Blood tests
Liver cancer is not diagnosed by routine blood tests, including a standard panel of liver tests. This is why the diagnosis of liver cancer depends so much on the vigilance of the physician screening with a tumor marker (alpha-fetoprotein) in the blood and radiological imaging studies. Since most patients with liver cancer have associated liver disease (cirrhosis), their liver blood tests may not be normal to begin with. If these blood tests become abnormal or worsen due to liver cancer, this usually signifies extensive cancerous involvement of the liver. At that time, any medical or surgical treatment would be too late.
Sometimes, however, other abnormal blood tests can indicate the presence of liver cancer. Remember that each cell type in the body contains the full complement of genetic information. What differentiates one cell type from another is the particular set of genes that are turned on or off in that cell. When cells become cancerous, certain of the cell's genes that were turned off may become turned on. Thus, in liver cancer, the cancerous liver cells may take on the characteristics of other types of cells. For example, liver cancer cells sometimes can produce hormones that are ordinarily produced in other body systems. These hormones then can cause certain abnormal blood tests, such as a high red blood count (erythrocytosis), low blood sugar (hypoglycemia) and high blood calcium (hypercalcemia).
Another abnormal blood test, high serum cholesterol (hypercholesterolemia), is seen in up to 10% of patients from Africa with liver cancer. The high cholesterol occurs because the liver cancer cells are not able to turn off (inhibit) their production of cholesterol. (Normal cells are able to turn off their production of cholesterol.)
There is no reliable or accurate screening blood test for liver cancer. The most widely used biochemical blood test is alpha-fetoprotein (AFP), which is a protein normally made by the immature liver cells in the fetus. At birth, infants have relatively high levels of AFP, which fall to normal adult levels by the first year of life. Also, pregnant women carrying babies with neural tube defects may have high levels of AFP. (A neural tube defect is an abnormal fetal brain or spinal cord that is caused by folic acid deficiency during pregnancy.)
In adults, high blood levels (over 500 nanograms/milliliter) of AFP are seen in only three situations:
• Liver cancer
• Germ cell tumors (cancer of the testes and ovaries)
• Metastatic cancer in the liver (originating in other organs)
Several assays (tests) for measuring AFP are available. Generally, normal levels of AFP are below 10 ng/ml. Moderate levels of AFP (even almost up to 500 ng/ml) can be seen in patients with chronic hepatitis. Moreover, many patients with various types of acute and chronic liver diseases without documentable liver cancer can have mild or even moderate elevations of AFP.
The sensitivity of AFP for liver cancer is about 60%. In other words, an elevated AFP blood test is seen in about 60% of liver cancer patients. That leaves 40% of patients with liver cancer who have normal AFP levels. Therefore, a normal AFP does not exclude liver cancer. Also, as noted above, an abnormal AFP does not mean that a patient has liver cancer. It is important to note, however, that patients with cirrhosis and an abnormal AFP, despite having no documentable liver cancer, still are at very high risk of developing liver cancer. Thus, any patient with cirrhosis and an elevated AFP, particularly with steadily rising blood levels, will either most likely develop liver cancer or actually already have an undiscovered liver cancer.
An AFP greater than 500 ng/ml is very suggestive of liver cancer. In fact, the blood level of AFP loosely relates to (correlates with) the size of the liver cancer. Finally, in patients with liver cancer and abnormal AFP levels, the AFP may be used as a marker of response to treatment. For example, an elevated AFP is expected to fall to normal in a patient whose liver cancer is successfully removed surgically (resected).
There are a number of other liver cancer tumor markers that currently are research tools and not generally available. These include des-gamma-carboxyprothrombin (DCP), a variant of the gamma-glutamyltransferase enzymes, and variants of other enzymes (for example, alpha-L-fucosidase), which are produced by normal liver cells. (Enzymes are proteins that speed up biochemical reactions.) Potentially, these blood tests, used in conjunction with AFP, could be very helpful in diagnosing more cases of liver cancer than with AFP alone.
Imaging studies
Imaging studies play a very important role in the diagnosis of liver cancer. A good study can provide information as to the size of the tumor, the number of tumors, and whether the tumor has involved major blood vessels locally or spread outside of the liver. There are several types of studies, each having its merits and disadvantages. In practice, several studies combined often complement each other. On the other hand, a plain X-ray is not very helpful, and therefore, is not routinely done in the diagnostic work-up of liver cancer. Further, there is no practical role for nuclear medicine scans of the liver and spleen in the work-up for liver cancer. Such scans are not very sensitive and they provide no additional information beyond that provided by the other (ultrasound, CT, and MRI) scans.
Ultrasound examination is usually the first study ordered if liver cancer is suspected in a patient. The accuracy of an ultrasound depends very much on the technician and radiologist who perform the study (operator dependent). Studies from Japan and Taiwan report that ultrasound is the most sensitive imaging study for diagnosing and characterizing liver cancer. But you should know that in these studies, highly experienced individuals performed the scans and spent up to one hour scanning each patient suspected of having liver cancer. An ultrasound has the advantages of not requiring intravenous contrast material and not involving radiation. Moreover, the price of an ultrasound is quite low as compared to the other types of scans.
Computerized axial tomography (CT scan) is a very common study used in the U.S. for the work-up of tumors in the liver. The ideal CT study is a multi-phase, spiral CT scan using oral and intravenous contrast material. Pictures are taken in three phases:
• Without intravenous contrast
• With intravenous contrast (enhanced imaging) that highlights the arterial system (arterial phase)
• When the contrast is in the venous phase
The pictures are taken at very frequent intervals (thin slices) as the body is moved through the CT scanner. Many radiologists use a specific protocol that determines how the contrast is infused in relation to how the pictures are taken. Therefore, CT is much less operator-dependent than is ultrasound. However, CT is considerably more expensive. Furthermore, CT requires the use of contrast material, which has the potential risks of an allergic reaction and adverse effects on kidney function.
There are several variations to CT scanning. For example, in a CT angiogram, which is a highly invasive (enters a part of the body) study, intravenous contrast is selectively infused through the hepatic artery (artery to the liver). The purpose is to highlight the vessels for better visualization of them by the CT scan. Also, in Japan, an oily contrast material called lipiodol, which is selectively taken up by liver cancer cells, has been used with CT. The purpose of this approach is to improve the sensitivity of the scan. That is to say, the goal is to increase the percentage of abnormal CT scans in patients who have liver cancer.
Magnetic resonance imaging (MRI) can provide very clear images of the body. Its advantage over CT is that MRI can provide sectional views of the body in different planes. The technology has evolved to the point that the newer MRIs can actually reconstruct images of the biliary tree (bile ducts and gallbladder) and of the arteries and veins of the liver. (The biliary tree transports bile from the liver to the duodenum, the first part of the intestine.) MRI studies can be made even more sensitive by using intravenous contrast material (for example, gadolinium).
MRI scans are very expensive and there is tremendous variability in the quality of the images. The quality depends on the age of the machine and the ability of the patients to hold their breath for up to 15 to 20 seconds at a time. Furthermore, many patients, because of claustrophobia, cannot tolerate being in the MRI scanner. However, the current open MRI scanners generally do not provide as high quality images as the closed scanners do.
Advances in ultrasound, CT, and MRI technology have almost eliminated the need for angiography. An angiography procedure involves inserting a catheter into the femoral artery (in the groin) through the aorta, and into the hepatic artery, the artery that supplies blood to the liver. Contrast material is then injected, and X-ray pictures of the arterial blood supply to the liver are taken. An angiogram of liver cancer shows a characteristic blush that is produced by newly formed abnormal small arteries that feed the tumor (neovascularization).
What, then, is the best imaging study for diagnosing liver cancer? There is no simple answer. Many factors need to be taken into consideration. For example, is the diagnosis of liver cancer known or is the scan being done for screening? What is the expertise of doctors in the patient's area? What is the quality of the different scanners at a particular facility? Are there economic considerations? Does the patient have any other conditions that need to be considered, such as claustrophobia or kidney impairment? Does the patient have any hardware, for example, a pacemaker or metal prosthetic device? (The hardware would make doing an MRI impossible.)
If you live in Japan or Taiwan and have access to a radiologist or hepatologist with expertise in ultrasound, then it may be as good as a CT scan. Ultrasound is also the most practical (easier and cheaper) for regular screening (surveillance). In North America, a multi-phase spiral CT scan is probably the most accurate type of scan. However, for patients with impaired renal function or who have access to a state-of-the-art MRI scanner, the MRI may be the diagnostic scan of choice. Finally, keep in mind that the technology of ultrasound, CT, and MRI is ever evolving with the development of better machines and the use of special contrast materials to further characterize the tumors.
Liver biopsy or aspiration
In theory, a definitive diagnosis of liver cancer is always based on microscopic (histological) confirmation. However, some liver cancers are well differentiated, which means they are made up of nearly fully developed, mature liver cells (hepatocytes). Therefore, these cancers can look very similar to non-cancerous liver tissue under a microscope. Moreover, not all pathologists are trained to recognize the subtle differences between well-differentiated liver cancer and normal liver tissue. Also, some pathologists can mistake liver cancer for adenocarcinoma in the liver. An adenocarcinoma is a different type of cancer, and, as previously mentioned, it originates from outside of the liver. Most importantly, a metastatic adenocarcinoma would be treated differently from a primary liver cancer (liver cancer). Therefore, all of this considered, it is important that an expert liver pathologist review the tissue slides of liver tumors in questionable situations.
Tissue can be sampled with a very thin needle. This technique is called fine needle aspiration. When a larger needle is used to obtain a core of tissue, the technique is called a biopsy. Generally, radiologists, using ultrasound or CT scans to guide the placement of the needle, perform the biopsies or fine needle aspirations. The most common risk of the aspiration or biopsy is bleeding, especially because liver cancer is a tumor that is very vascular (contains many blood vessels). Rarely, new foci (small areas) of tumor can be seeded (planted) from the tumor by the needle into the liver along the needle track.
The aspiration procedure is safer than a biopsy with less risk for bleeding. However, interpretation of the specimen obtained by aspiration is more difficult because often only a cluster of cells is available for evaluation. Thus, a fine needle aspiration requires a highly skilled pathologist. Moreover, a core of tissue obtained with a biopsy needle is more ideal for a definitive diagnosis because the architecture of the tissue is preserved. The point is that sometimes a precise diagnosis can be important clinically. For example, some studies have shown that the degree of differentiation of the tumor may predict the patient's outcome (prognosis). That is to say, the more differentiated (resembling normal liver cells) the tumor is, the better the prognosis.
All of that said, in many instances, there is probably no need for a tissue diagnosis by biopsy or aspiration. If a patient has a risk factor for liver cancer (for example, cirrhosis, chronic hepatitis B, or chronic hepatitis C) and a significantly elevated alpha-fetoprotein blood level, the doctor can be almost certain that the patient has liver cancer without doing a biopsy. The patient and physician should always ask two questions before deciding on doing a liver biopsy:
1. Is this tumor most likely an liver cancer?
2. Will the biopsy findings change the management of the patient?
If the answer to both questions is yes, then the biopsy should be done. Finally, there are two other situations related to liver cancer in which a biopsy may be considered. The first is to characterize a liver abnormality (for example, a possible tumor) seen by imaging in the absence of risk factors for liver cancer or elevated alpha-fetoprotein. The second is to determine the extent of disease when there are multiple areas of abnormalities (possibly tumors) seen by imaging in the liver.
Overall, no blanket recommendation can be given regarding the need for liver biopsy or aspiration. The decision has to be made on an individual basis, depending on the treatment options and the expertise of the medical and surgical teams.
Sunday, May 24, 2009
Symptoms and Signs of Liver Cancer
Symptoms
The initial symptoms (the clinical presentations) of liver cancer are variable. In countries where liver cancer is very common, the cancer generally is discovered at a very advanced stage of disease for several reasons. For one thing, areas where there is a high frequency of liver cancer are generally developing countries where access to healthcare is limited. For another, screening examinations for patients at risk for developing liver cancer are not available in these areas. In addition, patients from these regions actually have more aggressive liver cancer disease. In other words, the tumor usually reaches an advanced stage and causes symptoms more rapidly. In contrast, patients in areas of low liver cancer frequency tend to have liver cancer tumors that progress more slowly and, therefore, remain without symptoms longer.
Abdominal pain is the most common symptom of liver cancer and usually signifies a very large tumor or widespread involvement of the liver. Additionally, unexplained weight loss or unexplained fevers are warning signs of liver cancer in patients with cirrhosis. These symptoms are less common in individuals with liver cancer in the U.S. because these patients are usually diagnosed at an earlier stage. However, whenever the overall health of a patient with cirrhosis deteriorates, every effort should be made to look for liver cancer.
A very common initial presentation of liver cancer in a patient with compensated cirrhosis (no complications of liver disease) is the sudden onset of a complication. For example, the sudden appearance of ascites (abdominal fluid and swelling), jaundice (yellow color of the skin), or muscle wasting without causative (precipitating) factors (for example, alcohol consumption) suggests the possibility of liver cancer. What's more, the cancer can invade and block the portal vein (a large vein that brings blood to the liver from the intestine and spleen). When this happens, the blood will travel paths of less resistance, such as through esophageal veins. This causes increased pressure in these veins, which results in dilated (widened) veins called esophageal varices. The patient then is at risk for hemorrhage from the rupture of the varices into the gastrointestinal tract. Rarely, the cancer itself can rupture and bleed into the abdominal cavity, resulting in bloody ascites.
Signs
On physical examination, an enlarged, sometimes tender, liver is the most common finding. Liver cancers are very vascular (containing many blood vessels) tumors. Thus, increased amounts of blood feed into the hepatic artery (artery to the liver) and cause turbulent blood flow in the artery. The turbulence results in a distinct sound in the liver (hepatic bruit) that can be heard with a stethoscope in about one quarter to one half of patients with liver cancer. Any sign of advanced liver disease (for example, ascites, jaundice, or muscle wasting) means a poor prognosis. Rarely, a patient with liver cancer can become suddenly jaundiced when the tumor erodes into the bile duct. The jaundice occurs in this situation because both sloughing of the tumor into the duct and bleeding that clots in the duct can block the duct.
In advanced liver cancer, the tumor can spread locally to neighboring tissues or, through the blood vessels, to elsewhere in the body (distant metastasis). Locally, liver cancer can invade the veins that drain the liver (hepatic veins). The tumor can then block these veins, which results in congestion of the liver. The congestion occurs because the blocked veins cannot drain the blood out of the liver. (Normally, the blood in the hepatic veins leaving the liver flows through the inferior vena cava, which is the largest vein that drains into the heart.) In African patients, the tumor frequently blocks the inferior vena cava. Blockage of either the hepatic veins or the inferior vena cava results in a very swollen liver and massive formation of ascites. In some patients, as previously mentioned, the tumor can invade the portal vein and lead to the rupture of esophageal varices.
Regarding the distant metastases, liver cancer frequently spreads to the lungs, presumably by way of the blood stream. Usually, patients do not have symptoms from the lung metastases, which are diagnosed by radiologic (x-ray) studies. Rarely, in very advanced cases, liver cancer can spread to the bone or brain.
Risk factors for Liver Cancer
Hepatitis B infection
The role of hepatitis B virus (HBV) infection in causing liver cancer is well established. Several lines of evidence point to this strong association. As noted earlier, the frequency of liver cancer relates to (correlates with) the frequency of chronic hepatitis B virus infection. In addition, the patients with hepatitis B virus who are at greatest risk for liver cancer are men with hepatitis B virus cirrhosis (scarring of the liver) and a family history of liver cancer. Perhaps the most convincing evidence, however, comes from a prospective (looking forward in time) study done in the 1970's in Taiwan involving male government employees over the age of 40. In this study, the investigators found that the risk of developing liver cancer was 200 times higher among employees who had chronic hepatitis B virus as compared to employees without chronic hepatitis B virus!
