Liver cancer and Liver Transplant in India

What is liver cancer?

Cancer starts when cells in the body begin to grow out of control. Cells in nearly any part of the body can become cancer, and can spread to other areas of the body.

Only cancers that start in the liver are called liver cancer. To understand liver cancer, it helps to know about the normal structure and function of the liver.

 
About the liver  
The liver is the largest internal organ. It lies under your right ribs just beneath your right lung. It is shaped like a pyramid and divided into right and left lobes. The lobes are further divided into segments.   

 

Unlike most other organs, the liver gets blood from 2 sources: the hepatic artery supplies the liver with blood rich in oxygen from the heart, and the portal vein brings nutrient-rich blood from the intestines.
You cannot live without your liver. It has several important functions:

• It breaks down and stores many of the nutrients absorbed from the intestine that your body needs to function. Some nutrients must be changed (metabolized) in the liver before they can be used by the rest of the body for energy or to build and repair body tissues.
• It makes most of the clotting factors that keep you from bleeding too much when you are cut or injured.
• It secretes bile into the intestines to help absorb nutrients (especially fats).
• It filters out and breaks down toxic wastes in the blood, which are then removed from the body.

The liver is made up mainly of cells called hepatocytes. It also is made up of other types of cells, including cells that line its blood vessels and cells that line small tubes in the liver called bile ducts. The bile ducts extend out of the liver and carry bile from the liver to the gallbladder or directly to the intestines.

These different types of cells in the liver can form several types of malignant (cancerous) and benign (non-cancerous) tumors. These tumors have different causes, are treated differently, and have a different prognosis (outlook).

What are the risk factors for liver cancer?

A risk factor is anything that affects your chance of getting a disease, such as cancer. Different cancers have different risk factors. Some risk factors, like smoking, can be changed. Others, like a person's age or family history, can't be changed.
But risk factors don't tell us everything. Having a risk factor, or even several risk factors, does not mean that you will get the disease. And some people who get the disease may have few or no known risk factors.
Scientists have found several risk factors that make a person more likely to develop hepatocellular carcinoma (HCC).

Gender

Hepatocellular carcinoma is much more common in males than in females. Much of this is probably because of behaviors affecting some of the risk factors described below. The fibrolamellar subtype of HCC is more common in women.

 

Chronic viral hepatitis

Worldwide, the most common risk factor for liver cancer is chronic (long-term) infection with hepatitis B virus (HBV) or hepatitis C virus (HCV). These infections lead to cirrhosis of the liver (see above) and are responsible for making liver cancer the most common cancer in many parts of the world.
In the United States, infection with hepatitis C is the more common cause of HCC, while in Asia and developing countries, hepatitis B is more common. People infected with both viruses have a high risk of developing chronic hepatitis, cirrhosis, and liver cancer. The risk is even higher if they are heavy drinkers (at least 6 standard drinks a day).
HBV and HCV can spread from person to person through sharing contaminated needles (such as in drug use), unprotected sex, or childbirth. They can also be passed on through blood transfusions, although this is very rare in the United States since the start of blood product testing for these viruses. In developing countries, children sometimes contract hepatitis B infection from prolonged contact with family members who are infected.
HBV is more likely to cause symptoms, such as a flu-like illness and a yellowing of the eyes and skin (jaundice). But most people recover completely from HBV infection within a few months. Only a very small percentage of adults become chronic carriers (and have a higher risk for liver cancer). Infants and small children who become infected have a higher risk of becoming chronic carriers.
HCV, on the other hand, is less likely to cause symptoms. But most people with HCV develop chronic infections, which are more likely to lead to liver damage or even cancer.
Other viruses, such as the hepatitis A virus and hepatitis E virus, can also cause hepatitis. But people infected with these viruses do not develop chronic hepatitis or cirrhosis, and do not have an increased risk of liver cancer.

Cirrhosis

Cirrhosis is a disease in which liver cells become damaged and are replaced by scar tissue. People with cirrhosis have an increased risk of liver cancer. Most (but not all) people who develop liver cancer already have some evidence of cirrhosis.
There are several possible causes of cirrhosis. Most cases in the United States occur in people who abuse alcohol or have chronic HBV or HCV infections.
Non-alcoholic fatty liver disease, a condition in which people who consume little or no alcohol develop a fatty liver, is common in obese people. People with a type of this disease known as non-alcoholic steatohepatitis (NASH) might go on to develop cirrhosis.
Some types of autoimmune diseases that affect the liver can also cause cirrhosis. For example, there is also a disease called primary biliary cirrhosis (PBC). PBC seems to be an autoimmune condition, in which the immune system attacks the bile ducts in the liver. This causes the bile ducts to become damaged and even destroyed and can lead to cirrhosis. People with advanced PBC have a high risk of liver cancer.

