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.

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.

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).

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.

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

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