Studies in animals also have provided evidence that hepatitis B virus can cause liver cancer. For example, we have learned that liver cancer develops in other mammals that are naturally infected with hepatitis B virus-related viruses. Finally, by infecting transgenic mice with certain parts of the hepatitis B virus, scientists caused liver cancer to develop in mice that do not usually develop liver cancer. (Transgenic mice are mice that have been injected with new or foreign genetic material.)
How does chronic hepatitis B virus cause liver cancer? In patients with both chronic hepatitis B virus and liver cancer, the genetic material of hepatitis B virus is frequently found to be part of the genetic material of the cancer cells. It is thought, therefore, that specific regions of the hepatitis B virus genome (genetic code) enter the genetic material of the liver cells. This hepatitis B virus genetic material may then disrupt the normal genetic material in the liver cells, thereby causing the liver cells to become cancerous.
The vast majority of liver cancer that is associated with chronic hepatitis B virus occurs in individuals who have been infected most of their lives. In areas where hepatitis B virus is not always present (endemic) in the community (for example, the U.S.), liver cancer is relatively uncommon. The reason for this is that most of the people with chronic hepatitis B virus in these areas acquired the infection as adults. However, liver cancer can develop in individuals who acquired chronic hepatitis B virus in adulthood if there are other risk factors, such as chronic alcohol use or co-infection with chronic hepatitis C virus infection.
Hepatitis C infection
Hepatitis C virus (HCV) infection is also associated with the development of liver cancer. In fact, in Japan, hepatitis C virus is present in up to 75% of cases of liver cancer. As with hepatitis B virus, the majority of hepatitis C virus patients with liver cancer have associated cirrhosis (liver scarring). In several retrospective-prospective studies (looking backward and forward in time) of the natural history of hepatitis C, the average time to develop liver cancer after exposure to hepatitis C virus was about 28 years. The liver cancer occurred about eight to 10 years after the development of cirrhosis in these patients with hepatitis C. Several prospective European studies report that the annual incidence (occurrence over time) of liver cancer in cirrhotic hepatitis C virus patients ranges from 1.4 to 2.5% per year.
In hepatitis C virus patients, the risk factors for developing liver cancer include the presence of cirrhosis, older age, male gender, elevated baseline alpha-fetoprotein level (a blood tumor marker), alcohol use, and co-infection with hepatitis B virus. Some earlier studies suggested that hepatitis C virus genotype 1b (a common genotype in the U.S.) may be a risk factor, but more recent studies do not support this finding.
The way in which hepatitis C virus causes liver cancer is not well understood. Unlike hepatitis B virus, the genetic material of hepatitis C virus is not inserted directly into the genetic material of the liver cells. It is known, however, that cirrhosis from any cause is a risk factor for the development of liver cancer. It has been argued, therefore, that hepatitis C virus, which causes cirrhosis of the liver, is an indirect cause of liver cancer.
On the other hand, there are some chronic hepatitis C virus infected individuals who have liver cancer without cirrhosis. So, it has been suggested that the core (central) protein of hepatitis C virus is the culprit in the development of liver cancer. The core protein itself (a part of the hepatitis C virus) is thought to impede the natural process of cell death or interfere with the function of a normal tumor suppressor (inhibitor) gene (the p53 gene). The result of these actions is that the liver cells go on living and reproducing without the normal restraints, which is what happens in cancer.
Alcohol
Cirrhosis caused by chronic alcohol consumption
It is the most common association of liver cancer in the developed world. Actually, we now understand that many of these cases are also infected with chronic hepatitis C virus. The usual setting is an individual with alcoholic cirrhosis who has stopped drinking for ten years, and then develops liver cancer. It is somewhat unusual for an actively drinking alcoholic to develop liver cancer. What happens is that when the drinking is stopped, the liver cells try to heal by regenerating (reproducing). It is during this active regeneration that a cancer-producing genetic change (mutation) can occur, which explains the occurrence of liver cancer after the drinking has been stopped.
Patients who are actively drinking are more likely to die from non-cancer related complications of alcoholic liver disease (for example, liver failure). Indeed, patients with alcoholic cirrhosis who die of liver cancer are about 10 years older than patients who die of non-cancer causes. Finally, as noted above, alcohol adds to the risk of developing liver cancer in patients with chronic hepatitis C virus or hepatitis B virus infections.
Aflatoxin B1
Aflatoxin B1 is the most potent liver cancer-forming chemical known. It is a product of a mold called Aspergillus flavus, which is found in food that has been stored in a hot and humid environment. This mold is found in such foods as peanuts, rice, soybeans, corn, and wheat. Aflatoxin B1 has been implicated in the development of liver cancer in Southern China and Sub-Saharan Africa. It is thought to cause cancer by producing changes (mutations) in the p53 gene. These mutations work by interfering with the gene's important tumor suppressing (inhibiting) functions.
Drugs, medications, and chemicals
There are no medications that cause liver cancer, but female hormones (estrogens) and protein-building (anabolic) steroids are associated with the development of hepatic adenomas. These are benign liver tumors that may have the potential to become malignant (cancerous). Thus, in some individuals, hepatic adenoma can evolve into cancer.
Certain chemicals are associated with other types of cancers found in the liver. For example, thorotrast, a previously used contrast agent for imaging, caused a cancer of the blood vessels in the liver called hepatic angiosarcoma. Also, vinyl chloride, a compound used in the plastics industry, can cause hepatic angiosarcomas that appear many years after the exposure.
Hemochromatosis
Liver cancer will develop in up to 30% of patients with hereditary hemochromatosis. Patients at the greatest risk are those who develop cirrhosis with their hemochromatosis. Unfortunately, once cirrhosis is established, effective removal of excess iron (the treatment for hemochromatosis) will not reduce the risk of developing liver cancer.
Cirrhosis
Individuals with most types of cirrhosis of the liver are at an increased risk of developing liver cancer. In addition to the conditions described above (hepatitis B, hepatitis C, alcohol, and hemochromatosis), alpha 1 anti-trypsin deficiency, a hereditary condition that can cause emphysema and cirrhosis, may lead to liver cancer. Liver cancer is also strongly associated with hereditary tyrosinemia, a childhood biochemical abnormality that results in early cirrhosis.
Certain causes of cirrhosis are less frequently associated with liver cancer than are other causes. For example, liver cancer is rarely seen with the cirrhosis in Wilson's disease (abnormal copper metabolism) or primary sclerosing cholangitis (chronic scarring and narrowing of the bile ducts). It used to be thought that liver cancer is rarely found in primary biliary cirrhosid (PBC) as well. Recent studies, however, show that the frequency of liver cancer in PBC is comparable to that in other forms of cirrhosis.
Monday, May 11, 2009
Surgical Treatment of Hepatocellular Carcinoma ( HCC )
The treatment options are dictated by the stage of liver cancer and the overall condition of the patient. The only proven cure for liver cancer is liver transplantation for a solitary, small (<3cm)>
Liver resection
The goal of liver resection is to completely remove the tumor and the appropriate surrounding liver tissue without leaving any tumor behind. This option is limited to patients with one or two small (3 cm or less) tumors and excellent liver function, ideally without associated cirrhosis. As a result of these strict guidelines, in practice, very few patients with liver cancer can undergo liver resection. The biggest concern about resection is that following the operation, the patient can develop liver failure. The liver failure can occur if the remaining portion of the liver is inadequate to provide the necessary support for life. Even in carefully selected patients, about 10% of them are expected to die shortly after surgery, usually as a result of liver failure.
When a portion of a normal liver is removed, the remaining liver can grow back (regenerate) to the original size within one to two weeks. A cirrhotic liver, however, cannot grow back. Therefore, before resection is performed for liver cancer, the non-tumor portion of the liver should be biopsied to determine whether there is associated cirrhosis.
For patients whose tumors are successfully resected, the five-year survival is about 30 to 40%. This means that 30 to 40 % of patients who actually undergo liver resection for liver cancer are expected to live five years. Many of these patients, however, will have a recurrence of liver cancer elsewhere in the liver. Moreover, it should be noted that the survival rate of untreated patients with similar sized tumors and similar liver function is probably comparable. Some studies from Europe and Japan have shown that survival rates with alcohol injection or radiofrequency ablation procedures are comparable to the survival rates of those patients who underwent resection. But again, the reader should be cautioned that there are no head-to-head comparisons of these procedures versus resection.
Liver transplantation
Liver transplantation has become an accepted treatment for patients with end-stage (advanced) liver disease of various types (for example, chronic hepatitis B and C, alcoholic cirrhosis, primary biliary cirrhosis, and sclerosing cholangitis). Survival rates for these patients without liver cancer are 90% at one year, 80% at three years, and 75% at five years. Moreover, liver transplantation is the best option for patients with tumors that are less than 5 cm in size who also have signs of liver failure. In fact, as one would expect, patients with small cancers (less than 3 cm) and no involvement of the blood vessels do very well. These patients have a less than 10% risk of recurrent liver cancer after transplant. On the other hand, there is a very high risk of recurrence in patients with tumors greater than 5 cm or with involvement of blood vessels. For these reasons, when patients are being evaluated for treatment of liver cancer, every effort should be made to characterize the tumor and look for signs of spread beyond the liver.
There is a severe shortage of organ donors in the U.S. Currently, there are about 18,000 patients on the waiting list for liver transplantation. About 4,000 donated cadaver livers (taken at the time of death) are available per year for patients with the highest priority. This priority goes to patients on the transplant waiting list who have the most severe liver failure. As a result, in many liver cancer patients, while they are on the waiting list, the tumor may become too large for the patient to benefit from liver transplantation. Doing palliative treatments, such as TACE, while the patient is on the waiting list for liver transplantation is currently being evaluated.
The use of a partial liver from a healthy, live donor may provide a few patients with liver cancer an opportunity to undergo liver transplantation before the tumor becomes too large. This innovation is a very exciting development in the field of liver transplantation.
As a precaution, doing a biopsy or aspiration of liver cancer should probably be avoided in patients considering liver transplantation. The reason to avoid needling the liver is that there is about a 1-4% risk of seeding (planting) cancer cells from the tumor by the needle into the liver along the needle track. You see, after liver transplantation, patients take powerful anti-rejection medications to prevent the patient's immune system from rejecting the new liver. However, the suppressed immune system can allow new foci (small areas) of cancer cells to multiply rapidly. These new foci of cancer cells would normally be kept at bay by the immune cells of an intact immune system.
In summary, liver resection should be reserved for patients with small tumors and normal liver function (no evidence of cirrhosis). Patients with multiple or large tumors should receive palliative therapy with intra-arterial chemotherapy or TACE, provided they do not have signs of severe liver failure. Patients with an early stage of cancer and signs of chronic liver disease should receive palliative treatment and undergo evaluation for liver transplantation.
Is there a role for routine screening for liver cancer?
It makes sense to screen for liver cancer just as we do for colon, cervical, breast, and prostate cancer. However, the difference is that there is, as yet, no cost-effective way of screening for liver cancer. Blood levels of alpha-fetoprotein are normal in up to 50% of patients with small liver cancer. Ultrasound scanning, which is non-invasive and very safe, is, as mentioned before, operator-dependent. Therefore, the effectiveness of a screening ultrasound that is done at a small facility can be very suspect.
Even more disappointing is the fact that no study outside of Asia has shown, on a large scale, that early detection of liver cancer saved lives. Why is that? It is because, as already noted, the treatment for liver cancer, except for liver transplantation, is not very effective. Also, keep in mind that patients found with small tumors on screening live longer than patients with larger tumors only because of what is called a "lead time bias." In other words, they seem to liver longer (the bias) only because the cancer was discovered earlier (the lead time), not because of any treatment given.
Nevertheless, strong arguments can be made for routine screening. For example, the discovery of an liver cancer in the early stages allows for the most options for treatment, including liver resection and liver transplantation. Therefore, all patients with cirrhosis, particularly cirrhosis caused by chronic hepatitis B or C, hemochromatosis, and alcohol, should be screened at six- to 12-month intervals with a blood alpha-fetoprotein and an imaging study. I favor alternating between an ultrasound and CT scan (or MRI). Patients with chronically (long duration) elevated alpha-fetoprotein levels warrant more frequent imaging since these patients are at even higher risk of developing liver cancer.
Liver resection
The goal of liver resection is to completely remove the tumor and the appropriate surrounding liver tissue without leaving any tumor behind. This option is limited to patients with one or two small (3 cm or less) tumors and excellent liver function, ideally without associated cirrhosis. As a result of these strict guidelines, in practice, very few patients with liver cancer can undergo liver resection. The biggest concern about resection is that following the operation, the patient can develop liver failure. The liver failure can occur if the remaining portion of the liver is inadequate to provide the necessary support for life. Even in carefully selected patients, about 10% of them are expected to die shortly after surgery, usually as a result of liver failure.
When a portion of a normal liver is removed, the remaining liver can grow back (regenerate) to the original size within one to two weeks. A cirrhotic liver, however, cannot grow back. Therefore, before resection is performed for liver cancer, the non-tumor portion of the liver should be biopsied to determine whether there is associated cirrhosis.
For patients whose tumors are successfully resected, the five-year survival is about 30 to 40%. This means that 30 to 40 % of patients who actually undergo liver resection for liver cancer are expected to live five years. Many of these patients, however, will have a recurrence of liver cancer elsewhere in the liver. Moreover, it should be noted that the survival rate of untreated patients with similar sized tumors and similar liver function is probably comparable. Some studies from Europe and Japan have shown that survival rates with alcohol injection or radiofrequency ablation procedures are comparable to the survival rates of those patients who underwent resection. But again, the reader should be cautioned that there are no head-to-head comparisons of these procedures versus resection.
Liver transplantation
Liver transplantation has become an accepted treatment for patients with end-stage (advanced) liver disease of various types (for example, chronic hepatitis B and C, alcoholic cirrhosis, primary biliary cirrhosis, and sclerosing cholangitis). Survival rates for these patients without liver cancer are 90% at one year, 80% at three years, and 75% at five years. Moreover, liver transplantation is the best option for patients with tumors that are less than 5 cm in size who also have signs of liver failure. In fact, as one would expect, patients with small cancers (less than 3 cm) and no involvement of the blood vessels do very well. These patients have a less than 10% risk of recurrent liver cancer after transplant. On the other hand, there is a very high risk of recurrence in patients with tumors greater than 5 cm or with involvement of blood vessels. For these reasons, when patients are being evaluated for treatment of liver cancer, every effort should be made to characterize the tumor and look for signs of spread beyond the liver.
There is a severe shortage of organ donors in the U.S. Currently, there are about 18,000 patients on the waiting list for liver transplantation. About 4,000 donated cadaver livers (taken at the time of death) are available per year for patients with the highest priority. This priority goes to patients on the transplant waiting list who have the most severe liver failure. As a result, in many liver cancer patients, while they are on the waiting list, the tumor may become too large for the patient to benefit from liver transplantation. Doing palliative treatments, such as TACE, while the patient is on the waiting list for liver transplantation is currently being evaluated.
The use of a partial liver from a healthy, live donor may provide a few patients with liver cancer an opportunity to undergo liver transplantation before the tumor becomes too large. This innovation is a very exciting development in the field of liver transplantation.