Heavy alcohol use

Alcohol abuse is a leading cause of cirrhosis, which in turn is linked with an increased risk of liver cancer.

Obesity 

Being obese (very overweight) increases the risk of developing liver cancer. This is probably because it can result in fatty liver disease and cirrhosis.

Type 2 diabetes 
Type 2 diabetes has been linked with an increased risk of liver cancer, usually in patients who also have other risk factors such as heavy alcohol use and/or chronic viral hepatitis. This risk may be increased because people with type 2 diabetes tend to be overweight or obese, which in turn can cause liver problems.

Inherited metabolic diseases 
Certain inherited metabolic diseases can lead to cirrhosis.
People with hereditary hemochromatosis absorb too much iron from their food. The iron settles in tissues throughout the body, including the liver. If enough iron builds up in the liver, it can lead to cirrhosis and liver cancer.
Other rare diseases that increase the risk of liver cancer include:

• Tyrosinemia
• Alpha1-antitrypsin deficiency
• Porphyria cutanea tarda
• Glycogen storage diseases
• Wilson disease

 
Aflatoxins 
These cancer-causing substances are made by a fungus that contaminates peanuts, wheat, soybeans, ground nuts, corn, and rice. Storage in a moist, warm environment can lead to the growth of this fungus. Although this can occur almost anywhere in the world, it is more common in warmer and tropical countries. Developed countries such as the United States and those in Europe regulate the content of aflatoxins in foods through testing.
Long-term exposure to these substances is a major risk factor for liver cancer. The risk is increased even more in people with hepatitis B or C infections.

Vinyl chloride and thorium dioxide (Thorotrast) 

Exposure to these chemicals raises the risk of angiosarcoma of the liver. It also increases the risk of developing cholangiocarcinoma and hepatocellular cancer, but to a far lesser degree. Vinyl chloride is a chemical used in making some kinds of plastics. Thorotrast is a chemical that in the past was injected into some patients as part of certain x-ray tests. When the cancer-causing properties of these chemicals were recognized, steps were taken to eliminate them or minimize exposure to them. Thorotrast is no longer used, and exposure of workers to vinyl chloride is strictly regulated.

Anabolic steroids 

Anabolic steroids are male hormones used by some athletes to increase their strength and muscle mass. Long-term anabolic steroid use can slightly increase the risk of hepatocellular cancer. Cortisone-like steroids, such as hydrocortisone, prednisone, and dexamethasone, do not carry this same risk.

Arsenic 

Drinking water contaminated with naturally occurring arsenic, such as that from some wells, over a long period of time increases the risk of some types of liver cancer. 

Infection with parasites 

Infection with the parasite that causes schistosomiasis can cause liver damage and is linked to liver cancer. 

Tobacco use 

Smoking increases the risk of getting liver cancer. Former smokers have a lower risk than current smokers, but both groups have a higher risk than those who never smoked.

Factors with unclear effects on liver cancer risk 

 Birth control pills

In rare cases, birth control pills, also known as oral contraceptives, can cause benign tumors called hepatic adenomas. But it is not known if they increase the risk of hepatocellular cancer. Some of the studies that have looked at this issue have suggested there may be a link, but most of the studies were not of high quality and looked at types of pills that are no longer used. Current birth control pills use different types of estrogens, different estrogen doses, and different combinations of estrogens with other hormones. It is not known if the newer pills increase liver cancer risk.

 

Hepatocellular carcinoma (HCC) is the most common form of liver cancer. HCC can start as a single tumor that takes a long time to spread to other parts of the liver.

It can also manifest as many small cancerous nodules throughout the liver. This type of cancer is found most often in patients with cirrhosis (chronic liver damage).

Hemochromatosis

Hemochromatosis is a metabolic disease in which excess iron is absorbed from the digestive tract and deposited in tissues and organs through the body,

where it causes damage. Complications in the liver, heart, and pancreas can be life threatening.

Causes of Hemochromotosis

Hemochromotosis is most often caused by a genetic mutation to the HFE gene. Individuals who receive the genetic mutation from both parents have a 70% chance of developing the disease.

People who inherit one mutated gene do not develop hemochromotosis but carry the disease and may pass it on to their children.

