Advances in liver disease diagnosis and treatment

Endoscopic ultrasound is an increasingly important tool for both diagnosis and treatment of liver disease.

One of the few gastroenterologists focused on liver disease, Dr Corne Kruger, who practises at Mediclinic Durbanville, explains how endoscopic ultrasound and other medical advancements offer patients highly specialised expertise when they need it most.

Enhancing diagnosis and treatment with endoscopic ultrasound

Diagnosis and treatment of liver disease go hand in hand, explains Dr Kruger. “The first step is to make the correct diagnosis, so we can treat the patient properly with the right medication. So, when indicated, we often start with a liver biopsy.”

In the past, biopsies were performed percutaneously (through the skin), via the rib space. Now, in keeping with modern techniques, Dr Kruger uses an endoscopic ultrasound instead. “The endoscope looks like a gastroscope that we use to examine the stomach, but on the tip of the scope is an ultrasound,” he explains. “The ultrasound allows us to see through the tissue, so we can clearly visualise the liver and retrieve the sample.”

An added benefit for patients is that liver biopsy is less painful, and there’s a lower risk of bleeding. “Another advantage is that with a camera and ultrasound on the tip of the scope, we can assess complications of advanced liver disease,” Dr Kruger says. “It shows us how far the damage has progressed and whether we need to take further steps to protect the patient.”

The gastrointestinal link to the liver

“The liver is closely linked to gastroenterology,” explains Dr Kruger. “Diseases of the bile ducts can affect the liver and even lead to liver failure.” His focus on both the liver and the bile ducts ensures a more holistic approach to patient care.

An endoscopic ultrasound (EUS) is probably the best tool to visualise the pancreas and biliary tract, and biopsies can also be performed. Once we have the tissue, we can apply it to manage the patient appropriately with the correct medication.”

The endoscopic ultrasound is an effective intervention tool. For example, it can be used to place a stent at a cancer-related blockage. “So, it's becoming a very important tool for both diagnostic and therapeutic purposes in my field.”

In South Africa, Dr Kruger is one of the few doctors using this tool for advanced liver treatments. As a result, many doctors in the Mediclinic Durbanville area refer patients with liver problems to him.

Keeping up with treatment advances

“The progress with endoscopic ultrasound is amazing,” Dr Kruger says. “It just started with just working around the liver, bile ducts and pancreas, but the expansion has made it a very exciting field now.” To keep his international training and skills up to date in this rapidly evolving field, Dr Kruger attends the annual Florida Live EUS – the world’s leading event in endoscopic ultrasound.

The field is set to advance even further with emerging technology. For example, in patients with pancreatic cancer that causes gastric outlet obstruction, endoscopic ultrasound can create a bypass from the stomach to the small bowel – eliminating the need for surgery. “Surgery has a higher mortality rate, especially in a very sick patient, but if you can do it endoscopically, the patient has a much better outcome,” he adds.

Expanding treatment protocols

Aside from endoscopic ultrasound, there are constant developments in the treatment of various liver diseases. For example, Dr Kruger recently co-authored an article published in the New England Journal of Medicine. He formed part of an international study group investigating a new drug, elafibranor, for the treatment of primary biliary cholangitis (PBC) – a chronic autoimmune disease in which the body’s immune system attacks the small bile ducts in the liver.

Until now, only one primary drug has been available to treat PBC, sometimes combined with a second medication. However, some patients do not respond to this therapy, placing them at risk of progressing to cirrhosis and liver failure, Dr Kruger explains.

“The new drug that was examined as part of the international study group is more effective than the older drugs, and also comes with very few side-effects,” he says. Although the drug has already been approved by the FDA, it’s still in the early stages of rollout and not yet available in the United States. As a result, it will likely be a few more years before it becomes available in South Africa.

“While PBC is a rare disease, I see quite a few patients, and the treatment has always been limited, so this expands their options,” Dr Kruger explains. By collaborating with international colleagues and staying up to date with the latest advancements, Dr Kruger can offer patients at Mediclinic Durbanville the best possible treatment options.