As a precaution, doing a biopsy or aspiration of liver cancer should probably be avoided in patients considering liver transplantation. The reason to avoid needling the liver is that there is about a 1-4% risk of seeding (planting) cancer cells from the tumor by the needle into the liver along the needle track. You see, after liver transplantation, patients take powerful anti-rejection medications to prevent the patient's immune system from rejecting the new liver. However, the suppressed immune system can allow new foci (small areas) of cancer cells to multiply rapidly. These new foci of cancer cells would normally be kept at bay by the immune cells of an intact immune system.
In summary, liver resection should be reserved for patients with small tumors and normal liver function (no evidence of cirrhosis). Patients with multiple or large tumors should receive palliative therapy with intra-arterial chemotherapy or TACE, provided they do not have signs of severe liver failure. Patients with an early stage of cancer and signs of chronic liver disease should receive palliative treatment and undergo evaluation for liver transplantation.
Is there a role for routine screening for liver cancer?
It makes sense to screen for liver cancer just as we do for colon, cervical, breast, and prostate cancer. However, the difference is that there is, as yet, no cost-effective way of screening for liver cancer. Blood levels of alpha-fetoprotein are normal in up to 50% of patients with small liver cancer. Ultrasound scanning, which is non-invasive and very safe, is, as mentioned before, operator-dependent. Therefore, the effectiveness of a screening ultrasound that is done at a small facility can be very suspect.
Even more disappointing is the fact that no study outside of Asia has shown, on a large scale, that early detection of liver cancer saved lives. Why is that? It is because, as already noted, the treatment for liver cancer, except for liver transplantation, is not very effective. Also, keep in mind that patients found with small tumors on screening live longer than patients with larger tumors only because of what is called a "lead time bias." In other words, they seem to liver longer (the bias) only because the cancer was discovered earlier (the lead time), not because of any treatment given.
Nevertheless, strong arguments can be made for routine screening. For example, the discovery of an liver cancer in the early stages allows for the most options for treatment, including liver resection and liver transplantation. Therefore, all patients with cirrhosis, particularly cirrhosis caused by chronic hepatitis B or C, hemochromatosis, and alcohol, should be screened at six- to 12-month intervals with a blood alpha-fetoprotein and an imaging study. I favor alternating between an ultrasound and CT scan (or MRI). Patients with chronically (long duration) elevated alpha-fetoprotein levels warrant more frequent imaging since these patients are at even higher risk of developing liver cancer.
Sunday, April 12, 2009
Hepatocellular Carcinoma ( HCC )
hepatocellular carcinoma - HCC
What is liver cancer (hepatocellular carcinoma - HCC)?
Liver cancer (hepatocellular carcinoma) is a Cancer arising from the liver. It is also known as primary liver cancer or hepatoma. The liver is made up of different cell types (for example, bile ducts, blood vessels, and fat-storing cells). However, liver cells (hepatocytes) make up 80% of the liver tissue. Thus, the majority of primary liver cancers (over 90 to 95%) arises from liver cells and is called hepatocellular cancer or carcinoma.
When patients or physicians speak of liver cancer, however, they are often referring to cancer that has spread to the liver, having originated in other organs (such as the colon, stomach, pancreas, breast, and lung). More specifically, this type of liver cancer is called metastatic liver disease (cancer) or secondary liver cancer. Thus, the term liver cancer actually can refer to either metastatic liver cancer or hepatocellular cancer. The subject of this article is hepatocellular carcinoma, which I will refer to as liver cancer.
What is the problem of the liver cancer?
Liver cancer is the fifth most common cancer in the world. A deadly cancer, liver cancer will kill almost all patients who have it within a year. In 1990, the World Health Organization estimated that there were about 430,000 new cases of liver cancer worldwide, and a similar number of patients died as a result of this disease. About three quarters of the cases of liver cancer are found in Southeast Asia (China, Hong Kong, Taiwan, Korea, and Japan). Liver cancer is also very common in sub-Saharan Africa (Mozambique and South Africa).
The frequency of liver cancer in Southeast Asia and sub-Saharan Africa is greater than 20 cases per 100,000 population. In contrast, the frequency of liver cancer in North America and Western Europe is much lower, less than five per 100,000 population. However, the frequency of liver cancer among native Alaskans is comparable to that seen in Southeast Asia. Moreover, recent data show that the frequency of liver cancer in the U.S. overall is rising. This increase is due primarily to chronic Hepatits C , an infection of the liver that causes liver cancer.
What are the population characteristics (epidemiology) of liver cancer?
In the U.S. the highest frequency of liver cancer occurs in immigrants from Asian countries, where liver cancer is common. The frequency of liver cancer among Caucasians is the lowest, whereas among African-Americans and Hispanics, it is intermediate. The frequency of liver cancer is high among Asians because liver cancer is closely linked to hepatitis B chronic infection. This is especially so in individuals who have been infected with chronic hepatitis B for most of their lives. If you take a world map depicting the frequency of chronic hepatitis B infection, you can easily superimpose that map on a map showing the frequency of liver cancer.
The initial presentation (symptoms) of liver cancer in patients in areas of high liver cancer frequency is quite different from that seen in low frequency areas. Patients from high frequency areas usually start developing liver cancer in their 40s, and the cancer is usually more aggressive. That is, the liver cancer presents with severe symptoms and is inoperable (too advanced for surgery) at the time of diagnosis. Also, in these areas, the frequency of liver cancer is three to four times higher in men than in women, and most of these patients are infected with chronic hepatitis B. In contrast, liver cancer in lower risk areas occurs in patients in their 50s and 60s and the predominance of men is less striking.
What is the natural history of liver cancer?
The natural history of liver cancer depends on the stage of the tumor and the severity of associated liver disease (for example, cirrhosis) at the time of diagnosis. For example, a patient with a 1 cm tumor with no cirrhosis has a greater than 50% chance of surviving three years, even without treatment. In contrast, a patient with multiple tumors involving both lobes of the liver (multicentric tumors) with decompensated cirrhosis (signs of liver failure) is unlikely to survive more than six months, even with treatment.
What are the predictors of a poor outcome? Our knowledge of the prognosis is based on studying many patients with liver cancer, separating out their clinical characteristics, and relating them to the outcome. Grouped in various categories, the unfavorable clinical findings include;
• Population characteristics (demographics); male gender, older age, or alcohol consumption.
• Symptoms; weight loss or decreased appetite.
• Signs of impaired liver function; jaundice, ascites, or encephalopathy (altered mental state).
• Blood tests; elevated liver tests (bilirubin or transaminase), reduced albumin, elevated AFP, elevated blood urea nitrogen (BUN), or low serum sodium.
• Staging of tumor (based on imaging or surgical findings); more than one tumor, tumor over 3 cm (almost 1¼ inches), tumor invasion of local blood vessels (portal and/or hepatic vein), tumor spread outside of the liver (to lymph nodes or other organs).
There are various systems for staging liver cancer. Some systems look at clinical findings while others rely solely on pathological (tumor) characteristics. It makes the most sense to use a system that incorporates a combination of clinical and pathological elements. In any event, it is important to stage the cancer because staging can provide guidelines not only for predicting outcome (prognosis) but also for decisions regarding treatment.
The doubling time for a cancer is the time it takes for the tumor to double in size. For liver cancer, the doubling time is quite variable, ranging from one month to eighteen months. This kind of variability tells us that every patient with liver cancer is unique. Therefore, an assessment of the natural history and the evaluation of different treatments are very difficult. Nevertheless, in patients with a solitary liver cancer that is less than 3 cm, with no treatment, we can expect that 90% of the patients will survive (live) for one year, 50% for three years, and 20% for five years. In patients with more advanced disease, we can expect that 30% will survive for one year, 8% for three years, and none for five years.
What is fibrolamellar carcinoma?
Fibrolamellar carcinoma is an liver cancer variant that is found in non-cirrhotic livers, usually in younger patients between the ages of 20 and 40 years. In fact, these patients have no associated liver disease and no risk factors have been identified. The alpha-fetoprotein in these patients is usually normal. The appearance of fibrolamellar carcinoma under the microscope is quite characteristic. That is, broad bands of scar tissue are seen running through the cancerous liver cells. The important thing about fibrolamellar carcinoma is that it has a much better prognosis than the common type of liver cancer. Thus, even with a fairly extensive fibrolamellar carcinoma, a patient can have a successful surgical removal.
What's in the future for the prevention and treatment of liver cancer?
Prevention
Worldwide, the majority of liver cancer is associated with chronic hepatitis B virus infection. Today, however, all newborns are vaccinated against hepatitis B in China and other Asian countries. Therefore, the frequency of chronic hepatitis B virus in future generations will decrease. Eventually, perhaps in three or four generations, hepatitis B virus will be totally eradicated, thereby eliminating the most common risk factor for liver cancer.
Some retrospective (looking back in time) studies suggest that patients with chronic hepatitis C who were treated with interferon were less likely to develop liver cancer than patients who were not treated. Interestingly, in these studies, interferon treatment seemed to provide this benefit, even to patients who had less than an optimal antiviral response to interferon. Still, it remains to be seen whether the risk of developing cirrhosis and liver cancer is significantly decreased in prospectively (looking ahead) followed patients who responded to interferon.
One Japanese study has reported that a retinoid derivative (a compound related to vitamin A) was effective in preventing recurrence of liver cancer after resection of the liver. As of now, this compound is not available in the U.S. It would be of great interest to study the use of this compound in conjunction with other palliative therapy for liver cancer.
Treatment
Unfortunately, there have been no significant new developments in the treatment of liver cancer. Medical therapy remains a disappointment. Scientists are working hard, however, to address this problem. For example, anti-angiogenesis compounds, which inhibit blood vessel formation, may hold promise in the treatment of liver cancer since this tumor depends on a rich blood supply. Also, different ways to deliver drugs or treatment to the tumors are being investigated. This includes attaching radioactive material to antibodies that are directed at specific targets in liver cancer cells (immunotherapy).
What is liver cancer (hepatocellular carcinoma - HCC)?
Liver cancer (hepatocellular carcinoma) is a Cancer arising from the liver. It is also known as primary liver cancer or hepatoma. The liver is made up of different cell types (for example, bile ducts, blood vessels, and fat-storing cells). However, liver cells (hepatocytes) make up 80% of the liver tissue. Thus, the majority of primary liver cancers (over 90 to 95%) arises from liver cells and is called hepatocellular cancer or carcinoma.
When patients or physicians speak of liver cancer, however, they are often referring to cancer that has spread to the liver, having originated in other organs (such as the colon, stomach, pancreas, breast, and lung). More specifically, this type of liver cancer is called metastatic liver disease (cancer) or secondary liver cancer. Thus, the term liver cancer actually can refer to either metastatic liver cancer or hepatocellular cancer. The subject of this article is hepatocellular carcinoma, which I will refer to as liver cancer.
What is the problem of the liver cancer?
Liver cancer is the fifth most common cancer in the world. A deadly cancer, liver cancer will kill almost all patients who have it within a year. In 1990, the World Health Organization estimated that there were about 430,000 new cases of liver cancer worldwide, and a similar number of patients died as a result of this disease. About three quarters of the cases of liver cancer are found in Southeast Asia (China, Hong Kong, Taiwan, Korea, and Japan). Liver cancer is also very common in sub-Saharan Africa (Mozambique and South Africa).
The frequency of liver cancer in Southeast Asia and sub-Saharan Africa is greater than 20 cases per 100,000 population. In contrast, the frequency of liver cancer in North America and Western Europe is much lower, less than five per 100,000 population. However, the frequency of liver cancer among native Alaskans is comparable to that seen in Southeast Asia. Moreover, recent data show that the frequency of liver cancer in the U.S. overall is rising. This increase is due primarily to chronic Hepatits C , an infection of the liver that causes liver cancer.
What are the population characteristics (epidemiology) of liver cancer?
In the U.S. the highest frequency of liver cancer occurs in immigrants from Asian countries, where liver cancer is common. The frequency of liver cancer among Caucasians is the lowest, whereas among African-Americans and Hispanics, it is intermediate. The frequency of liver cancer is high among Asians because liver cancer is closely linked to hepatitis B chronic infection. This is especially so in individuals who have been infected with chronic hepatitis B for most of their lives. If you take a world map depicting the frequency of chronic hepatitis B infection, you can easily superimpose that map on a map showing the frequency of liver cancer.
The initial presentation (symptoms) of liver cancer in patients in areas of high liver cancer frequency is quite different from that seen in low frequency areas. Patients from high frequency areas usually start developing liver cancer in their 40s, and the cancer is usually more aggressive. That is, the liver cancer presents with severe symptoms and is inoperable (too advanced for surgery) at the time of diagnosis. Also, in these areas, the frequency of liver cancer is three to four times higher in men than in women, and most of these patients are infected with chronic hepatitis B. In contrast, liver cancer in lower risk areas occurs in patients in their 50s and 60s and the predominance of men is less striking.
What is the natural history of liver cancer?
The natural history of liver cancer depends on the stage of the tumor and the severity of associated liver disease (for example, cirrhosis) at the time of diagnosis. For example, a patient with a 1 cm tumor with no cirrhosis has a greater than 50% chance of surviving three years, even without treatment. In contrast, a patient with multiple tumors involving both lobes of the liver (multicentric tumors) with decompensated cirrhosis (signs of liver failure) is unlikely to survive more than six months, even with treatment.
What are the predictors of a poor outcome? Our knowledge of the prognosis is based on studying many patients with liver cancer, separating out their clinical characteristics, and relating them to the outcome. Grouped in various categories, the unfavorable clinical findings include;
• Population characteristics (demographics); male gender, older age, or alcohol consumption.
• Symptoms; weight loss or decreased appetite.
• Signs of impaired liver function; jaundice, ascites, or encephalopathy (altered mental state).
• Blood tests; elevated liver tests (bilirubin or transaminase), reduced albumin, elevated AFP, elevated blood urea nitrogen (BUN), or low serum sodium.
• Staging of tumor (based on imaging or surgical findings); more than one tumor, tumor over 3 cm (almost 1¼ inches), tumor invasion of local blood vessels (portal and/or hepatic vein), tumor spread outside of the liver (to lymph nodes or other organs).
There are various systems for staging liver cancer. Some systems look at clinical findings while others rely solely on pathological (tumor) characteristics. It makes the most sense to use a system that incorporates a combination of clinical and pathological elements. In any event, it is important to stage the cancer because staging can provide guidelines not only for predicting outcome (prognosis) but also for decisions regarding treatment.
The doubling time for a cancer is the time it takes for the tumor to double in size. For liver cancer, the doubling time is quite variable, ranging from one month to eighteen months. This kind of variability tells us that every patient with liver cancer is unique. Therefore, an assessment of the natural history and the evaluation of different treatments are very difficult. Nevertheless, in patients with a solitary liver cancer that is less than 3 cm, with no treatment, we can expect that 90% of the patients will survive (live) for one year, 50% for three years, and 20% for five years. In patients with more advanced disease, we can expect that 30% will survive for one year, 8% for three years, and none for five years.
What is fibrolamellar carcinoma?
Fibrolamellar carcinoma is an liver cancer variant that is found in non-cirrhotic livers, usually in younger patients between the ages of 20 and 40 years. In fact, these patients have no associated liver disease and no risk factors have been identified. The alpha-fetoprotein in these patients is usually normal. The appearance of fibrolamellar carcinoma under the microscope is quite characteristic. That is, broad bands of scar tissue are seen running through the cancerous liver cells. The important thing about fibrolamellar carcinoma is that it has a much better prognosis than the common type of liver cancer. Thus, even with a fairly extensive fibrolamellar carcinoma, a patient can have a successful surgical removal.