Symptoms of Hemochromotosis

Hemochromotosis causes excess iron to accumulate in the joints and organs, where it may cause serious complications including:

• Cirrhosis and abnormal functioning of the liver
• Diabetes (from damage to the pancreas)
• Congestive heart failure, abnormal heart rhythm (arrhythmias), and  heart failure
• Disruption of the reproductive system including erectile dysfunction, loss of menstruation, loss of sex drive
• Skin changes (bronze or yellowing tint to the skin) resulting from deposits of iron in the skin

Symptoms often do not appear until age 50 to 60 in men, and after age 60 in women. Other common symptoms include:

• Lethargy
• Weakness
• Irritability
• Joint pain
• Depression
• Hair loss
• Infection
• Enlarged spleen

Diagnosing Hemochromotosis

Diagnosis may require testing including:

• Blood testing for iron overload, including tests to measure iron levels in the blood and in the liver
• Liver function tests
• MRI
• Genetic testing
• Liver biopsy

Treatment for Hemochromotosis

Treatments for hemochromotosis will depend on age, overall health, severity of disease, and other factors. Treatments can alleviate symptoms such as fatigue,

abdominal pain, and skin changes, but will not reverse damage such as cirrhosis or end joint pain. Primary therapies include:

• Phlebotomy: periodic removal of the blood from the body. Depending on age and severity of disease, patients may initially have a pint of blood removed once or twice per week.
• Once iron levels are normalized, blood may be removed monthly or every three to four months.
• Chelation therapy: Medication that binds to the excess iron and removes it from the body. Chelation medications may be administered via pill or intravenously.

Supplemental measures include:

• Avoidance of iron and vitamin C supplements
• Avoidance of alcohol
• Treatment for associated complications

Types of primary liver cancer and its treatment

Familial Amyloidosis

Amyloidosis is a disease in which the body produces abnormal proteins called amyloid. Deposits of these proteins build up in tissues and organs of the body and can cause a range of symptoms.

There are various types of amyloidosis, including primary amyloidosis, secondary amyloidosis, and familial amyloidosis.

Causes of familial amyloidosis

Familial amyloidosis, also called ATTR amyloidosis, is caused by an abnormal gene inherited from an affected parent. The most common form is caused by the transthyretin (TTR) protein,

and more than 100 mutations of this protein have been associated with the disease.

Familial amyloidosis is autosomal dominant, which means that a child has a 50% chance of inheriting the disease if just one parent carries the genetic trait for it.

Symptoms of familial amyloidosis

Although the abnormal gene is present at birth, symptoms do not appear until later in life, after amyloid deposits have accumulated. Familial amyloidosis often affects the liver, heart, kidneys, and nerves.
Symptoms may include:

• Neuropathy (numbness or tingling in the hands and feet)
• Cardiomyopathy (enlargement of the heart)
• Irregular heartbeat
• Diarrhea or constipation
• Weight loss
• Dizziness upon standing (orthostatic hypotension)
• Swelling of the legs and ankles
• Weakness
• Shortness of breath
• Severe fatigue
• Purplish patches around the eyes
• Enlarged tongue
• Skin changes such as easy bruising or thickening
• Protein in the urine

If the disease causes damage to the kidney, nerves, or heart, such damage can be life threatening.

Diagnosing familial amyloidosis

The following tests may be used to diagnose familial amyloidosis:

• Blood tests
• Urine tests
• Physical exam
• Tissue biopsy

Treatments for familial amyloidosis

The primary treatment for familial amyloidosis is liver transplantation. The abnormal TTR protein is made in the liver, but a newly transplanted liver will make only normal transthyretin protein.

In addition to liver transplantation, other supportive measures may be needed to address the effects of amyloidosis on other organs.

For instance if the kidneys are affected, patients may need to take diuretics, restrict dietary salt, wear compression garments, and elevate their legs to reduce swelling.

Dietary changes and medications may be needed to treat gastrointestinal effects.

Ex Vivo Surgery and Multivisceral Transplantation

Intestinal and Multivisceral Transplantation

By transplanting several organs at once, we can give patients with serious intestinal malformations or infections hope for a healthy future.

MedWorld India has managed nearly many patients with devastating intestinal problems in recent years.

#MedWorld India works with the top hospitals in India with dedicated specialists in pediatric surgery and transplantation;

pediatric gastrointestinal medicine and nutrition; advanced practice nursing; and child life and social support services. This range of services,

essential to helping these children and their families cope with overwhelming health problems.

Intestinal or '#short bowel' transplantation is now recognized as a viable option for irreversible intestinal failure or short bowel syndrome.

Patients who develop intestinal failure can become candidates for intestinal transplantation if life threatening complications are present or if bowel rehabilitation is impossible due to the congenital nature of the intestinal disease.

