You Can’t Live without Your LIVEr Podcast Transcript
Original Air Date: June 20, 2022
Dr. Michael Koren and Dr. Bharat Misra
Introduction: Welcome to the MedEvidence podcast, hosted by Dr. Michael Koren and Michelle McCormick. MedEvidence, where we help you navigate the real truth behind medical research with both a clinical and research perspective. In this podcast, we'll have discussions with physicians that have extensive experience in patient care and research. How do you know that something works in medicine? We conduct clinical trials to see if things work. Now let's get the truth behind the data. Welcome to MedEvidence, powered by ENCORE Research Group. Go to Encoredocs.com.
Dr. Koren: Good afternoon. My name is Dr. Michael Koren, and I'll be the host today, as well as a participant in our Med Evidence Hour. I am so delighted to have my good buddy, my research colleague, and the best gastroenterologist in town, sitting side by side, Dr. Bharat Misra. He's just a tremendous resource for our town, and he's been growing this beard that makes him look like a guru that I would meet on top of the mountain. So I think his words will be really insightful today. Bharat is a good friend and we're going to have some fun over the course of the next hour talking about liver disease and fibroscanning. So, Bharat, maybe you can just kind of start us off by just giving us a real overview on what should people be worried about liver disease, what is cirrhosis? And tell us a little bit more about it from your perspective as a gastroenterologist.
Dr. Misra: Thank you, Mike, and I second the sentiment. I'm looking forward to a very engaging and hopefully informative session. So first, the liver is a very critical organ. You cannot live without your liver. And we have only one liver. And the other problem with liver disease is until it's very advanced, it does not cause any symptoms or signs. So typically by the time you have symptoms, it's already quite too late. You have advanced liver disease. And this is what makes liver disease very challenging. It used to be after the ’60 drug use, Hepatitis C was the big liver disease in the United States. Now Hepatitis C is waning, partly because drug use is down, we have better treatments, but now we are faced with another liver disease called fatty liver. Liver disease has always been around, and it's what causes liver damage and is increasing. So in the United States, increased deposition of fat, fatty liver alcohol, and Hepatitis C would be the top three liver diseases.
Dr. Koren: And just to clear the air on Hepatitis C, we have drugs that pretty much have eradicated that. Or how far along are we in getting rid of hepatitis C?
Dr. Misra: The treatment of Hepatitis C is a true miracle of modern medicine. And we at Borland Grover and ENCORE participated in some of the pivotal trials. Right now we have several oral medications taken for eight to twelve weeks which have cure rates approaching 98%.
Dr. Koren: Beautiful, with minimal side effects.
Dr. Misra: So theoretically, you could eradicate Hepatitis C in the world if everybody could afford the medications.
Dr. Koren: So researchers have solved Hepatitis C and now our focal point is on Fatty Liver as the next stage in terms of preventing end-stage liver disease.
Dr. Misra: That is correct. I think all hepatologists and researchers can pat themselves on the back, but we got to look to the future. There is another 800-pound gorilla in the room, which is Fatty Liver.
Dr. Koren: Terrific. So one of our focal points today is fibroscanning. And we find this very interesting piece of technology that most people have never heard of and there are some interesting reasons why people have never heard of it. But it's a technology that we have used extensively in the research environment and we're fascinated by the fact that it has not spread into clinical practice very well and that this technology that is in the research environment is something that may be more people should be able to access. So why don't we tell the audience a little bit more about what is fibroscanning and why we're having such a hard time getting into the general population.
Dr. Misra: Sure, I think that's a very important point. But before that, I want to tell people how do we diagnose liver disease in the first place? You don't have any symptoms and signs are very late. So typically you need some imaging of the liver. And traditionally we have used an ultrasound, which is a good test. And then we go on to more invasive tests like Cat scans and MRIs and even a liver biopsy. All these four imaging modalities are very commonly available. Unfortunately, they tell you that you have fat in the liver, but they don't tell you how bad it is. And for that, you need either a liver biopsy, which is very invasive or an MRI, which is very expensive. Well, it turns out that there is actually a very noninvasive simple, inexpensive test that has been around for decades and that's called a Fibroscan. It's similar to an ultrasound as far as doing it is concerned. And it tells you the two most important things you need to know how much fat you have, and how much scar tissue you have in the liver. And with these two pieces of information, any gastroenterologist hepatologist, or any physician interested in Fatty Liver can stage your disease and develop a treatment plan for you.
Dr. Koren: So for the audience standpoint, let's just explain that fiberscan is actually a trade name.
Dr. Misra: That is correct.
