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. An ounce of prevention is
worth a pound of cure
Henry de Bracton
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

3. Is life worth living? It all
depends on the liver
William James
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

4. Hepatic artery Hepatic vein
Liver cells
Bile duct
Portal vein

6. Liver cells Blood vessels
Text

7. 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 vessels
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

8. Liver injury
Spontaneous resolution Chronic liver disease
Acute virus hepatitis A,B,C Chronic hepatitis B,C
Acute drug injury Fatty liver
Acute 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

9. 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” supplements
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

10. “Slim-10” and liver failure

11. Health supplements: side effects
Adverse events associated
with health supplements
Palmer et al, Lancet
2003;361:101

12. Health supplements: liver side effects
2% is not a negligible problem
Adverse events associated
with health supplements
Palmer et al, Lancet
2003;361:101

13. Liver injury Prevention
Prevention
Alcohol: avoid
Limit to 40 g alcohol a day for males
Maintain healthy BMI:
weight/height2 <23
Healthy diet and exercise
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

14. Hepatitis B follow up
Hepatitis B
Liver function (SGPT)
HBe antigen
AFP
HBV DNA Aim
Ultrasound liver To identify silent inflammation that is
Liver biopsy in selected cases the window of opportunity for
Endoscopy in selected cases to treatment
diagnose and treat varices
To screen for liver cancer at an early
Every 4-6 months stage, especially with cirrhosis
ALT
AFP
Ultrasound scan
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

15. Normal Varices

16. Bleeding from esophageal varices
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

17. Ultrasound scan showing cancer
Diagnose cancer early, as small as possible

18. Hepatitis B: risk of liver cancer

19. Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

20. Radio-Frequency Ablation
RFA
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

21. Trans-arterial chemo-embolization TACE
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

22. 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 scan
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

23. Hepatitis B: Treatment
Currently, there is no ideal treatment, so treatment
is advised for patients who fulfill certain criteria
and in whom benefits outweigh the risks
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

24. Phases of chronic hepatitis B

25. Hepatitis B treatment: considerations
Virus Liver Patient
HBe Ag/Ab ALT Cost
HBV DNA Cirrhosis Compliance
Mutations Varices Coexistent medical problems
Cancer Pregnancy plans
Tolerance to side effects
Preference
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

26. 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/mL
American Association for Study of Liver Diseases (AASLD)
European Association for the Study of Liver (EASL)
Asia Pacific Association for the Study of Liver (APASL)

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
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

28. 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

29. 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

30. 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

31. Hepatitis C treatment
Virus Liver Patient
Genotype ALT Cost
Viral load Cirrhosis Compliance
Varices Coexistent medical problems
Cancer Pregnancy plans
Medications Tolerance to side effects
Tablets Preference
ribavirin
Injections
PEG interferon
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

32. Fatty liver treatment
Patient habits
Healthy life-style habits
Exercise
Diet
Discipline & compliance
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

34. Excessive calories

35. Insufficient exercise

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37. Fatty liver treatment
Patient habits Coexisting medical problems
Healthy life-style habits Diabetes
Exercise Hypertension
Diet Cholesterol, triglycerides
Discipline & compliance Sleep apnea
Heart disease
Medications Bariatric surgery
Reductil Gastric bypass
Metformin Gastric “lap band”
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

38. 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

39. 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

40. 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

41. Take home messages
An ounce of prevention is
worth a pound of cure
Henry de Bracton
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health

42. Thank you for your attention
www.gastroliver.com.sg
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health