Intestinal transplantation is frequently associated with liver transplantation. Certain diseases, such as biliary atresia, and the use of total parenteral nutrition (TPN) for conditions such as short bowel syndrome, can contribute to liver failure. If the child has both intestinal and liver failure, intestinal transplantation may be performed in conjunction with liver transplantation. If the patient does not have liver failure, isolated intestinal transplantation may be performed while leaving the liver in place. Multivisceral transplantation may be considered if the patient's condition involves failure of multiple abdominal organs, with or without transplanting the liver.

Ex vivo Surgery

Ex vivo transplant surgery entails the removal and re-implantation of as many as six abdominal organs in order to excise tumors that have grown to involve the organs and or blood vessels. In these complex operations, the surgical team removes affected internal organs and blood vessels, excises the tumor, and reimplants the organs. Some procedures require extensive surgical repair and grafting of blood vessels.

About the Procedures: Isolated Small Bowel or Multiorgan Transplantation

Intestinal transplant is a complex procedure that may entail an isolated intestinal transplant, multivisceral transplant, or a modified multivisceral transplant. Depending on the cause of your child's intestinal failure and overall medical condition, the transplant team will determine the type of surgery that best meets your child's medical needs.

Our pediatric transplant surgeons can perform small bowel transplantation for specific sections of the colon, such as the large bowel. We also can combine liver and small bowel transplantation, as well as liver, small bowel, and colon transplantation if necessary. For some patients, our surgeons rebuild the colon to avoid any permanent colostomy. They can also perform a multi-visceral transplantation-the transplantation of more than four organs: stomach, small bowel, pancreas, liver, and large bowel.

Types of Multivisceral Transplant Surgery

Multivisceral transplant surgical options include the following:

• Isolated Intestinal Transplant: an isolated intestinal transplant involves removing the diseased portion of the small intestine and replacing it with a healthy small intestine from a donor. This type of transplant is considered for patients with complications caused by intestinal failure, but who do not have liver failure.
• Multivisceral Transplant: a multivisceral transplant may be considered for patients who have multiple organ failure, including stomach, pancreas, liver, small intestine and/or kidney failure. This type of transplant involves removing the diseased organs and replacing them with healthy organs from a donor.
• Modified Multivisceral: a modified multivisceral transplant may be considered for patients who do not have liver disease/failure, but have organ failure of the stomach, pancreas, small intestine and/or kidney(s. This type of transplant involves keeping your own liver, and removing the remaining diseased organs and replacing them with healthy organs from a donor. Life-threatening complications include: loss, or impending loss of vascular access for total parenteral nutrition (TPN); development of TPN-induced liver failure with cholestatic disease (jaundice) and portal hypertension (which can lead to gastro-intestinal bleeding episodes); episodes of frequent sepsis from central venous line catheters and/or intestinal translocation; and recurrent, severe episodes of dehydration.

Indications for Intestinal Transplantation

Intestinal transplantation may be indicated for patients with the following conditions:

• Gastroschisis
• Volvulus
• Necrotizing Enterocolitis
• Intestinal Atresia
• Intestinal Pseudo-Obstruction
• Megacystis Microcolon Intestinal Hypoperistalsis Syndrome
• Microvillus Inclusion Disease
• Hirschsprung's Disease
• Gardner's Syndrome/Familial Adenomatous Polyposis
• Mesenteric Venous Thrombosis or Arterial Thrombosis 
• Crohn’s Disease
• Desmoid Tumor with Intra-Abdominal Infiltration
• Trauma:
• Multiple resections and explorations
• Vascular Abdominal Trauma such as Superior Mesenteric Artery (SMA) or Superior Mesenteric Vein (SMV) Injuries
• Endocrine Tumors
• Infiltrative Diseases leading to intestinal failure: Sarcoidosis/Amyloidosis
• Short Bowel Syndrome

Most patients needing a combined liver-intestine or multivisceral transplantation have:

• TPN Cholestasis that has progressed to irreversible liver injury (fibrosis/cirrhosis)
• End-Stage Liver Disease

Complications of Intestinal and Multivisceral Transplantation

Intestinal, multivisceral, or modified multivisceral transplantation is a life-saving therapy. However, your physicians cannot predict exactly how your child's body will respond to this transplant. The operation is extremely complex and the risks are significant.
The most common complications include postoperative hemorrhage, vascular leaks or obstruction, and biliary leaks or obstruction. Other potential complications include:

• bleeding
• infection
• bile leaks
• vascular complications
• intestinal leaks
• rejection of the transplanted tissue
• side-effects of immunosuppressant medications
• depression, anxiety, and mood-related disorders
• increased risk of skin and certain other cancers

 

Cystic Fibrosis

Cystic fibrosis (CF) is an inherited disease characterized by an abnormality in the body's salt, water- and mucus-making cells. It is chronic, progressive, and is usually fatal. In general, children with CF live into their 30s. 

