these are the kind of things I’ll screen for.

Melanie: Tell us about some of the different screening tests for liver function, and you mentioned screening for hepatitis C. So, speak about the screening and why would somebody even get screened for liver function or hepatitis C. You want baby boomers all tested for hepatitis C, correct?

Dr. ElGenaidi: That’s correct, yes. You want to--

Melanie: How do we get tested?

Dr. ElGenaidi: Yes, that test is just really looking at the hepatitis C antibody test, and it’s just really one test. If it comes up positive, then they have about an 85% risk that they actually have chronic hepatitis C and, therefore, chronic liver disease. So, elevated liver function tests kind of give away some of the reasons why you screen for anything; however, you can actually have absolutely normal liver enzymes and still have hepatitis C. So, it’s important that all baby boomers should be screened. Other people that should be screened as well should be anyone with a history of IV drug abuse, anyone with a history of snorting cocaine--it doesn’t have to be IV, just by sharing that straw, people can get transmission that way as well. This is the population--anyone who was transfused before 1992, had a transfusion of blood product also is at risk. People who had tattoos that were not professionally done in a tattoo parlor. So, for example, I've heard people having tattoo parties. So, they have a party, someone comes over using the same needle and the same ink and just basically tattooing anyone. People who’ve have had tattoos that were incarcerated. Sometimes they do tattooing during incarceration and, again, they’re passing along the infection one to the other. So, there are a variety of ways you can get hepatitis C and I think of all these questions should be asked when a patient presents. But, even, if they say “no” to all of this and they are in that population of baby boomers, you still should check for hepatitis C antibody.

Melanie: So, sticking with hepatitis C for a second, what are some treatments? If you have determined that somebody carries this virus, then what do you do for them, and is it a lifelong intervention that you have to do with them?

Dr. ElGenaidi: Fortunately, it’s not. Right now what we have is these direct-acting antivirals that work right on the replication process of the virus, and prevent its replication, and ultimately the virus is eradicated. The treatment duration can range from somewhere between 8 weeks to 24 weeks depending on the patient type, whether they have cirrhosis, non-cirrhosis, the medication you’re using. They’re covered by the insurance, and they also show us the cure rate of somewhere between 90% and, in some cases, up to 100%. So, it’s not a long duration, they’re very well tolerated in most cases and a high cure rate.

Melanie: And then, what about liver disease? When you’ve determined that someone has fatty liver disease or non-alcoholic fatty liver disease, then what are some of the latest treatments that you do for them? And, again, you mentioned lifestyle modifications and weight loss, diabetes management, that sort of thing. So, speak about the treatments and the interventions you would use and those lifestyle modifications you would like the patient to do.

Dr. ElGenaidi: So, as far as medications for fatty liver disease, they really don’t exist. There is no FDA approval for any medications right now in the market. There are studies going on about new medications that should be coming out soon but, for now, it’s now anecdotal information. There are some small trials but nothing that reached the Phase Three trial to allow the FDA to actually approve anything. So, lifestyle modification is the treatment of choice. It’s really what we have in our possession here. So, for example, if a patient is diabetic, we want him to lose weight, control their hemoglobin A1C to bring it down to a reasonable level working with their endocrinologist and primary care. So, it’s actually kind of a multidisciplinary approach to how this is managed. And, sometimes when patients are just too obese and they can't seem to be able to lose the weight with diet and exercise, we actually do refer them for possible bariatric surgery solution. Gastric sleeves have been performed on these patients and they do quite well where I see cholesterols coming down; blood sugars coming down. So, I work with our bariatric surgery department on some of these cases, which do quite well.

Melanie: If somebody does to some of those lifestyle modifications, can they--

Dr. ElGenaidi: Yes, yes.

Melanie: Reverse the liver disease or is this something that’s already the damage has been done and now they’re just not going to do further damage?

Dr. ElGenaidi: Well, there are no studies, actually, looking at what happens after you do get to a point where you reached your goal, in other words, an appropriate basal metabolic index and appropriate diabetes control and blood sugar. The only way we really measure it today is by just checking liver enzymes and seeing them improve to a normal state. That’s the best we have. Now, there are some other studies you can do. You can do liver biopsies; however, it’s pretty invasive to do that, and we’ve been moving away from liver biopsies more and more. We try to implement something called the FibroScan which is a new device that’s now FDA approved for use where it actually measures the thickness of the liver, and it can actually give you a score to tell you how much scar tissue is on the liver. But, there aren’t long-term studies that show that, “Hey, you know, we had a patient who had Stage 2 fibrosis, and after we reached our goal, we looked back and we saw an improvement in their histology.” That doesn’t exist but we assume, just by getting to that point, that there will be, not only stability but possibly even improvement because we see it in other liver disease states. For example, you can cure hepatitis C. We see that whatever scar tissue started out with, we see that the majority of patients, at least half the patients, will improve in their histology. We also see it in other disease states like hepatitis B but fatty liver disease has not undergone any long-term studies to prove that theory.

Melanie: And, in just the last few minutes, doctor, give us your best advice about liver disease, getting tested and screened for liver function and hepatitis C, what you really want the listeners to know and why they should come to Lourdes Health System for their care.

Dr. ElGenaidi: Well, like I said, it’s important if you have any of the risk factors that I discussed--there are definitely other diseases and there’s more risk factors that we can talk about--but you should talk to your primary care physician and discuss to see if they are possibly at risk for fatty liver disease or any other liver disease state, get screened by them. And, coming to us is--well, of course, I’m biased but I will say that we have a wonderful team of people. We have an endocrinologist and we have bariatric and we have great primary care physicians where we work together and try and reach to patients’ goals. So, it’s a multidisciplinary approach to our liver transplant. Same thing. I think no one has really come to our program and not loved the whole team, whether it’s the coordinator or the social worker or the surgeons. Again, we work really well together and we’re all about caring for the patient from A to Z.

Melanie: Well, thank you so much. It’s really been a pleasure to have you with us today. You're listening to Lourdes Health Talk. And for more information, you can go to www.lourdesnet.org. That's www.lourdesnet.org. This is Melanie Cole. Thanks so much for listening.