What's in the future for the prevention and treatment of liver cancer?
Prevention
Worldwide, the majority of liver cancer is associated with chronic hepatitis B virus infection. Today, however, all newborns are vaccinated against hepatitis B in China and other Asian countries. Therefore, the frequency of chronic hepatitis B virus in future generations will decrease. Eventually, perhaps in three or four generations, hepatitis B virus will be totally eradicated, thereby eliminating the most common risk factor for liver cancer.
Some retrospective (looking back in time) studies suggest that patients with chronic hepatitis C who were treated with interferon were less likely to develop liver cancer than patients who were not treated. Interestingly, in these studies, interferon treatment seemed to provide this benefit, even to patients who had less than an optimal antiviral response to interferon. Still, it remains to be seen whether the risk of developing cirrhosis and liver cancer is significantly decreased in prospectively (looking ahead) followed patients who responded to interferon.
One Japanese study has reported that a retinoid derivative (a compound related to vitamin A) was effective in preventing recurrence of liver cancer after resection of the liver. As of now, this compound is not available in the U.S. It would be of great interest to study the use of this compound in conjunction with other palliative therapy for liver cancer.
Treatment
Unfortunately, there have been no significant new developments in the treatment of liver cancer. Medical therapy remains a disappointment. Scientists are working hard, however, to address this problem. For example, anti-angiogenesis compounds, which inhibit blood vessel formation, may hold promise in the treatment of liver cancer since this tumor depends on a rich blood supply. Also, different ways to deliver drugs or treatment to the tumors are being investigated. This includes attaching radioactive material to antibodies that are directed at specific targets in liver cancer cells (immunotherapy).
Problem of the Liver Cancer
What is the problem of the Liver Cancer?
Liver cancer is the fifth most common cancer in the world. A deadly cancer, liver cancer will kill almost all patients who have it within a year. In 1990, the World Health Organization estimated that there were about 430,000 new cases of liver cancer worldwide, and a similar number of patients died as a result of this disease. About three quarters of the cases of liver cancer are found in Southeast Asia (China, Hong Kong, Taiwan, Korea, and Japan). Liver cancer is also very common in sub-Saharan Africa (Mozambique and South Africa).
The frequency of liver cancer in Southeast Asia and sub-Saharan Africa is greater than 20 cases per 100,000 population. In contrast, the frequency of liver cancer in North America and Western Europe is much lower, less than five per 100,000 population. However, the frequency of liver cancer among native Alaskans is comparable to that seen in Southeast Asia. Moreover, recent data show that the frequency of liver cancer in the U.S. overall is rising. This increase is due primarily to chronic Hepatits C , an infection of the liver that causes liver cancer.
Liver cancer is the fifth most common cancer in the world. A deadly cancer, liver cancer will kill almost all patients who have it within a year. In 1990, the World Health Organization estimated that there were about 430,000 new cases of liver cancer worldwide, and a similar number of patients died as a result of this disease. About three quarters of the cases of liver cancer are found in Southeast Asia (China, Hong Kong, Taiwan, Korea, and Japan). Liver cancer is also very common in sub-Saharan Africa (Mozambique and South Africa).
The frequency of liver cancer in Southeast Asia and sub-Saharan Africa is greater than 20 cases per 100,000 population. In contrast, the frequency of liver cancer in North America and Western Europe is much lower, less than five per 100,000 population. However, the frequency of liver cancer among native Alaskans is comparable to that seen in Southeast Asia. Moreover, recent data show that the frequency of liver cancer in the U.S. overall is rising. This increase is due primarily to chronic Hepatits C , an infection of the liver that causes liver cancer.
Tuesday, July 24, 2007
وظائف الكبد
الكـبد عضو هام جدا بجسم الانسان ولا يمكن الاستغناء عنه لاهميته الشديده
الوضع التشريحى يوجد فى بطن الانسان باعلا الجانب الايمن تحت الحجاب الحاجز مباشرا يتكون الكبد من جزئين اساسيان هما الفص الايمن والفص الايسر الفص الايمن وهو الفص الاكبر حجما وعدد خلايه اكثر من الفص الايسر ينقسم كل فص الى اجزاء صعيرة الدورة الدموية للكبد يستقبل الكبد الدم الرئيسى من الوريد البابى الذى يجمع الدم من الجهاز الهضمى ( المعدة – الامعاء الدقيقة – الامعاء الغليظة – المستقيم – الطحال ) وايضا يستقبل الدم من الشريان الكبدى ويصب الدم من الفصين الايمن والايسر فى الوريد الاجوف السفلى ما هى فؤائد الكـبد
يعتبر الكبد مصنع كبير للكمياء الحيوية فهو يقوم بالعمليات الاتية
تخليق البروتنات لجسم الانسان تكوين العوامل اللازمة لتجلط الدم تحويل عناصر الطعام من صورة الى أخرة من تبسيط وتعقيد لمركبات الطعام تخزين بعض عناصر الطعام المركبة مثل الجليكوجين التعامل مع الادوية فى تنشيطها وابطال مفعولها الضار التعامل مع السموم وابطال مفعولها الضار تكوين العصارة الصفراوية الهامة لهضم الطعام تخليق وتجديد خلايا الكبد التالفة
الوضع التشريحى يوجد فى بطن الانسان باعلا الجانب الايمن تحت الحجاب الحاجز مباشرا يتكون الكبد من جزئين اساسيان هما الفص الايمن والفص الايسر الفص الايمن وهو الفص الاكبر حجما وعدد خلايه اكثر من الفص الايسر ينقسم كل فص الى اجزاء صعيرة الدورة الدموية للكبد يستقبل الكبد الدم الرئيسى من الوريد البابى الذى يجمع الدم من الجهاز الهضمى ( المعدة – الامعاء الدقيقة – الامعاء الغليظة – المستقيم – الطحال ) وايضا يستقبل الدم من الشريان الكبدى ويصب الدم من الفصين الايمن والايسر فى الوريد الاجوف السفلى ما هى فؤائد الكـبد
يعتبر الكبد مصنع كبير للكمياء الحيوية فهو يقوم بالعمليات الاتية
تخليق البروتنات لجسم الانسان تكوين العوامل اللازمة لتجلط الدم تحويل عناصر الطعام من صورة الى أخرة من تبسيط وتعقيد لمركبات الطعام تخزين بعض عناصر الطعام المركبة مثل الجليكوجين التعامل مع الادوية فى تنشيطها وابطال مفعولها الضار التعامل مع السموم وابطال مفعولها الضار تكوين العصارة الصفراوية الهامة لهضم الطعام تخليق وتجديد خلايا الكبد التالفة
Thursday, February 8, 2007
Liver Transplant Complete Guide
Medications A number of diseases can directly damage the liver. Damage to the liver can seriously affect the absorption of vitamins and nutrients, prevent waste products from being effectively removed from the system, and reduce the production of proteins needed to clot the blood. If the damage is severe enough, transplantation may be necessary.
A transplant provides a patient with a liver that can keep up with the demands of a full, active life.
What the Liver Does?
The liver is the largest organ in the body.
It is located on the right side of the abdomen (to the right of the stomach) behind the lower ribs and below the lungs.
The liver performs more than 400 functions each day to keep the body healthy. Some of its major jobs include:
• converting food into nutrients the body can use (for example, the liver produces bile to help break down fats)
•storing fats, sugars, iron, and vitamins for later use by the body
• making the proteins needed for normal blood clotting
• removing or chemically changing drugs, alcohol, and other substances that may be harmful or toxic to the body Basic Functions of the Liver The liver is the largest and one of the most complex organs in the body.
The liver performs four basic functions:
• It aids in digestion by helping in the absorption of fat and certain vitamins, including vitamins A, D, E, and K
• It helps distribute the nutrients found in food
• It helps "clean" the blood by removing medications and toxin
•It produces important proteins that affect the blood, such as factorsthat are essential in making the blood clot after an injury.
The liver produces bile, which aids in the digestion and absorption of fats.
Bile also aids inthe absorption of substances such as vitamins A, D, E, and K and medication that patients take as an immunosuppressive agent following liver transplantation.
The bile is stored in the gallbladder (which is located just below the liver) and then released into the intestines as needed. Together, these organs process the nutrients found in the foods we eat.
The liver also helps filter many chemical substances and waste products from the blood.
Most medicines are cleaned from the blood stream by the liver.
The liver also removes any alcohol that's consumed.
Symptoms of Liver Disease
• jaundice (yellowing of eyes and skin)
• severe itching
• dark urine
• mental confusion or coma
• vomiting of blood
• easy bruising and tendency to bleed
• gray or clay-colored stools
• abnormal buildup of fluid in the abdomen
Before Liver Transplant
Pretransplant Evaluation The Transplant Team Preparing and Waiting for a Transplant PRETRANSPLANT EVALUATION Pretransplant tests, as well as giving a clear picture of the patient's overall health status, help in identifying potential problems before they occur.
They also help in determining whether transplantation is truly the best option. This increases the likelihood of success.
The following procedures help in evaluating a patient's health status:
Chest x-ray - Determines the health of the patient's lungs and lower respiratory tract.
Electrocardiogram (EKG or ECG) - Determines how well the patient's heart is working and may reveal heart damage that was previously unsuspected. Ultrasound with Doppler examination - Determines the openness of the bile ducts and major vessels.
It is commonly done in all liver transplant recipients before and after transplantation. CT (CAT) scan - This computerized image will show the size and shape of the patient's liver and major blood vessels.
MRI (magnetic resonance imaging) - May be used in place of CT scan or ultrasound to see inside the patient's body.
Total-body bone scan - If the patient has a liver tumor, ensures that it has not spread to his bones.
Blood tests - The patient's blood count, blood and tissue type, blood chemistries, and immune system function will all be checked.
In addition, blood tests for certain infectious diseases will be performed. Pulmonary function test - The patient will be asked to breathe into a tube attached to a measuring device, which will reveal how well his lungs are working and determine his blood's capacity to carry oxygen.
Hepatic angiograph - Dye injected into the patient's arteries will enable the transplant physician to see if there are any abnormalities or blockages in the patient's blood vessels.
Cholangiogram - Reveals any obstructions or growths in the patient's bile ducts. Gallium, colloidal gold, or technetium scan - Gives the transplant physician a view of the patient's liver, gallbladder, and pancreas.
Peritoneoscopy - By inserting a flexible tube through a tiny incision in the patient's abdomen, the transplant physician will be able to see any structural changes in the liver.
Upper gastrointestinal (GI) series - This will show whether the patient's esophagus and stomach are disease free.
Lower GI series - Ensures that the patient is free of intestinal abnormalities. Renal function studies - Urine may be collected from the patient for 24 hours in order to determine if the kidneys are working correctly.
Blood tests such as serum creatinine are also performed to measure kidney function.
The Transplant Team
• Transplant Surgeon
• Transplant Physician (Hepatologist)
• Transplant Coordinator
• Nurse Practitioner
• Floor or Staff Nurse
• Physical Therapist
• Floor or Staff Nurse
• Dietician
• Psychologist / Psychiatrist
• Pharmacist Each of the skilled health care professionals who make up the transplant team take a personal interest in answering a patient's questions and taking care of his medical needs. They will also help the patient keep his spirits up along the way.
The patient is the most important member of the transplant team. To a certain extent, all the other team members will respond to his cues.
The patient's physical, emotional, and practical needs will help them shape a personalized pretransplant and posttransplant treatment program.
Preparing and Waiting for A Liver Transplant Days and weeks may pass while the transplant team waits?to locate the right liver for a specific patient.
During this time, the patient should prepare as much as possible and take positive steps to deal with the stresses of waiting, always staying focused on reaching the goal of transplant.
During Liver Transplant
Getting the Go-Ahead At the Hospital Preparing the Patient for Surgery Liver Transplant Surgery Procedure T-Tube Placement and Bile Drainage Getting the Go-Ahead When that important phone call comes, the patient should make sure to bring the following to the hospital:
• A list of all the medications the patient is taking • A list of the patient's drug allergies, if he has any
• The patient's health insurance information IMPORTANT: As soon as a liver is available, the patient should stop all eating and drinking immediately.
The patient's stomach must be empty when he is taken into the operating room. At the Hospital After admission, the patient will have a thorough physical examination, including more blood work, a chest x-ray, and EKG, and, possibly, other tests. Unfortunately, surgery must be postponed in some cases. The patient will be sent home again if:
• he has an infection or has developed any other medical problem that would interfere with surgery or recovery
• The donor liver shows signs of deterioration or poor function If surgery is postponed, the transplant team can help the patient through the disappointment.
This is only a temporary setback, and the search for a new liver will go on. Preparing the Patient for Surgery The patient may receive an enema to clean out his intestines and prevent constipation after surgery.
His chest and abdomen will be shaved clean to prevent infection, and an intravenous (IV) line will be inserted in his arm or just under his collarbone to give medication and keep him from getting dehydrated.
The patient will also be given a sedative to help him relax and feel sleepy before going to the operating room.
IMPORTANT:
Because transplantation is a major surgical procedure, the patient may need a transfusion.
Today, all blood is screened very carefully; the likelihood of contracting a disease is very small.
Any concerns that the patient has regarding the source of the blood should be relayed to the transplant team during the waiting period, before getting to the hospital.
Most hospitals offer the option of "autotransfusion" - this is when the patient donates his own blood before surgery. His own blood is stored and hen used during transplantation. The Liver Transplant Surgery Procedure The patient will be under general anesthesia throughout the surgery.
Once asleep, the transplant surgeon will make an incision shaped like a boomerang on the upper part of the abdomen. The surgical team will then remove the patient's old liver, leaving portions of his major blood vessels in place.
The new liver will then be inserted and attached to these blood vessels and to the patient's bile ducts.
To help with bile drainage, a tube will also be inserted in the bile duct during surgery. T-Tube Placement and Bile Drainage During liver-transplant surgery, the surgeon may find it necessary to place a small tube, called a T-tube, into the bile duct.
The T-tube allows bile to drain out of the patient's body into a small pouch, known as a bile bag. The amount of bile, which varies in color from deep gold to dark green, can then be measured.
If a T-tube is put in place, it may remain attached to a bile bag for a week or possibly longer.
When the bile bag is removed the T-tube will be tied or capped. It will remain in place for several months so that it can be used for special testing.
The T-tube is attached to the skin with a stitch.
The dressing around the tube should be changed at least once daily, and more often if it becomes moist.
The transplant nurse will show the patient how to change the dressing without pulling out the T-tube.
Other drains may be in the patient's abdomen during the postoperative period. A common name for these drains is Jackson-Pratt (JP).
They are used to drain fluid from around the liver. Generally, these drains are removed before the patient goes home.
The surgical team will then place the donor kidney into the abdomen and connect the kidney's blood vessels to the recipient's iliac artery and vein.
The surgeons will then connect the ureter to the bladder. A small drain, called a Jackson Pratt, may be placed into the abdominal cavity to drain any excess fluid.
After Liver Transplant
Waking Up in the Intensive Care Unit Medical Management in the Acute Care Unit Clinic and Follow-Up Visits Lab Tests Additional Tests and Procedures Monitoring at Home Resuming Normal Activities Avoiding Infection Communicating with the Healthcare Team Waking Up in the Intensive Care Unit (ICU) After the surgery, the patient will wake up in the intensive care unit after the anesthesia wears off.