Children with CF have an abnormality in the     function of a cell protein called the cystic fibrosis transmembrane regulator (CFTR). CFTR controls the flow of water and certain salts in and out of the body's cells. As the movement of salt and water in and out of cells is altered, mucus becomes thickened. The thickened mucus can affect many organs and body systems including:

• respiratory - sinuses and lungs
• digestive - pancreas, liver, gallbladder, intestines
• reproductive - more so in the male, where sperm-carrying ducts become clogged
• sweat glands

Many children with cystic fibrosis develop liver problems later in life.

Cystic Fibrosis Liver Disease

Cystic fibrosis affects the lungs, pancreas, liver, and other organs. Although the lung and pancreas are primarily affected in many patients with CF, fat in the liver is common and can be serious. In some patients, severe scarring, or cirrhosis, can develop.

In patients with CF, bile produced by the liver cells becomes stickier than normal and begins to block the small bile ducts. This causes damage and scarring to the surrounding liver tissue (called biliary fibrosis). Biliary fibrosis progresses and spreads through the liver, causing it to become hardened and unable to function optimally.

Symptoms of CF Liver Disease

Some patients have no symptoms, but those with advanced liver disease may have symptoms including:

• enlarged liver and spleen
• portal hypertension (high blood pressure in the vein leading to the liver)
• ascites (fluid accumulation in the abdomen)
• varices (bleeding from dilated veins) in the esophagus or stomach
• difficulty maintaining adequate weight
• jaundice
• bleeding problems 

Treatment for CF Liver Disease

Medications and nutritional changes can help to reduce the health problems associated with CF liver disease. Patients should avoid alcohol use.

Bile Duct Cancer (Cholangiocarcinoma)  

Cholangiocarcinoma is cancer located in one of the bile ducts, which carries bile from the liver to the small intestine. Bile duct cancer may occur anywhere in the ducts, either inside or outside the liver. Although they are slow growing, often they are not detected until in advanced stages when they block the bile duct and cause symptoms.
Also called biliary cancer, cholangiocarcinoma looks different under the microscope, often has different blood markers, and is treated differently than tumors originating in the liver tissue.  

 

Symptoms of cholangiocarcinoma

Symptoms may include:

• Jaundice
• Itchy skin
• Fever
• Abdominal pain
• Weight loss

Causes of cholangiocarcinoma

Cholangiocarcinoma is rare, occurring in only 2 out of 100,000 people. Risk factors include:

• Primary sclerosing cholangitis
• Inflammation to the liver from hepatitis C virus, NASH, and other liver disease
• In Asia and other regions, parasitic infection (biliary flukes)
• Bile duct cysts
• Ulcerative colitis

Treatment of cholangiocarcinoma

Treatments may include surgery, radiation therapy, and chemotherapy.

Surgery

If found early enough that the tumor can be removed, surgery is curative. The bile duct and part of the liver may need to be removed.  If the tumor is blocking the bile duct, a small tube called a stent may be placed to allow bile to drain more easily to the intestine.
There are also local approaches to treat the tumor using endoscopic retrograde cholangiopancreatography (ERCP). During ERCP, an endoscope is inserted into the patient’s mouth and threaded into the bile ducts to relieve obstruction and to deliver various therapies, which may include photodynamic therapy (PDT) and local ablation.

#MedWorld India offers liver transplantation complete review and advise for patients with biliary cancers which are considered unresectable. 

Radiation Therapy

Radiation therapy may include external beam radiation (SBRT, protons), and radiolabelled beads such as Y90. There are few data yet for these treatments in biliary cancers, but they are under active investigation. Similarly, there are few data yet for chemoembolization in this disease, but it is sometimes used.

Chemotherapy

Chemotherapy is the use of medication to destroy cancer cells. It is usually given intravenously but may be administered orally. If cholangiocarcinoma is advanced, the standard first-line treatment is a chemotherapy combination of gemcitabine and cisplatin. Side effects of these treatments include fatigue, lowering of the blood counts, occasionally kidney dysfunction and hair thinning.
Chemotherapy drugs may be given alone or in combination. Other commonly-used chemotherapy medications for cholangiocarcinoma include: 5FU, capecitabine, irinotecan and oxaliplatin.

Large randomized trials have not yet been completed to determine whether chemotherapy is effective in preventing recurrences after surgery to remove cholangiocarcinomas. The base the treatment of biliary tumors from pancreatic cancer literature. Chemotherapy alone is often recommended, while chemotherapy and radiation is often used if there is a positive margin (cancerous cells remaining after surgery). Sometimes chemotherapy is administered for those with a positive margin, allowing time for the liver to regenerate, and surgery can be re-attempted in order to clear the margin.

