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).
Sunday, April 12, 2009
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
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