This is what the patient should expect:
• Some pain and discomfort, which medication will help to relieve.
• A tube will be inserted through the patient's nose. This tube will run down the patient's throat and into his stomach. This tube will keep the stomach empty, to help prevent nausea and vomiting.
• A tube may be inserted into the patient's throat to help him get enough oxygen. It will be connected to a breathing machine called a ventilator. The patient should try to relax and let the machine breathe for him. The patient will not be able to talk with this tube in place, but he will only need it for a few days. Nurses will do everything they can to help the patient communicate. The patient's throat may feel sore or scratchy for a few days afterward.
• The patient will be asked to cough periodically to keep his lungs clear. If it hurts to cough, the patient should ask someone to support his abdomen.
• The patient will have an IV line in his arm or neck under the collarbone, which will be used to give fluids and medication for the first few days after surgery.
• For several days after surgery, the patient will have a catheter in his bladder to drain urine. He may feel uncomfortable, and may feel that he has to urinate constantly, but it is only temporary.
• During surgery, several drains will be placed in or near the incision. These drains will be removed 5 to 10 days after surgery.
Medical Management in the Acute Care Unit After the patient's medical condition has stabilized, he will be transferred from the ICU to the acute care unit. During the patient's stay on this unit, his laboratory studies, medications, nutritional status and exercise tolerance will be monitored.
As soon as the patient is able, discharge instructions will begin to prepare him for going home.
Clinic and Follow-up Visits Upon leaving the hospital, the patient will receive a schedule of follow-up clinic visits for lab tests and checkups.
The purpose is to track your progress and detect potential complications as early as possible.
On days when the patient is scheduled for follow-up visits, he should bring his medication list and his surgery handbook.
He will be given specific instructions for routine lab work or special tests that he might need.
Lab Tests A usual lab test monitors blood count, clotting, kidney function, liver function, electrolytes, and medication levels in the patient's blood.
Other tests may be ordered as necessary.
Tests for BLOOD COUNT: WBC tell if the patient's white blood cells have increased (usually a sign of infection) or decreased (indicating a lower defense against infection).
HCT measures the hematocrit, which is the percentage of red blood cells in the blood. Red blood cells carry oxygen to all parts of the body.
When a patient's HCT is low, he may feel tired or have little energy.
PLTmeasures the level of platelets. Platelet cells form a blood clot when the body is injured.
Low platelet levels may cause someone to bruise easily and to bleed for a longer time when injured.
Test for KIDNEY FUNCTION: Creatinine and BUN tell how well the kidneys work by measuring levels of creatinine and blood urea nitrogen, waste products normally removed from the blood by the kidneys.
Tests for LIVER FUNCTION: Bili measures the level of bilirubin, a normal byproduct when hemoglobin from red blood cells breaks down.
The liver removes bilirubin from the blood and excretes it in the bile.
When the liver is not functioning normally, bilirubin levels can increase, often resulting in jaundiced (yellowed) skin and eyes.
Alk Phos measures alkaline phosphatase, which is made in the bones, liver, pancreas, and intestines and removed from the blood by the liver. AST, ALT, and GGTP test enzymes that are made in the liver.
These tests tell how well the liver is working. K measures potassium, which is needed for normal heart and muscle function.
Tests for ELECTROLYTES (dissolved minerals): Ca measures calcium, which is necessary for strong bones and teeth, blood clotting, and heart and nerve function.
NOTE: The desired level (normal range) will differ for each person, depending on the combination of immunosuppressive medications and the length of time since the transplant.
PO4 measures phosphate, which works closely with calcium to strengthen bones. Mg measures magnesium, which is necessary for normal functioning of muscles and for blood clotting.
K measures potassium, which is needed for normal heart and muscle function. Na measures sodium, which helps maintain the balance of salt and water in the body.
Other blood tests: Drug levels measure PROGRAF or SANDIMMUME in the blood. PROGRAF or SANDIMMUNE blood levels must be checked regularly to avoid levels that are too high or too low.
High levels could lead to toxicity or over-immunosuppression, and low levels may lead to rejection.
NOTE: The desired level (normal range) will differ for each person, depending on the combination of immunosuppressive medications and the length of time since the transplant.
Glu measures glucose, levels of sugar in the blood; some medications may produce a diabetes-like condition in which blood-sugar levels are too high.
Additional Tests and Procedures The transplant team may perform one or more of the following tests and procedures to monitor a patient's transplant: Ultrasound - This test is performed to make sure all the main blood vessels leading to the liver are functioning normally.
This test is also used to check for collections of fluid, such as blood or bile.
The procedure consists of placing a cool gel on the patient's abdomen, over which a wand (transducer) is moved to transmit sound waves.
These are converted into images of the liver and projected onto a television screen.
Percutaneous transhepatic cholangiogram (PTC) - This is an X ray that shows the patient's bile ducts to check for leaks, blockages, or other potential problems.
The procedure starts with a dye injection into the T-tube. The dye makes the ducts easy to see on X ray.
If a T-tube was not placed during your surgery, this X ray will be performed after dye has been injected directly into the liver-bile ducts. Liver biopsy (test sample) This test is usually performed to check for rejection, hepatitis, or other possible problems.
This may be done in the hospital or in the outpatient/short-stay unit. The patient will receive special instructions regarding the procedure.
Before the procedure, the patient will receive a numbing injection (local anesthetic) on the right side of his abdomen.
Then a special needle will be inserted to withdraw a small sample of liver tissue that will be examined with a microscope.
After this procedure, the patient must lie on his right side for at least 1 hour and stay in bed for about 4 hours.
Computerized tomography (CT) scan - This is a type of X ray that allows the physician to view the patient's liver from many different angles to detect infections, fluid collections, or other problems.
The procedure requires that the patient drink a liquid that outlines his stomach and intestines and makes his liver more visible; then he lies flat for 1 hour while the machine takes X rays around him. Magnetic resonance imaging (MRI) - This is another type of test that produces an image.
Somewhat like a CT scan, it also allows a patient's liver to be viewed from different angles and in three-dimensional images.
An MRI shows soft tissues, such as the liver, more clearly than a CT scan does. Endoscopic retrograde cholangiopancreatogram (ERCP) - This test allows the physician to see the patient's biliary tree (the various ducts in and around the liver), as well as the ducts from the pancreas.
The patient will be given medicine to relax him before the procedure. An endoscope (a type of tube) is placed in his mouth; it is advanced through to his stomach and into his intestine to the liver.
A dye is then infected through the endoscope that makes the ducts visible in X rays.
Monitoring Health and A New Liver at Home After a patient is discharged from the hospital, he may be asked to monitor: Temperature - A patient should check and record temperature any time he feels chilled, hot, achy, or ill.
This may be the first sign of infection.
WARNING: DO NOT USE TYLENOLR, ADVILR (Ibuprofen), aspirin, or other such products except under the direction of a physician, as these drugs may cause further symptoms.
If a patient's temperature is higher than normal at any time, he should notify his transplant coordinator immediately.
This is considered an emergency, because an elevated temperature could indicate a serious infection or rejection. Blood pressure - A nurse or transplant coordinator will show how to measure blood pressure, if necessary.
The top number (systolic) is noted at the first sound, and the bottom number (diastolic) is noted when the sound changes (not stops).
It is important that a patient knows his normal blood pressure, normal changes, and when he should be concerned.
Pulse - If a patient is taking medication that affects heart rate, the nurse or coordinator will show how to check his own pulse at home. NOTE: If a patient experiences chest pain or has difficulty breathing, he should call 911 for an ambulance and go to the nearest emergency room.
He SHOULD NOT attempt to drive himself. Weight - The patient may weigh himself on a standard bathroom scale at the same time every morning (after going to the toilet).
If he gains more than 2 pounds per day, he could be retaining fluid.
This should be reported to the transplant coordinator.
Resuming Normal Activities Although the patient is encouraged to resume normal activities after recovery, it is important to understand that having a new liver brings new responsibilities.
• Skin and Hair Care
• Sexual Activity
• Smoking
• Vacations and Travel
• Dental Care
• Pregnancy
• Exercise
• Diet and Nutrition
• Alcoholic Beverages Signs to Watch Out For While primary concerns involve infection and rejection, many other problems, such as colds or flu, adjustment of other medications, and minor infections can be handled by a local physician.
A patient needs to take precautions and learn to watch for signs of infection and rejection that necessitate notifying a local physician or transplant team immediately. These include:
• a fever that continues for more than 2 days
• shortness of breath
• a cough that produces a yellowish or greenish substance
• a dry cough that continues for more than 1 week
• prolonged nausea, vomiting, or diarrhea
• an inability to take prescribed medication
• bleeding, bruising, black stools, red or rusty-brown urine
• a rash or other skin changes
• pain, discharge, or swelling at the T-tube site
• vaginal discharge or itching
• burning discomfort with urination
• exposure to mumps, measles, chicken pox, or shingles
• unusual weakness or light-headedness
• emergency-room treatment or hospitalization Avoiding Infection Because immunosuppressive medications interfere with a patient's natural immune system, he needs to protect himself consciously from infection after the surgery by taking the following precautions:
• Wash hands often.
• Keep hands away from face and mouth.
• Stay away from people with colds or other infections.
• Ask friends to visit only when they are well.
• If the patient has a wound and must change his own dressing, wash hands before and after.
• Wash hands after coughing or sneezing, and throw tissues into the trash immediately.
• If someone in the patient's family becomes ill with a cold of flu, have that individual follow normal precautions (use separate drinking glasses, covering their mouths when coughing, etc.)
• Avoid working in the soil for 6 months after the transplant. Thereafter, wear gloves. • Avoid handling animal waste and avoid contact with animals who roam outside.
Do not clean bird cages or fish or turtle tanks or cat litter.
The cat litter box should be covered and taken out of a patient's home before it is changed.
• Avoid vaccines that consist of live viruses, such as Sabin oral polio, measles, mumps, German measles, yellow fever, or smallpox.
The live virus can cause infections. If a patient or any family member intends to receive any vaccinations, they should notify the transplant team or local physician.
SPECIAL WARNING TO PARENTS OF CHILDREN WHO HAVE HAD TRANSPLANTS:
Ask the school nurse or other official to notify you immediately of any communicable diseases (for example, measles, chicken pox) that may be circulating in your school.
Communicating with the Healthcare Team Communication and cooperation between the transplant team, local physician, pharmacist, dentist, and the patient himself is vital to his well-being. Having a transplanted liver and taking the medications needed to prevent rejection put a patient at risk for a number of complications.
It is important to follow the instructions that will help prevent or lessen complications.
One of a patient's most important jobs is to make certain that all members of his local healthcare team - family physician, dentist, local pharmacist, and any other healthcare professionals he sees - are aware of the transplant, the medications he takes each day, and the precautions he must follow to stay healthy.
Each of his local healthcare providers should be given the telephone number of his transplant team.
He should ask that they contact the transplant center for specific
information.
Anxiety and Depression A serious procedure such as the one just experienced can create many personal and family stresses.
It is not uncommon for transplant patients to experience anxiety and perhaps depression following their surgery, hospital confinement, and return home.
To help a patient adjust to life at home and an eventual return to work or school, counseling and support group services are available.
The patient should consult the transplant social worker or coordinator for information regarding services available to help resolve stress and anxiety.
Medications Medication Guidelines Postoperative Complications Medication Guidelines The patient is responsible for taking the medications that have been prescribed for him. He should talk to his physician, pharmacist, transplant nurse, and/or coordinator to understand fully:
• the name and purpose of each medication
• when to take each medication
• how to take each medication
• how long to continue taking each medication
• principal side effects of each medication
• what to do if he forgets to take a dose
• when to order more medication so it doesn't run out
• how to order or obtain medications
• what to avoid while taking medications At home, the recovering patient will continue taking most of the medicines he began taking in the hospital after the transplant surgery, especially the anti-rejection medications.
His immune system recognizes the new liver as foreign and will try to reject it. Therefore, his immune system must be controlled with immunosuppressive medications.
The patient probably will have to take one or more of these drugs for the rest of his life, in addition to other medications.
REMINDER :
Never stop taking medication or change the dosage without a physician's approval.
Before taking medications:
• Ask the nurse, coordinator, or pharmacist to help in selecting the best times to take medications.
• Try to take each medication at the same time every day.
• Follow a written schedule.
• DO NOT cut or crush a tablet unless advised to do so. Storing medications
• Keep medications in the original container, tightly capped.
If a special container is used to hold the pills, keep the container tightly sealed.
• Store in a cool, dry place away from direct sunlight.
• Do not store medications in the bathroom -- moisture can cause medications to lose their strength.
• Do not allow liquid medications to freeze.
• Do not store medications in the refrigerator unless the physician or pharmacist advises to do so.
• Keep all medications away from children.
Postoperative Complications
A number of postoperative complications are possible:
• Infection of the T-tube site and dislodgment of the T-tube
• Bile leak and biliary stenosis (narrowing of the bile duct)
• Infections
• High blood pressure
• Rejection
• Diabetes There is no way to predict accurately which patients will have problems.
The transplant team will do their best to reduce the likelihood of complications and to treat them promptly if they occur.
Following instructions carefully and keeping the transplant team informed of any difficulties will help a patient return quickly to a normal, active life. A patient should notify the transplant team if he:
• has prolonged illness (nausea, vomiting, diarrhea)
• is unable to take medicines by mouth due to illness
• thinks the directions on the label may be different from what he was told
• has trouble removing child-resistant caps
• has a reason to take aspirin, TYLENOLR (acetaminophen), other pain relievers, cold remedies, or diet pills
• feels he is having a reaction to the medications
• has had a change in health or eating habits
• has a new prescription from his local doctor or a change in a current prescription
• experiences any unusual symptoms or side effects, as they may be related to the medications he is taking
• is undergoing dental work of any
A transplant provides a patient with a liver that can keep up with the demands of a full, active life.
What the Liver Does?
The liver is the largest organ in the body.
It is located on the right side of the abdomen (to the right of the stomach) behind the lower ribs and below the lungs.
The liver performs more than 400 functions each day to keep the body healthy. Some of its major jobs include:
• converting food into nutrients the body can use (for example, the liver produces bile to help break down fats)
•storing fats, sugars, iron, and vitamins for later use by the body
• making the proteins needed for normal blood clotting
• removing or chemically changing drugs, alcohol, and other substances that may be harmful or toxic to the body Basic Functions of the Liver The liver is the largest and one of the most complex organs in the body.
The liver performs four basic functions:
• It aids in digestion by helping in the absorption of fat and certain vitamins, including vitamins A, D, E, and K
• It helps distribute the nutrients found in food
• It helps "clean" the blood by removing medications and toxin
•It produces important proteins that affect the blood, such as factorsthat are essential in making the blood clot after an injury.
The liver produces bile, which aids in the digestion and absorption of fats.
Bile also aids inthe absorption of substances such as vitamins A, D, E, and K and medication that patients take as an immunosuppressive agent following liver transplantation.
The bile is stored in the gallbladder (which is located just below the liver) and then released into the intestines as needed. Together, these organs process the nutrients found in the foods we eat.
The liver also helps filter many chemical substances and waste products from the blood.
Most medicines are cleaned from the blood stream by the liver.
The liver also removes any alcohol that's consumed.
Symptoms of Liver Disease
• jaundice (yellowing of eyes and skin)
• severe itching
• dark urine
• mental confusion or coma
• vomiting of blood
• easy bruising and tendency to bleed
• gray or clay-colored stools
• abnormal buildup of fluid in the abdomen
Before Liver Transplant
Pretransplant Evaluation The Transplant Team Preparing and Waiting for a Transplant PRETRANSPLANT EVALUATION Pretransplant tests, as well as giving a clear picture of the patient's overall health status, help in identifying potential problems before they occur.