Molecular and targeted therapies

Targeted agents under study include:

• MEK inhibitors
• Immunotherapies
• IDH inhibitors
• DNA demethylating agents
• Antiangiogenic therapies

Gallbladder Cancer

About one percent of people have cancer in their gallbladders that is found incidentally (during testing for some other reason). In patients who are diagnosed with cancer of the gallbladder, it is very important to check the pathology of these tumors. Many patients need more extensive surgery with resection of part of the liver and hepatic lymph nodes. This has been shown to improve survival significantly.
The primary risk for gallbladder cancer is gallstones. The following risk factors for gallstones are the most common: being overweight, being female, and age around 40. Because gallstones are related to fat intake, ethnicity and diet are important risk factors. Among Pima Indians in Peru, 80% of women develop gallstones at some point in their lives. Virtually all native Indian women in Chile and Peru develop gallstones. In some parts of the world such as India, the incidence of gallstones is high due to the prevalence of salmonella.

Alpha-1 Antitrypsin Deficiency

Alpha-1 antitrypsin is one of many proteins that the liver produces from food and circulates into the bloodstream. People with alpha-1 antitrypsin deficiency make a slightly abnormal form of this protein, which becomes trapped in the liver.
Inability to make proper alpha-1 antitrypsin is inherited from both parents.

Symptoms of alpha-1 antitrypsin deficiency

Some people have no visible symptoms. Some are healthy for many years, but later in life develop emphysema and lung damage. Yet other children develop inflammation of the liver and display signs of liver damage within the first four months of life. In such cases, symptoms may include:

• Jaundice
• Persistently yellow urine
• Poor weight gain
• Abnormal bleeding from the nose or umbilicus
• Enlargement of the liver and or spleen

Older children with alpha-1 antitrypsin deficiency may experience symptoms including:

• Jaundice
• Ascites  (accumulation of fluid in the abdomen)
• Portal hypertension (increased blood vessel pressure in the portal vein)

Treatments for alpha-1 antitrypsin deficiency

Although there is no cure for this condition, treatments can help to reduce symptoms associated with alpha-1 antitrypsin deficiency. Treatments include regular monitoring in order to recognize and treat changes in the liver promptly, as well as dietary recommendations, which may include extra calories, vitamins or other.

  Acute Liver Failure  

In most cases of liver failure, decrease in function occurs gradually over years. In acute liver failure, the liver rapidly loses function within days. Acute liver failure can develop suddenly in an otherwise healthy person and requires immediate medical attention.

Acute liver failure is a medical emergency that can cause complications including excessive bleeding, pressure in the brain (cerebral edema), kidney failure, infection, and death.

 

 

Causes of acute liver failure

• Acute liver failure is most commonly caused by:
• Tylenol (acetaminophen) overdose
• Hepatitis A, B, and C viruses
• Reactions to prescription or herbal medications
• Toxins such as poisonous wild mushrooms
• Autoimmune hepatitis
• Vascular diseases such as Budd-Chiari syndrome which block the veins in the liver
• Metabolic diseases such as Wilson’s disease
• Cancer

Symptoms of acute liver failure 

Symptoms may be difficult to detect initially because they can be present with many conditions. They may include:

• Jaundice  (yellow skin and eyes)
• Abdominal pain
• Nausea
• Vomiting
• General malaise
• Disorientation, confusion, inability to concentrate
• Sleepiness

Acute liver failure may be diagnosed with blood tests, imaging with ultrasound, and biopsy of liver tissue.

Treatment of acute live failure

Medications

If the cause of acute failure is acetaminophen overdose or a toxin such as a poisonous mushroom, medications to reverse the toxic effects may be administered. If the cause is viral, medical care may allow the patient to heal and the liver to recover.

Complications caused by acute liver failure may be treated with medications and blood transfusion.

Treatment of Hepatocellular carcinoma (HCC) depends on the stage of the cancer and other factors. It may be treated with surgery (transplantation and resection), local therapies, systemic treatments, or combinations of these approaches.

Surgery: Resection

If the tumor is detected at an early stage, when it is typically a single lesion, and there is no significant liver disease, surgeons may be able to surgically remove the tumor. This is called resection. For tumors which are very small, typically less than 2-3 cm, sometimes the tumor can be ablated, or destroyed, most often using radiofrequency ablation. 

Surgery: Liver Transplantation

Because most patients with primary hepatocellular carcinoma have underlying liver disease, liver transplantation allows the best chance for cure. MedWorld India offers liver transplantation patients with bile duct cancers. For patients whose bile duct cancer can not be removed surgically, transplantation can offer an unprecedented chance for cure.