Dr. Koren: And the actual technology is called ultrasonic elastography.
Dr. Misra: That is correct. So basically they use sound waves to shake up the liver and see how much it moves, that's kind of layman's term of what FibroScan really is. And FibroScan is a brand and it's been around the longest in research and in clinical practice they have, we think, the best device.
Dr. Koren: The physicist to me is going to come out here for a second, so indulge me, please. But what it's really doing is looking at the speed of the ultrasound wave in different types of tissues. And in harder fibrosis tissue, it's going to move slower than a nice soft pliant tissue.
Dr. Misra: That is correct. That's actually the mechanism. And it came out of a PhD project, and the guy who wrote the project actually developed a company called Echo Sense in France, and it's become the most widely used instrument to measure fibrosis based on the principles we talked about.
Dr. Koren: And I guess it just also helps people understand. Unlike a standard ultrasound, you're not creating a picture of a tumor or bioducts per se, but you're really just looking at tissue characterization. So a FibroScan does not replace a standard ultrasound of the liver. Would that be correct?
Dr. Misra: Correct, Fibroscan is complementary to all these other tests that physically look at the shape of the liver. Fibroscan is a kind of one-trick horse, but it does that very well. So going back to the original question, why are there many more MRIs in Florida and in the United States than an inexpensive Fibroscan?
Dr. Koren: So, just for the audience, we looked this up right before the program and elucidate to the audience how many Fibroscans are in the entire state of Florida. Based on our current research?
Dr. Misra: I believe it's about 14 or 15.
Dr. Koren: And you have that many MRIs in your basement, don't you?
Dr. Misra: Yes, in Jacksonville. But it's one of the quirks of American medicine is that a test that costs upwards of $800 is widely prevalent. On the otherhand test that cost $50 is not available. And I think that boils down to how institutions and physicians are reimbursed. The reason we have only 14 Fibroscans and a gazillion MRIs is because of reimbursement. Doctors and staff who do this are not reimbursed adequately for buying the equipment, which is very expensive. So because of that, we tend to shy away from owning a Fibroscan.
Dr.Koren: Now, there's no downside to Fiberscanning? It's not like radiation or anything that can damage your liver or cause any complications, to your knowledge, is there?
Dr. Misra: No. Fibroscan is a very safe test. A safety profile is very similar to an ultrasound.
Dr. Koren: Right. So for cat scanning, for example, things that use radiation, there is some concern about overutilization of the technology for individual patients because of side effects that would not be the case at all for fiberscanning or ultrasound in general?
Dr. Misra: Yeah, I believe that is correct. I think an even more accurate comparison is there are only two other tests that tell you the information you get from a Fibroscan. One is an MRI of the liver, and the other is a liver biopsy. MRI is safe but very expensive. A liver biopsy is somewhat risky and very expensive. On the other hand, Fibroscan gives you very similar information at low risk and low cost.
Dr. Koren: Any comments about the accuracy of fiber scanning?
Dr. Misra: So in general, a liver biopsy is considered the gold standard. Looking at tissue under the microscope is almost difficult to replace. After that is an MRI. But a Fibroscan is a very close third for the amount of information it gives you. It is approaching the accuracy of an MRI, and that's why it's the study of choice in clinical trials.
Dr. Koren: Now, one of the important things about Fibroscanning for the technology to work is that the beam that's being used, the wave that's penetrating your liver, needs to go directly from your skin to pretty much touch the liver. And one of the concerns is, if people have other stuff in the way, can that interfere with the accuracy of the test?
Dr. Misra: Yes. So if you have a foreign body, like a pacemaker or a paint pump in the area, that would interfere. Another concern is that individuals are very overweight and have a significant amount of fat on their abdomen, which we call the orange distribution of fat, which makes the Fibroscan a little bit less reliable. So that is typically after a BMI of 35. That is a limitation to fiber.
Dr. Koren: And so from my understanding is that there is some technical expertise required. So, for example, if it's an obese patient, you may have to find the right window to get good information from the liver using fiberscanning.
Dr. Misra: That is correct. Then you have to go and look at other ways of reaching the liver. And most of the people who do this for us have done dozens of these exams. They're fully trained, and they can usually find a window.
Dr. Koren: Okay, so you convinced me fiberscanning is almost as good as mother's milk, almost less likely to cause Fatty Liver Disease than mother's milk, by the way. So the question is, who should get a Fibroscan? That's a question to be discussed in the next episode.
Michelle McCormick: I'm your host, Michelle McCormick, and we want to thank Dr. Michael Koren for his clinical and research perspective behind the science in this episode of MedEvidence! The Truth behind the Data.