They also help in determining whether transplantation is truly the best option. This increases the likelihood of success.
The following procedures help in evaluating a patient's health status:
Chest x-ray - Determines the health of the patient's lungs and lower respiratory tract.
Electrocardiogram (EKG or ECG) - Determines how well the patient's heart is working and may reveal heart damage that was previously unsuspected. Ultrasound with Doppler examination - Determines the openness of the bile ducts and major vessels.
It is commonly done in all liver transplant recipients before and after transplantation. CT (CAT) scan - This computerized image will show the size and shape of the patient's liver and major blood vessels.
MRI (magnetic resonance imaging) - May be used in place of CT scan or ultrasound to see inside the patient's body.
Total-body bone scan - If the patient has a liver tumor, ensures that it has not spread to his bones.
Blood tests - The patient's blood count, blood and tissue type, blood chemistries, and immune system function will all be checked.
In addition, blood tests for certain infectious diseases will be performed. Pulmonary function test - The patient will be asked to breathe into a tube attached to a measuring device, which will reveal how well his lungs are working and determine his blood's capacity to carry oxygen.
Hepatic angiograph - Dye injected into the patient's arteries will enable the transplant physician to see if there are any abnormalities or blockages in the patient's blood vessels.
Cholangiogram - Reveals any obstructions or growths in the patient's bile ducts. Gallium, colloidal gold, or technetium scan - Gives the transplant physician a view of the patient's liver, gallbladder, and pancreas.
Peritoneoscopy - By inserting a flexible tube through a tiny incision in the patient's abdomen, the transplant physician will be able to see any structural changes in the liver.
Upper gastrointestinal (GI) series - This will show whether the patient's esophagus and stomach are disease free.
Lower GI series - Ensures that the patient is free of intestinal abnormalities. Renal function studies - Urine may be collected from the patient for 24 hours in order to determine if the kidneys are working correctly.
Blood tests such as serum creatinine are also performed to measure kidney function.
The Transplant Team
• Transplant Surgeon
• Transplant Physician (Hepatologist)
• Transplant Coordinator
• Nurse Practitioner
• Floor or Staff Nurse
• Physical Therapist
• Floor or Staff Nurse
• Dietician
• Psychologist / Psychiatrist
• Pharmacist Each of the skilled health care professionals who make up the transplant team take a personal interest in answering a patient's questions and taking care of his medical needs. They will also help the patient keep his spirits up along the way.
The patient is the most important member of the transplant team. To a certain extent, all the other team members will respond to his cues.
The patient's physical, emotional, and practical needs will help them shape a personalized pretransplant and posttransplant treatment program.
Preparing and Waiting for A Liver Transplant Days and weeks may pass while the transplant team waits?to locate the right liver for a specific patient.
During this time, the patient should prepare as much as possible and take positive steps to deal with the stresses of waiting, always staying focused on reaching the goal of transplant.
During Liver Transplant
Getting the Go-Ahead At the Hospital Preparing the Patient for Surgery Liver Transplant Surgery Procedure T-Tube Placement and Bile Drainage Getting the Go-Ahead When that important phone call comes, the patient should make sure to bring the following to the hospital:
• A list of all the medications the patient is taking • A list of the patient's drug allergies, if he has any
• The patient's health insurance information IMPORTANT: As soon as a liver is available, the patient should stop all eating and drinking immediately.
The patient's stomach must be empty when he is taken into the operating room. At the Hospital After admission, the patient will have a thorough physical examination, including more blood work, a chest x-ray, and EKG, and, possibly, other tests. Unfortunately, surgery must be postponed in some cases. The patient will be sent home again if:
• he has an infection or has developed any other medical problem that would interfere with surgery or recovery
• The donor liver shows signs of deterioration or poor function If surgery is postponed, the transplant team can help the patient through the disappointment.
This is only a temporary setback, and the search for a new liver will go on. Preparing the Patient for Surgery The patient may receive an enema to clean out his intestines and prevent constipation after surgery.
His chest and abdomen will be shaved clean to prevent infection, and an intravenous (IV) line will be inserted in his arm or just under his collarbone to give medication and keep him from getting dehydrated.
The patient will also be given a sedative to help him relax and feel sleepy before going to the operating room.
IMPORTANT:
Because transplantation is a major surgical procedure, the patient may need a transfusion.
Today, all blood is screened very carefully; the likelihood of contracting a disease is very small.
Any concerns that the patient has regarding the source of the blood should be relayed to the transplant team during the waiting period, before getting to the hospital.
Most hospitals offer the option of "autotransfusion" - this is when the patient donates his own blood before surgery. His own blood is stored and hen used during transplantation. The Liver Transplant Surgery Procedure The patient will be under general anesthesia throughout the surgery.
Once asleep, the transplant surgeon will make an incision shaped like a boomerang on the upper part of the abdomen. The surgical team will then remove the patient's old liver, leaving portions of his major blood vessels in place.
The new liver will then be inserted and attached to these blood vessels and to the patient's bile ducts.
To help with bile drainage, a tube will also be inserted in the bile duct during surgery. T-Tube Placement and Bile Drainage During liver-transplant surgery, the surgeon may find it necessary to place a small tube, called a T-tube, into the bile duct.
The T-tube allows bile to drain out of the patient's body into a small pouch, known as a bile bag. The amount of bile, which varies in color from deep gold to dark green, can then be measured.
If a T-tube is put in place, it may remain attached to a bile bag for a week or possibly longer.
When the bile bag is removed the T-tube will be tied or capped. It will remain in place for several months so that it can be used for special testing.
The T-tube is attached to the skin with a stitch.
The dressing around the tube should be changed at least once daily, and more often if it becomes moist.
The transplant nurse will show the patient how to change the dressing without pulling out the T-tube.
Other drains may be in the patient's abdomen during the postoperative period. A common name for these drains is Jackson-Pratt (JP).
They are used to drain fluid from around the liver. Generally, these drains are removed before the patient goes home.
The surgical team will then place the donor kidney into the abdomen and connect the kidney's blood vessels to the recipient's iliac artery and vein.
The surgeons will then connect the ureter to the bladder. A small drain, called a Jackson Pratt, may be placed into the abdominal cavity to drain any excess fluid.
After Liver Transplant
Waking Up in the Intensive Care Unit Medical Management in the Acute Care Unit Clinic and Follow-Up Visits Lab Tests Additional Tests and Procedures Monitoring at Home Resuming Normal Activities Avoiding Infection Communicating with the Healthcare Team Waking Up in the Intensive Care Unit (ICU) After the surgery, the patient will wake up in the intensive care unit after the anesthesia wears off.
This is what the patient should expect:
• Some pain and discomfort, which medication will help to relieve.
• A tube will be inserted through the patient's nose. This tube will run down the patient's throat and into his stomach. This tube will keep the stomach empty, to help prevent nausea and vomiting.
• A tube may be inserted into the patient's throat to help him get enough oxygen. It will be connected to a breathing machine called a ventilator. The patient should try to relax and let the machine breathe for him. The patient will not be able to talk with this tube in place, but he will only need it for a few days. Nurses will do everything they can to help the patient communicate. The patient's throat may feel sore or scratchy for a few days afterward.
• The patient will be asked to cough periodically to keep his lungs clear. If it hurts to cough, the patient should ask someone to support his abdomen.
• The patient will have an IV line in his arm or neck under the collarbone, which will be used to give fluids and medication for the first few days after surgery.
• For several days after surgery, the patient will have a catheter in his bladder to drain urine. He may feel uncomfortable, and may feel that he has to urinate constantly, but it is only temporary.
• During surgery, several drains will be placed in or near the incision. These drains will be removed 5 to 10 days after surgery.
Medical Management in the Acute Care Unit After the patient's medical condition has stabilized, he will be transferred from the ICU to the acute care unit. During the patient's stay on this unit, his laboratory studies, medications, nutritional status and exercise tolerance will be monitored.
As soon as the patient is able, discharge instructions will begin to prepare him for going home.
Clinic and Follow-up Visits Upon leaving the hospital, the patient will receive a schedule of follow-up clinic visits for lab tests and checkups.
The purpose is to track your progress and detect potential complications as early as possible.
On days when the patient is scheduled for follow-up visits, he should bring his medication list and his surgery handbook.
He will be given specific instructions for routine lab work or special tests that he might need.
Lab Tests A usual lab test monitors blood count, clotting, kidney function, liver function, electrolytes, and medication levels in the patient's blood.
Other tests may be ordered as necessary.
Tests for BLOOD COUNT: WBC tell if the patient's white blood cells have increased (usually a sign of infection) or decreased (indicating a lower defense against infection).
HCT measures the hematocrit, which is the percentage of red blood cells in the blood. Red blood cells carry oxygen to all parts of the body.
When a patient's HCT is low, he may feel tired or have little energy.
PLTmeasures the level of platelets. Platelet cells form a blood clot when the body is injured.
Low platelet levels may cause someone to bruise easily and to bleed for a longer time when injured.
Test for KIDNEY FUNCTION: Creatinine and BUN tell how well the kidneys work by measuring levels of creatinine and blood urea nitrogen, waste products normally removed from the blood by the kidneys.
Tests for LIVER FUNCTION: Bili measures the level of bilirubin, a normal byproduct when hemoglobin from red blood cells breaks down.
The liver removes bilirubin from the blood and excretes it in the bile.
When the liver is not functioning normally, bilirubin levels can increase, often resulting in jaundiced (yellowed) skin and eyes.
Alk Phos measures alkaline phosphatase, which is made in the bones, liver, pancreas, and intestines and removed from the blood by the liver. AST, ALT, and GGTP test enzymes that are made in the liver.
These tests tell how well the liver is working. K measures potassium, which is needed for normal heart and muscle function.
Tests for ELECTROLYTES (dissolved minerals): Ca measures calcium, which is necessary for strong bones and teeth, blood clotting, and heart and nerve function.
NOTE: The desired level (normal range) will differ for each person, depending on the combination of immunosuppressive medications and the length of time since the transplant.
PO4 measures phosphate, which works closely with calcium to strengthen bones. Mg measures magnesium, which is necessary for normal functioning of muscles and for blood clotting.
K measures potassium, which is needed for normal heart and muscle function. Na measures sodium, which helps maintain the balance of salt and water in the body.
Other blood tests: Drug levels measure PROGRAF or SANDIMMUME in the blood. PROGRAF or SANDIMMUNE blood levels must be checked regularly to avoid levels that are too high or too low.
High levels could lead to toxicity or over-immunosuppression, and low levels may lead to rejection.
NOTE: The desired level (normal range) will differ for each person, depending on the combination of immunosuppressive medications and the length of time since the transplant.
Glu measures glucose, levels of sugar in the blood; some medications may produce a diabetes-like condition in which blood-sugar levels are too high.
Additional Tests and Procedures The transplant team may perform one or more of the following tests and procedures to monitor a patient's transplant: Ultrasound - This test is performed to make sure all the main blood vessels leading to the liver are functioning normally.
This test is also used to check for collections of fluid, such as blood or bile.
The procedure consists of placing a cool gel on the patient's abdomen, over which a wand (transducer) is moved to transmit sound waves.
These are converted into images of the liver and projected onto a television screen.
Percutaneous transhepatic cholangiogram (PTC) - This is an X ray that shows the patient's bile ducts to check for leaks, blockages, or other potential problems.
The procedure starts with a dye injection into the T-tube. The dye makes the ducts easy to see on X ray.
If a T-tube was not placed during your surgery, this X ray will be performed after dye has been injected directly into the liver-bile ducts. Liver biopsy (test sample) This test is usually performed to check for rejection, hepatitis, or other possible problems.
This may be done in the hospital or in the outpatient/short-stay unit. The patient will receive special instructions regarding the procedure.
Before the procedure, the patient will receive a numbing injection (local anesthetic) on the right side of his abdomen.
Then a special needle will be inserted to withdraw a small sample of liver tissue that will be examined with a microscope.
After this procedure, the patient must lie on his right side for at least 1 hour and stay in bed for about 4 hours.
Computerized tomography (CT) scan - This is a type of X ray that allows the physician to view the patient's liver from many different angles to detect infections, fluid collections, or other problems.
The procedure requires that the patient drink a liquid that outlines his stomach and intestines and makes his liver more visible; then he lies flat for 1 hour while the machine takes X rays around him. Magnetic resonance imaging (MRI) - This is another type of test that produces an image.
Somewhat like a CT scan, it also allows a patient's liver to be viewed from different angles and in three-dimensional images.
An MRI shows soft tissues, such as the liver, more clearly than a CT scan does. Endoscopic retrograde cholangiopancreatogram (ERCP) - This test allows the physician to see the patient's biliary tree (the various ducts in and around the liver), as well as the ducts from the pancreas.
The patient will be given medicine to relax him before the procedure. An endoscope (a type of tube) is placed in his mouth; it is advanced through to his stomach and into his intestine to the liver.
A dye is then infected through the endoscope that makes the ducts visible in X rays.
Monitoring Health and A New Liver at Home After a patient is discharged from the hospital, he may be asked to monitor: Temperature - A patient should check and record temperature any time he feels chilled, hot, achy, or ill.
This may be the first sign of infection.
WARNING: DO NOT USE TYLENOLR, ADVILR (Ibuprofen), aspirin, or other such products except under the direction of a physician, as these drugs may cause further symptoms.
If a patient's temperature is higher than normal at any time, he should notify his transplant coordinator immediately.
This is considered an emergency, because an elevated temperature could indicate a serious infection or rejection. Blood pressure - A nurse or transplant coordinator will show how to measure blood pressure, if necessary.
The top number (systolic) is noted at the first sound, and the bottom number (diastolic) is noted when the sound changes (not stops).
It is important that a patient knows his normal blood pressure, normal changes, and when he should be concerned.
Pulse - If a patient is taking medication that affects heart rate, the nurse or coordinator will show how to check his own pulse at home. NOTE: If a patient experiences chest pain or has difficulty breathing, he should call 911 for an ambulance and go to the nearest emergency room.
He SHOULD NOT attempt to drive himself. Weight - The patient may weigh himself on a standard bathroom scale at the same time every morning (after going to the toilet).
If he gains more than 2 pounds per day, he could be retaining fluid.
This should be reported to the transplant coordinator.
Resuming Normal Activities Although the patient is encouraged to resume normal activities after recovery, it is important to understand that having a new liver brings new responsibilities.
• Skin and Hair Care
• Sexual Activity
• Smoking
• Vacations and Travel
• Dental Care
• Pregnancy
• Exercise
• Diet and Nutrition
• Alcoholic Beverages Signs to Watch Out For While primary concerns involve infection and rejection, many other problems, such as colds or flu, adjustment of other medications, and minor infections can be handled by a local physician.
A patient needs to take precautions and learn to watch for signs of infection and rejection that necessitate notifying a local physician or transplant team immediately. These include:
• a fever that continues for more than 2 days
• shortness of breath
• a cough that produces a yellowish or greenish substance
• a dry cough that continues for more than 1 week
• prolonged nausea, vomiting, or diarrhea
• an inability to take prescribed medication
• bleeding, bruising, black stools, red or rusty-brown urine
• a rash or other skin changes
• pain, discharge, or swelling at the T-tube site
• vaginal discharge or itching
• burning discomfort with urination
• exposure to mumps, measles, chicken pox, or shingles
• unusual weakness or light-headedness
• emergency-room treatment or hospitalization Avoiding Infection Because immunosuppressive medications interfere with a patient's natural immune system, he needs to protect himself consciously from infection after the surgery by taking the following precautions:
• Wash hands often.