The Milan Criteria is the internationally accepted guideline used to select patients for liver transplantation. According to these criteria, patients may be eligible for liver transplantation if they have a single tumor 5 cm or smaller, or 3 or fewer tumors that are each 3 cm or less in size, and no obvious invasion of the blood vessels on imaging before the transplant.  Patients who have more than one tumor above the sizes specified by these criteria are usually not eligible for transplantation unless the tumor can be “downsized” or shrunk. In some cases, tumors can be reduced sufficiently through chemoembolization, radiation, or other approaches.

Liver Transplantation 

#MedWorld India boasts one of the largest and most experienced team of consultants advising on liver transplantation in collaboration with the leading hospitals in India, offering living donor liver transplantation and employing minimally invasive surgical approaches whenever possible.

Liver transplant procedures the take advantage of the most sophisticated medical knowledge and surgical technology available today, including living donor transplantation, partial liver transplantation, advanced organ preservation techniques, liver transplantation in HIV- and Hepatitis C co-infected individuals, and antiviral therapy to prevent or treat recurrent hepatitis C after liver transplantation.

Our program routinely achieves excellent outcomes for donors and recipients.  Additionally, nearly all donors are very satisfied or satisfied with the experience of donating a portion of their liver. After surgery, we also offer specialized nursing, nutritional support, smoking cessation, weight loss and pain management.

ERCP for Management of Bile Duct Obstruction

Blockage of the bile duct is a potential complication of liver tumors, liver surgery, and bile duct cancer. Our interventional endoscopists often utilize endoscopic retrograde cholangiopancreatography (ERCP) to relieve bile duct obstructions. During this procedure, a physician inserts a stent into the duct to relieve the obstruction and allow drainage to proceed into the intestine, sparing the patient from having to wear an external bag on the abdomen to drain fluids. This approach improves the patient’s quality of life and relieves symptoms associated with jaundice.

Local Therapy

Localized therapy, also called locoregional therapy, includes the following approaches:

• Radiofrequency or Microwave Embolization

  The tumor is destroyed with highly targeted radiowave or microwave energy.

• Radio arterial embolization

  Tiny spheres of a radioactive substance (yttrium-90) are delivered to the tumor site via the hepatic arterial system. The radioactive substance then kills cancer cells at the tumor site.

• Radiation Therapy

  Several hospitals are also examining new forms of targeted external beam radiation, particularly for trying to shrink the tumor out of the portal vein. This also looks very promising, potentially with less toxicity than with Y-90.

• Chemoembolization

  Chemotherapy (injected into the hepatic artery via a catheter) may be used to target larger tumors. The chemotherapy is combined with a substance that temporarily blocks off the hepatic artery, trapping much of the chemotherapy near the tumor. This approach spares nearby healthy tissue from the toxic effects of chemotherapy.
  In some cases, chemotherapy can reduce the size of a tumor enough that it can be surgically removed. Most often, this is delivered locally using beads treated with different types of chemotherapy agents, a therapy called chemoembolization. By inserting them into the tiny blood vessels that feed the tumor, the radiation effectively targets the cancer cells without affecting the whole body. Chemoembolization therapies most commonly include drug-eluting beads labelled with doxorubicin or irinotecan.

Systemic Chemotherapy

Chemotherapy (systemic therapy) is offered to patients who are not good candidates for surgery or locoregional therapy. Chemotherapy drugs are designed to kill cancer, and are generally given in cycles, with a period of treatment followed by a period of rest. These drugs can be administered before surgery, after surgery, or both. When given before surgery, chemotherapy is called neoadjuvant. When given after surgery, chemotherapy is called adjuvant. Chemotherapy can be administered orally, by injection, or intravenously depending on the regimen and the drug. The best course of therapy is selected after considering the specific characteristics of the patient's cancer to maximize the results of the treatment and increase survival.

Traditional chemotherapy medications historically have not been very successful in HCC patients because many are metabolized in the liver, which is not functioning normally in many patients, and because many HCCs have “pumps” which can get the chemotherapy out of the cancer cells, and thus make them resistant.

Adjuvant chemotherapy is usually administered after surgery or liver transplantation, although there adjuvant therapy in HCC has not yet been proven effective. 

For advanced liver cancer with blood vessel invasion or metastatic disease, the standard of care now is a drug called sorafenib (nexavar), which has been shown to improve survival for patients with advanced liver cancer, kidney cancer, and thyroid cancer. It acts by blocking pathways that cause blood vessels to grow. As such, it is considered a “targeted” therapy.  Given in pill form, it is usually taken twice a day on an empty stomach. Side effects include redness of the hands and feet (which can be lessened by using urea cream twice a day while on the drug), diarrhea, fatigue, and high blood pressure.