• Keep hands away from face and mouth.
• Stay away from people with colds or other infections.
• Ask friends to visit only when they are well.
• If the patient has a wound and must change his own dressing, wash hands before and after.
• Wash hands after coughing or sneezing, and throw tissues into the trash immediately.
• If someone in the patient's family becomes ill with a cold of flu, have that individual follow normal precautions (use separate drinking glasses, covering their mouths when coughing, etc.)
• Avoid working in the soil for 6 months after the transplant. Thereafter, wear gloves. • Avoid handling animal waste and avoid contact with animals who roam outside.
Do not clean bird cages or fish or turtle tanks or cat litter.
The cat litter box should be covered and taken out of a patient's home before it is changed.
• Avoid vaccines that consist of live viruses, such as Sabin oral polio, measles, mumps, German measles, yellow fever, or smallpox.
The live virus can cause infections. If a patient or any family member intends to receive any vaccinations, they should notify the transplant team or local physician.
SPECIAL WARNING TO PARENTS OF CHILDREN WHO HAVE HAD TRANSPLANTS:
Ask the school nurse or other official to notify you immediately of any communicable diseases (for example, measles, chicken pox) that may be circulating in your school.
Communicating with the Healthcare Team Communication and cooperation between the transplant team, local physician, pharmacist, dentist, and the patient himself is vital to his well-being. Having a transplanted liver and taking the medications needed to prevent rejection put a patient at risk for a number of complications.
It is important to follow the instructions that will help prevent or lessen complications.
One of a patient's most important jobs is to make certain that all members of his local healthcare team - family physician, dentist, local pharmacist, and any other healthcare professionals he sees - are aware of the transplant, the medications he takes each day, and the precautions he must follow to stay healthy.
Each of his local healthcare providers should be given the telephone number of his transplant team.
He should ask that they contact the transplant center for specific
information.
Anxiety and Depression A serious procedure such as the one just experienced can create many personal and family stresses.
It is not uncommon for transplant patients to experience anxiety and perhaps depression following their surgery, hospital confinement, and return home.
To help a patient adjust to life at home and an eventual return to work or school, counseling and support group services are available.
The patient should consult the transplant social worker or coordinator for information regarding services available to help resolve stress and anxiety.
Medications Medication Guidelines Postoperative Complications Medication Guidelines The patient is responsible for taking the medications that have been prescribed for him. He should talk to his physician, pharmacist, transplant nurse, and/or coordinator to understand fully:
• the name and purpose of each medication
• when to take each medication
• how to take each medication
• how long to continue taking each medication
• principal side effects of each medication
• what to do if he forgets to take a dose
• when to order more medication so it doesn't run out
• how to order or obtain medications
• what to avoid while taking medications At home, the recovering patient will continue taking most of the medicines he began taking in the hospital after the transplant surgery, especially the anti-rejection medications.
His immune system recognizes the new liver as foreign and will try to reject it. Therefore, his immune system must be controlled with immunosuppressive medications.
The patient probably will have to take one or more of these drugs for the rest of his life, in addition to other medications.
REMINDER :
Never stop taking medication or change the dosage without a physician's approval.
Before taking medications:
• Ask the nurse, coordinator, or pharmacist to help in selecting the best times to take medications.
• Try to take each medication at the same time every day.
• Follow a written schedule.
• DO NOT cut or crush a tablet unless advised to do so. Storing medications
• Keep medications in the original container, tightly capped.
If a special container is used to hold the pills, keep the container tightly sealed.
• Store in a cool, dry place away from direct sunlight.
• Do not store medications in the bathroom -- moisture can cause medications to lose their strength.
• Do not allow liquid medications to freeze.
• Do not store medications in the refrigerator unless the physician or pharmacist advises to do so.
• Keep all medications away from children.
Postoperative Complications
A number of postoperative complications are possible:
• Infection of the T-tube site and dislodgment of the T-tube
• Bile leak and biliary stenosis (narrowing of the bile duct)
• Infections
• High blood pressure
• Rejection
• Diabetes There is no way to predict accurately which patients will have problems.
The transplant team will do their best to reduce the likelihood of complications and to treat them promptly if they occur.
Following instructions carefully and keeping the transplant team informed of any difficulties will help a patient return quickly to a normal, active life. A patient should notify the transplant team if he:
• has prolonged illness (nausea, vomiting, diarrhea)
• is unable to take medicines by mouth due to illness
• thinks the directions on the label may be different from what he was told
• has trouble removing child-resistant caps
• has a reason to take aspirin, TYLENOLR (acetaminophen), other pain relievers, cold remedies, or diet pills
• feels he is having a reaction to the medications
• has had a change in health or eating habits
• has a new prescription from his local doctor or a change in a current prescription
• experiences any unusual symptoms or side effects, as they may be related to the medications he is taking
• is undergoing dental work of any
Thursday, January 25, 2007
الالتهاب الكبدي الوبائي و
Hepatitis G الالتهاب الكبدي الوبائي و
اكتشف الفيروس عام 1996 ولكن المعلومات المتوفرة قليلة جدا ولا تزال الأبحاث جارية لمعرفة المزيد. والمعلومات المتوفرة حاليا ربما تتغير مع ظهور نتائج الأبحاث.طرق انتقالهعن طريق الدم، وربما تكون بشكل يشبه انتقال فيروس التهاب الكبد الوبائي (ج) Hepatitis C.نسبة حدوثه وأعراضهتقدر نسبة حدوثه بـ 0.3% أو 3 حالات من كل 1000 حالة من حالات الالتهابات الكبدية الحادة. ويعتقد بأنه يسبب من 900 إلى 2000 حالة التهاب فيروسي في السنة معظمها بدون أعراض وبأن نسبة 90-100% من المصابين به تصبح إصابتهم مزمنة ولكنه نادرا ما يسبب مرضا مزمنا شديد المضار مقارنة بفيروسات الكبد الأخرى.طرق انتقال العدوى
نقل الدم أو منتجات الدم
إدمان المخدرات عن طريق الحقن
تزامن وتعدد الإصابة بفيروس الكبد الوبائي (ج) Hepatitis C
طرق أخرى (لا تزال غير مؤكدة أو معروفه) طرق منع انتشار العدوىحاليا لا يوجد تعليمات إلى أن يتم التأكد من خصائص ومسببات هذا الفيروس، طرق انتقال العدوى، وتطوير طرق سهلة للكشف عنه.
الالتهاب الكبدي الوبائي هـ
Hepatitis E الالتهاب الكبدي الوبائي هـ
التهاب الكبد الوبائي (هـ) يعتبر من الأمراض الوبائية المرتبطة بتلوث المياه. لقد تسبب الفيروس (هـ) في حدوث عدة كوارث وبائية في عدة بلدان كالهند (1955 و1975-1976) والاتحاد السوفيتي (1975-1976) ونيبال (1973) وبرما (1976-1977) والجزائر (1980-1981) وساحل العاج (1983-1984) ومخيمات اللاجئين في شرق السودان والصومال (1985-1986) والمكسيك (1986).بينت بعض الأبحاث أن هذا الفيروس تقريبا أصاب 10% من سكان المملكة العربية السعودية و25% من سكان جمهورية مصر العربية.طريقة انتقالهينتقل هذا الفيروس إلى الإنسان عن طريق الفم بواسطة الأكل أو الشرب الملوثين. ولأن الفيروس يخرج من جسم المصاب عن طريق البراز فعادة يكون سبب العدوى مياه الشرب الملوثة بمياه الصرف الصحي. تتراوح فترة حضانة الفيروس بين أسبوعين و 9 أسابيع. ويعتبر الأشخاص بين 15-40 سنة أكثر عرضة للإصابة به. النساء الحوامل أكثر المعرضين وبشكل خاص للإصابة بهذا الفيروس وتكون نسبة الوفاة لديهم أعلى بكثير، إذ ربما تصل إلى 20% مقارنة بأقل من 1% عند الآخرين.الأعراضسر يريا لا يوجد فرق بين التهاب الكبد الوبائي (هـ) والتهاب الكبد الوبائي (أ). الفيروس (هـ) يسبب التهاب كبدي حاد عادة يزول تلقائيا والأعراض تشمل الصفار (اليرقان)،ضعف عام، ضعف الشهية، الغثيان، آلام البطن، وارتفاع الحرارة. من الممكن أن يؤدي الالتهاب إلى قتل خلايا الكبد وبالتالي إلى فشل كبدي ثم الوفاة خاصة عند النساء الحوامل.التشخيصالمعرفة بوجود كارثة وبائية تساعد على سرعة التشخيص. ويتم التأكد بعمل فحص للدم.العلاجالفيروس (هـ) يسبب التهاب كبدي حاد عادة يزول تلقائيا لذلك لا يتم إعطاء أدوية ولكن ينصح المريض بالإكثار من شرب السوائل وتناول غذاء صحي ومتوازن.طرق الوقاية
منع تلوث مياه الشرب بمياه الصرف الصحي
شرب الماء النظيف
تناول الأطعمة الغير ملوثة أو المطبوخة (الحرارة تقضي على الفيروس)
الاهتمام بالنظافة الشخصية خاصة لدى المصابين وذلك بغسل اليدين بالماء والصابون بعد استعمال الحمام
منع تلوث مياه الشرب بمياه الصرف الصحي
شرب الماء النظيف
تناول الأطعمة الغير ملوثة أو المطبوخة (الحرارة تقضي على الفيروس)
الاهتمام بالنظافة الشخصية خاصة لدى المصابين وذلك بغسل اليدين بالماء والصابون بعد استعمال الحمام
الإلتهاب الكبدي الوبائي د
Hepatitis D (delta) الإلتهاب الكبدي الوبائي د
الفيروس (د) ويسمى أيضا بفيروس الدلتا Delta virus لا يستطيع استنساخ نفسه (التكاثر) إلا بوجود فيروس أخر، لذلك ففيروس
التهاب الكبد الوبائي (د) يوجد دائما مع التهاب الكبد الوبائي (ب) Hepatitis B. يوجد الفيروس (د) في المملكة العربية السعودية عند 8% من المصابين بالتهاب الكبد الوبائي (ب) وعند أقل من 2% من حاملي فيروس التهاب الكبد الوبائي (ب).طرق انتقالهينتقل التهاب الكبد الوبائي (د) عن طريق نقل الدم أو منتجاته. أو بالاتصال الجنسي. العوامل المساعدة على انتقاله تشبه العوامل المساعدة على انتشار فيروس التهاب الكبد الوبائي (ب). والمدمنون على المخدرات عن طريق الحقن هم أكثر المصابين.أعراضهعندما يصاب المريض بعدوى الفيروس (د) و الفيروس (ب) في نفس الوقت تسمى العدوى عدوى متزامنة co-infection وعندما تحدث الإصابة بفيروس (د) في أي وقت عند المريض المصاب بفيروس التهاب الكبد الوبائي (ب) تسمى عدوى إضافية super-infection.يجب وضع احتمال العدوى الإضافية بالفيروس (د) عند أي مريض بالتهاب الكبد الوبائي (ب) المزمن والذي يعاني من تطور سيئ ومفاجئ للمرض. وعادة يوجد سابقة أو سوابق للتعرض للدم الملوث، مثلا مدمن على المخدرات عن طريق الحقن. وفي الحالات الحادة والشديدة بشكل خاص من التهاب الكبد الوبائي (ب) فإنه يوجد احتمال كبير بأن تكون هناك إصابة متزامنة بالفيروس (د).العلاجيستخدم دواء انترفيرون ألفا interferon-alpha لعلاج المرضى المصابين بالتهاب الكبد الوبائي (ب) و (د). بعض الدراسات تقترح بأن استخدام جرعات أعلى من تلك المستخدمة لعلاج التهاب الكبد الوبائي (ب) ربما يكون مفيدا.التشخيصيتم تشخيص العدوى المتزامنة أو الإضافية للفيروس (د) عن طريق اختبار للكشف عن وجود الأجسام المضادة للفيروس (د).طرق الوقايةلا يوجد إلى الآن تطعيم ضد هذا الفيروس، ولكن بما أته يلزم وجود الفيروس (ب) لتتم العدوى بالفيروس (د) فالتطعيم ضد الفيروس (ب) يوفر الحماية ضد الفيروسين ولو بطريقة غير مباشرة بالنسبة للفيروس (د). أما المرضى المصابين بالفيروس (ب) فهم معرضين للإصابة بالفيروس (د)، ولذلك يجب اتخاذ إجراءات الوقاية الضرورية لتفادي الإصابة.
الالتهاب الكبدي الوبائي ج
Hipatitis C الالتهاب الكبدي الوبائي ج
وهو يوصف غالبا بالوباء "الصامت" ، الالتهاب الكبدي الوبائي (ج) يبقى مجهول بشكل نسبي وعادة يتم تشخصيه في مراحله المزمنة عندما يتسبب بمرض كبدي شديد. الالتهاب الكبدي الوبائي (ج) أكثر عدوى وأكثر شيوعا من فيروس إتش آي في HIV (الفيروس الذي يسبب مرض الإيدز) ويمكن أن يكون مميت. فالالتهاب الكبدي الوبائي (ج) يصيب على الأقل 170 مليون إنسان على مستوى العالم بضمن ذلك 9 مليون أوربي و4 مليون أمريكي. فهو يعتبر أكثر من تهديد للصحة عامة، إذ بإمكانه أن يكون الوباء العالمي القادم.
في الولايات المتحدة الأمريكية وحدها يصاب 180,000 إنسان سنويا ويقدر عدد الذين يموتون سنويا بسبب الالتهاب الكبدي الوبائي (ج) بـ 10,000 إنسان. يتوقّع ارتفاع هذا العدد إلى ثلاثة أضعاف خلال العشرة سنوات القادمة. الحقيقة القاسية هي أننا إلى الآن نعرف فقط القليل جدا عن الالتهاب الكبدي الوبائي (ج).
ما هو الالتهاب الكبدي الوبائي (ج) ، وماذا ينتج عنه؟
ينتقل بشكل أساسي من خلال الدم أو منتجات الدم المصابة بالفيروس. فهو واحد من عائلة من ستة فيروسات (أ ، ب ، ج ، د ، هـ ، و) أو (A, B, C, E, D, G) تسبب التهاب كبدي والسبب الرئيسي لأغلبية حالات التهاب الكبد الفيروسي. بعد الإصابة بالفيروس يستغرق تطور مرض الكبد الحقيقي حوالي 15 سنة. ربما تمر 30 سنة قبل أن يضعف الكبد بالكامل أو تظهر الندوب أو الخلايا السرطانية. "القاتل الصامت" ، الالتهاب الكبدي الوبائي (ج) ، لا يعطي إشارات سهلة التمييز أو أعراض. المرضى يمكن أن يشعروا ويظهروا بشكل صحي تام، لكنهم مصابون ويصيبون الآخرون.