Molecular and targeted therapies

Many other targeted agents are being studied in clinical trials. These include MET-inhibitors, mTOR inhibitors, demethylating agents, and immunotherapies, among many other types of targeted therapies.  We now have the capability to identify novel targets in each cancer patient’s tumor, so that we can try to identify new therapies which might not have ordinarily been considered for them.

The following blood tests may be ordered to determine if a mass found in the liver is cancerous.

Liver function tests (LFTs)

A series of blood tests can help assess how well the liver is working.

Blood clotting tests

A damaged liver may not make enough of the proteins that allow the blood to clot and therefore prevent bleeding.

Tests for viral hepatitis

Infection with hepatitis B virus (HBV) or hepatitis C virus (HCV) is linked both to cirrhosis of the liver (see above) and to liver cancer.

Kidney function tests

A series of blood tests can help assess the how well the kidneys are working.

Complete blood count (CBC)

This test measures levels of red blood cells, white blood cells (which fight infections), and platelets (which help the blood clot). It also shows how well the bone marrow, where new blood cells are made, is functioning.

Blood chemistry tests and other tests

Blood chemistry tests check the levels of a number of minerals and other substances in the blood, some of which might be affected by liver cancer.

Alpha-fetoprotein blood (AFP) test

The AFP level can help determine what treatment options might be appropriate. Also ordered during treatment, to find out how well the therapy is working, or find out if the cancer has come back.

The diagnosis of liver cancer is usually confirmed through imaging studies. These include:

CT scan

Computed Tomography (CT) scans take many different x-rays to produce detailed, cross-sectional images of the liver and other organs.

Magnetic resonance imaging (MRI)

MRI scans use radio waves and strong magnets instead of x-rays to take pictures of the body. MRIs map the location, size, and sometimes even the type of tissue contained in the tumor, and are useful tools for planning biopsies.

Ultrasound

This diagnostic technique uses sound waves to take create images of parts of the body. A small instrument called a transducer emits sound waves and picks up the echoes as they bounce off the liver. A computer converts these sound wave echoes into an image that is displayed on monitor.

Endoscopy

An endoscope is a long, lighted tube that is passed through the patient’s esophagus, stomach and beginning of the lower intestine, allowing the physician to explore these areas without surgery. This technique, along with ERCP (described below) is used to evaluate cholangiocarcinomas.

Endoscopic Retrograde Cholangiopancreatography (ERCP)

A smaller tube or catheter is passed through the endoscope and into the bile ducts. Dye is injected into the ducts, and the physician takes X-rays to discover whether a tumor is present in the bile ducts.

The physician may also need to take a biopsy of the tissue to be examined under a microscope. This tissue can be obtained in the following procedures:

Laparoscopy

In this procedure, the physician inserts a thin, lighted tube with a small video camera on the end through a small incision in the front of the abdomen to examine the liver and other internal organs. This procedure is done in the operating room usually under general anesthesia.

Laparoscopy can help doctors confirm the stage (extent) of the cancer and decide upon a treatment plan.

Laparoscopy is usually done at an outpatient surgery. Because the surgeon only makes a small incision to insert the tubes and there is no need for general anesthesia, the patient can expect less pain and faster recovery time.

Needle biopsy

A hollow needle is placed through the skin in the abdomen and into the liver. The skin is first numbed with local anesthesia.

During a fine needle aspiration (FNA) biopsy, tumor cells are sucked into a very thin needle with a syringe.
During a core needle biopsy, a slightly larger needle is used to take a bigger sample from the liver.

Often a patient has no symptoms until the disease has reached its later stages. Many of these complaints may be caused by other illnesses, so it is important to be evaluated by a physician.

• Unexplained weight loss or loss of appetite
• Feeling very full after eating very little
• Nausea or vomiting
• An enlarged liver
• An enlarged spleen
• Pain in the abdomen or near the right shoulder blade
• Swelling or fluid build-up in the abdomen
• Itching
• Yellowing of the skin and eyes (jaundice)
• Fever
• Enlarged veins on the belly that are visible through the skin
• Abnormal bruising or bleeding

People who have chronic hepatitis or cirrhosis may feel worse than usual and produce excess hormones that cause:

• High blood calcium levels (hypercalcemia), and symptoms of nausea, confusion, constipation, weakness, or muscle problems
• Low blood sugar levels (hypoglycemia) and symptoms of fatigue or fainting
• Breast enlargement (gynecomastia) and/or shrinking of the testicles in men
• High red blood cells counts (erythrocytosis) causing redness and flushed skin
• High cholesterol levels

 

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