طبقا لمنظمة الصحة العالمية، 80% من المرضى المصابين يتطورون إلى التهاب الكبد المزمن. ومنهم حوالي 20 بالمائة يصابون بتليف كبدي ، ومن ثم 5 بالمائة منهم يصابون بسرطان الكبد خلال العشرة سنوات التالية. حاليا ، يعتبر الفشل الكبدي بسبب الالتهاب الكبدي (ج) المزمن السبب الرئيسي لزراعة الكبد في الولايات المتحدة. ويكلف ما يقدر بـ 600 مليون دولار سنويا في النفقات الطبية ووقت العمل المفقود.لقد تم التعرف على الفيروسات المسببة للالتهاب الكبدي (أ) و (ب) منذ زمن طويل إلا أن الفيروس المسبب للالتهاب الكبدي (ج) لم يتم التعرف عليه إلا في عام 1989 م. ولقد تم تطوير وتعميم استخدام اختبار للكشف عن الفيروس (ج) عام 1992. هذا الاختبار يعتمد على كشف الأجسام المضادة للفيروس ويعرف باسم (ANTI-HCV).
كيفية انتقال العدوى بالفيروس (ج)
يتم انتقال العدوى بهذا الفيروس بالطرق التالية:
· نقل الدم ، منتجات الدم (المواد المخثرة للدم ، إدمان المخدرات عن طريق الحقن، الحقن).
· زراعة الأعضاء (كلية، كبد، قلب) من متبرع مصاب.
· مرضى الفشل الكلوي الذين يقومون بعملية الغسيل الكلوي معرضين لخطر العدوى بفيروس الالتهاب الكبدي (ج).
· استخدام إبر أو أدوات جراحية ملوثة أثناء العمليات الجراحية أو العناية بالأسنان.
· الإصابة بالإبر الملوثة عن طريق الخطأ.
· المشاركة في استعمال الأدوات الحادة مثل أمواس الحلاقة أو أدوات الوشم.
· العلاقات الجنسية المتعددة الشركاء. الفيروس لا ينتقل بسهولة بين المتزوجين أو من الأم إلى الطفل ولا ينصح باستخدام الواقي أو العازل الطبي للمتزوجين، ولكن ينصح باستخدامه لذوي العلاقات الجنسية المتعددة.
أهم طريقتين لانتقال العدوى هما إدمان المخدرات عن طريق الحقن بسبب استعمال الإبر وتداولها بين المدمنين لحقن المخدرات، ونقل الدم ومنتجاته. لذلك كان مستقبلو الدم، حتى عام 1991، معرضين لخطر العدوى بفيروس الالتهاب الكبدي (ج). كذلك أصبح الالتهاب الكبدي من نوع (ج) واسع الانتشار بين مرضى الناعور أو الهيموفيليا Hemophilia (مرض عدم تجلط الدم) والذين يتم علاجهم بواسطة مواد تساعد على تخثر الدم والتي كانت تعد من دم آلاف المتبرعين قبل اكتشاف الفيروس. وتحدث العدوى أيضاً بين الأشخاص دون وجود العوامل التي تم ذكرها ولأسباب غير معروفة.على العكس من فيروس الالتهاب الكبدي (أ) ففيروس الالتهاب الكبدي (ج) لا يتم نقله عن طريق الطعام أو الماء أو البراز. كما أن فيروس الالتهاب الكبدي (ج) غير معد بصورة كبيرة بين أفراد الأسرة.يوجد بضعة عوامل مساعدة تلعب دور مهم في تطور التليف الكبدي:
1. العمر الوقت العدوى (في المعدل، المرضى الذين يصابون بالمرض في عمر أكبر يكونون عرضة لتتطور المرض بشكل سريع، بينما التطور يكون أبطأ في المرضى الأصغر).
2. إدمان الخمور (كل الدراسات تأكد على أن الكحول عامل مشارك مهم جدا في تطور إلإلتهاب الكبدي المزمن إلى تليف كبدي)
3. عدوى متزامنة مع إتش آي في HIV (الفيروس الذي يسبب مرض الإيدز)
4. عدوى متزامنة مع فيروس الالتهاب الكبدي (ب)
ماذا يحدث بعد الإصابة بعدوى الالتهاب الكبدي (ج)؟
معظم المصابين بالفيروس لا تظهر عليهم أعراض في بادئ الأمر ولكن البعض ربما يعاني من أعراض الالتهاب الكبدي الحاد (يرقان أو ظهور الصغار). قد يستطيع الجسم التغلب على الفيروس والقضاء عليه، ونسبة حدوث ذلك تكون بحدود 15%. النسبة الباقية يتطور لديها المرض إلى الحالة المزمنة.
ماذا يحدث في الالتهاب الكبدي (ج) المزمن؟
نسبة الحالات التي تتحول من التهاب حاد إلى مزمن تقدر بـ 85% - 70%. وأن نسبة 25% منها تتحول من التهاب مزمن إلى تليف في الكبد خلال 10 سنوات أو أكثر. الالتهاب المزمن مثل الحاد يكون بلا أعراض ولا يسبب أي ضيق، ماعدا في بعض الحالات التي يكون من أعراضها الإحساس بالتعب وظهور الصفار وبعض الأعراض الأخرى. عندما يصاب المريض بتليف الكبد تظهر أعراض الفشل الكبدي عند البعض ، وربما لا تظهر أعراض للتليف وربما يكون السبب الوحيد لاكتشافه تضخم الكبد والطحال أو غيره من الأعراض. التليف في الكبد من الممكن أن يعرضه لظهور سرطان الكبد. تطور الالتهاب الكبدي (ج) بطئ ويحتاج إلى عقود من الزمن، لذلك فأي قرار تنوي اتخاذه بخصوص العلاج ليس مستعجلا ولكن يجب أن لا تهمل العلاج.
هل هناك احتمال لنقل العدوى من خلال الممارسات الجنسية؟
الفيروس لا ينتقل بسهولة بين المتزوجين ولا ينصح باستخدام الواقي أو العازل الطبي للمتزوجين، ولكن ينصح باستخدامه لذوي العلاقات الجنسية المتعددة الشركاء. نسبة الالتهاب الكبدي (ج) أعلى بين المجموعات التي تمارس علاقات جنسية مختلطة أو شاذة مثل محترفي الدعارة أو ممارسي اللواط. وهنا يصعب التفريق بين تأثير عوامل أخرى مثل إدمان المخدرات عن طريق الحقن.يوجد بضعة عوامل قد تلعب دور في نسبة الإصابة بالالتهاب الكبدي (ج) من خلال الممارسات الجنسية مثل مستوى الفيروس في الدم وطبيعة الممارسة الجنسية من ناحية التعرض للتلوث بالدم (أثناء الدورة الشهرية أو وجود تقرحات في الجهاز التناسلي) أو تزامن عدوى مع إتش آي في HIV (الفيروس الذي يسبب مرض الإيدز) أو أمراض جنسية أخرى أو الاتصال جنسيا عن طريق الشرج (اللواط).
هل هناك احتمال لنقل العدوى إلى أفراد العائلة؟
فيروس الالتهاب الكبدي (ج) لا يتم نقله عن طريق الطعام أو الماء أو البراز ولذلك فهو غير معد بصورة كبيرة بين أفراد الأسرة. نسبة انتقال العدوى تزداد قليلا إذا تمت المشاركة في استعمال الأدوات الحادة مثل أمواس الحلاقة أو فرش الأسنان. لا يجب القلق من احتمال نقل العدوى عن طريق الطعام والشراب عن طريق الشخص الذي يقوم بتجهيزها.
هل هناك إحتمال لنقل العدوى من الأم وليدها؟
لا يمنع الحمل بالنسبة للنساء المصابات بفيروس الالتهاب الكبدي (ج). ولا يوصى بإجراء فحص لفيروس الالتهاب الكبدي (ج) للنساء الحوامل. فنسبة الانتقال العمودي (من الأم إلى الطّفل) أقل من 6%. ولا يوجد أي طريقة لمنع ذلك. ومع ذلك فالأطفال المصابين بهذا الفيروس منذ الولادة لا يتعرضوا لمشاكل صحية في سنوات العمر الأولى. يلزم إجراء مزيد من الدراسات لمعرفة تأثير الفيروس عليهم مع تقدمهم في العمر.يبدو أن خطر الانتقال أكبر في النساء ذوات المستويات العالية من الفيروس في الدم أو مع وجود عدوى متزامنة مع إتش آي في HIV (الفيروس الذي يسبب مرض الإيدز). طريقة الولادة (قيصرية أو طبيعية) لا يبدو أنها تؤثر على نسبة انتقال فيروس الالتهاب الكبدي (ج) من الأم إلى الطفل. كما لا يوجد ارتباط بين الإرضاع عن طريق الثدي والعدوى من الأم إلى الطفل. ولكن ينصح بوقف الإرضاع عن طريق الثدي إذا تعرضت حلمات الثدي للتشقق أو إذا أصيب الثدي بعدوى جرثومية إلى أن يتم حل المشكلة.
ما هي أعراض الالتهاب الكبدي؟
· يأتي المريض أحياناً بأعراض تشير إلى وجود تليف بالكبد مثل الصفار الذي يصاحب الاستسقاء ، أو تضخم الكبد والطحال أو نزيف الدوالي أو أي أعراض شائعة مثل التعب.
· الأعراض عادة غير شائعة وإذا وجدت فإن هذا ربما يدل على وجود حالة مرضية حادة أو حالة مزمنة متقدمة.
· يكتشف بعض الأشخاص وجود المرض لديهم بالمصادفة عند إجراء اختبار دم والذي يظهر وجود ارتفاع في بعض أنزيمات الكبد والمعروفة باسم ALT وAST والفحوصات الخاصة بفيروس (ج).
ماذا إذا كنت لا تشعر بالمرض؟
العديد من الأشخاصِ المصابين بالالتهاب الكبدي (ج) المزمن لا يوجد لديهم أعراض ، لكن يجب مراجعة الطبيب لتلقي العلاج. بعض الأشخاصِ يشكون فقط من تعب شديد.
كيف يتم تشخيص الالتهاب الكبدي (ج)؟
· عند احتمال إصابة شخص بالالتهاب الكبدي عن طريق وجود أعراض أو ارتفاع في أنزيمات الكبد فإن الالتهاب الكبدي (ج) يمكن التعرف عليه بواسطة اختبارات الدم والتي تكشف وجود أجسام مضادة للفيروس (ج) ANTI-HCV.
· إذا كان فحص الدم بواسطة اختبار (إليزا ELISA) إيجابياً ، فهذا يعني أن الشخص قد تعرض للفيروس وأن مرض الكبد ربما قد سببه الفيروس (ج). ولكن أحياناً يكون الاختبار إيجابياً بالخطاء ، ولذا يجب أن نتأكد من النتيجة. عادة تكون هناك عدة أسابيع تأخير بين الإصابة الأولية بالفيروس وبين ارتفاع نسبة الأجسام المضادة في الدم. لذا فقد يكون الاختبار سلبياً في المراحل الأولى للعدوى بالفيروس ويجب أن يعاد الاختبار مرة أخرى بعد عدة شهور إذا كان مستوى أنزيم الكبد ALT مرتفعاً.
· من المعروف أن حوالي %5 من المرضى المصابين بالالتهاب الكبدي (ج) لا يكونون أجساماً مضادة للفيروس (ج) ولكن تكون نتيجة اختبار الدم HCV-RNA إيجابية.
· إذا كان الفحص السريري واختبارات الدم طبيعية فيجب أن يتكرر الاختبار لأن الالتهاب الكبدي (ج) يتميز بأن أنزيمات الكبد فيه ترتفع وتنخفض وأن الأنزيم الكبدي ALT من الممكن أن يبقى طبيعياً لمدة طويلة ، ولذا فإن الشخص الذي يكون إيجابياً لاختبار ANTI-HCV يعد حاملاً للفيروس إذا كانت أنزيمات الكبد طبيعية.
· أما إذا كانت الأجسام المناعية المضادة للفيروس (ج) موجودة في الدم ANTI-HCV فهذا يمكن ترجمته على أنه دليل لوجود عدوى سابقة بالفيروس (ج) ، ونظراً لأن الاختبار التأكيدي HCV-RNA للفيروس إيجابي ، فيجب أن يتم تحويل هؤلاء الأشخاص إلى طبيب متخصص بأمراض الكبد لإجراء مزيد من الفحوصات وأخذ عينة من الكبد نظراً لأن نسبة كبيرة منهم مصابون بالتهاب كبدي مزمن.
هل من الممكن تجنب الالتهاب الكبدي (ج)؟
لسوء الحظ لا يوجد حتى الآن تطعيم أو علاج وقائي ضد الالتهاب الكبدي (ج) ولكن توجد بعض الإرشادات التي يمكن اتباعها للحد من الإصابة به:
· استعمال الأدوات والآلات الطبية ذات الاستعمال الواحد لمرة واحدة فقط مثل الإبر.
· تعقيم الآلات الطبية بالحرارة (أوتوكلاف - الحرارة الجافة).
· التعامل مع الأجهزة والنفايات الطبية بحرص.
· تجنب الاستعمال المشترك للأدوات الحادة مثل (أمواس الحلاقة والإبر وفرش الأسنان ومقصات الأظافر).
· تجنب المخدرات.
· المرضى المصابون بالالتهاب الكبدي (ج) يجب أن لا يتبرعوا بالدم لأن الالتهاب الكبدي (ج) ينتقل عن طريق الدم ومنتجاته.
هناك شبه إجماع في الوقت الحالي على أن الأشخاص المصابين بالفيروس (ج) يجب ألا يقلقوا من انتقال العدوى إلى ذويهم في البيت ، أو إلى الذين يعملون أو يتعاملون معهم إذا اتبعوا التعليمات السابقة. لأن الفيروس (ج) لا ينتقل عن طريق الأكل والشرب ، لذا فإن الأشخاص المصابين بالفيروس (ج) يمكن أن يشاركوا في إعداد الطعام للآخرين.الشخص المصاب بالالتهاب الكبدي (ج) معرض أيضا للإصابة بالالتهاب الكبدي (أ) و (ب). ويلزم استشارة طبيب بخصوص إمكانية التطعيم ضد الالتهاب الكبدي (أ) أو (ب).
هل يوجد علاج للالتهاب الكبدي (ج)؟
إلى أواخر التسعينيات تم استخدام دواء إنترفيرون ألفا Alfa Interferon عن طريق الحقن 3 مرات أسبوعيا مع دواء ريبافيرين ribavirin عن طريق الفم لعلاج الالتهاب الكبدي المزمن (ج) لمدة 6 أو 12 شهرا وكانت نتائجه غير مشجعة وبالذات في العالم العربي. ولكن الآن وبعد أن تم تطوير دواء الإنترفيرون بشكل مختلف أدى إلى زيادة فاعليته بشكل كبير فإن الأطباء ينصحون باستخدام الإنترفيون المطور والمسمى بيج-إنترفيرون peginterferon alfa ويعطى مرة واحدة أسبوعيا بدلا من 3 مرات . والنتائج تعتبر فعلا مشجعة جدا إذ أصبح بإمكان الأطباء الآن القول بأنه يتوفر علاج للالتهاب الكبدي الوبائي ج . نتيجة لهذا التطور يتوفر الآن مستحضرين :بيج-انترفيرون الفا 2 ب peginterferon alfa-2bبيج-انترفيرون ألفا 2 أ peginterferon alfa-2aوبناء على نوع الفيروس فإنهما يستخدمان إما لوحدهما أو مع دواء ريبافيرين ribavirin عن طريق الفم لمدة 6 أو 12 شهرا .
تحذير:دواء ريبافيرين ribavirin ضار بالجنين ويسبب تشوهات، لذلك يمنع الحمل أثناء تعاطيه سواء من قبل الأم أو الأب. ويجب اتخاذ جميع الاحتياطات لمنع حدوث الحمل عن طريق استخدام وسائل منع الحمل.
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