Below is a listing of conditions treated and information patients may find useful when deciding on what treatment to choose

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Liver cancers either start in the liver or spread (metastasize) to the liver from another site. The most common cancer that starts in the liver is hepatocellular cancer (HCC or hepatoma). The most common cancers that spread to the liver that can be surgically removed are from the colon and rectum. Neuroendocrine tumors/cancers from the pancreas and intestine also can be surgically removed from the liver with good long term survival. Other cancers that spread to the liver that can be treated with surgery are ovary, uterus, germcell, prostate, kidney, stomach, and melanoma.



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Early diagnosis of a hepatoma (also called primary liver cancer, hepatocellular cancer, or HCC) gives the best chance of long term survival. Patients needing routine liver cancer surveillance are: 1) all patients with cirrhosis, and 2) patients with hepatitis B infection and detectable virus growing in their blood. The most common causes of cirrhosis in the United States are hepatitis C and/or B infection, alcohol over use, and fatty liver. Unfortunately, 7 out of 10 patients with liver cancer have advanced cancer when found and will not benefit from surgical removal or liver transplant.

Patient surveillance for liver cancer includes an imaging study of the liver using ultrasound and a blood test called an "alpha fetal protein" (AFP). Liver cancer surveillance should be done every 6 to 12 months. If a patient is found to have a abnormal liver nodule, further testing is needed. Below are the guidlines for further evaluation according to the American Association for the Study of Liver Disease (AASLD). A 4-phase multi-detector-CT scan or dynamic contrast enhanced MRI are confirmatory imaging studies to evaluate a suspicious liver nodule. A 4-phase study includes non-contast, arterial, portal venous, and delayed venous contrast imaging study. Because a non-contrast scout study is always obtained, the 4-phase study is more commonly called a triple-phase CAT or MRI scan.

AASLD HCC guidelines

In a patient that is found to have a nodule in the liver, a triple phase scan of the liver can be enough to make the diagnosis. A triple phase CAT or MRI scan has an arterial, portal venous and delayed venous phase. To make the diagnosis, the cancer becomes bright in the arterial phase, has the same density as the liver in the portal venous phase, and become darker than the liver in the delayed venous phase. Below are arterial, portal venous, and delayed venous phase CAT scan images of a hepatoma.




Because liver cancer usually occurs with cirrhosis of the liver, only 1 out of 10 patients are eligible for surgical removal. In patients with early cirrhosis, surgery can be used when the patient has normal liver chemistries, a normal platelet count, and no evidence of portal hypertension. Most liver surgery for removal of a liver cancer can be performed laparoscopically

In patients with advanced cirrhosis and small cancers, liver transplant is a treatment option. Eligible patients either have a single cancer, less than 5 centimeters in size or no more than 3 cancers, each being no greater than 3 centimeters in size. There can be no cancer outside the liver or invasion of cancer into visible vessels in the the liver.


The liver is divided into compartments that can be used to guide surgery to remove a cancer. See picture below for description of liver compartments. Most liver cancers can be removed laparoscopically

Liver compartments
Patients with early stage liver cancer with advanced cirrhosis, portal hypertension, or poor liver function are eligible for a liver transplant. A patient has to meet the following conditions to be eligible: 1) a single cancer no more than 5 centimeters in size or no more than 3 cancers with none being larger than 3 centimeters in size, 2) no cancer outside the liver, and 3) the cancer cannot be invading any vessel (vein or artery) in the liver.

A patient with early stage liver cancer is given 22 MELD points and receives an additional point every 3 months while listed and waiting for an liver transplant.

The Model of Enstage Liver Disease or MELD score.
The Model for End-Stage Liver Disease (MELD) score has been in use since February 2002. It is used to measure a patient's risk of dying from chronic liver failure over a 90 day period from the day it was measured. It is used to determine the order and urgency of patients waiting for a liver transplant. The "MELD score" is a number scale. The range is from 6 (less ill) to 40 (gravely ill). The number is calculated using the following laboratory tests:
  • Total Bilirubin: a measure of how well the liver clears certain body wastes.
  • INR (International Normalized Ratio or previously known as the prothrombin time): a measures the liver’s ability to make blood clotting factors.
  • Creatinine: a measure of kidney function. Severe liver failure often results in kidney failure.
In general:
If the MELD score is greater than 10 patients are evaluated for a liver transplant. However, even if placed on the liver transplant list, patients are not actively called in for a liver transplant until their MELD score is 15 or greater. Bear in mind, a patient's chances of being alive at one year after receiving a liver transplant is between 85%-90%. A MELD score of 15 means a patient's chance of being alive in a year is about 85%. So a MELD of 15 is the break point favoring a liver transplant is when a patient has a higher chance of being a live with a liver transplant versus to dying from liver failure. As the MELD score increases, patients are progressively sicker and more debilitated.

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Although patients are activated for liver transplant at a MELD of 15, patient debility usually significantly worsens at a MELD of 19 or greater. Unfortunately, MELD does not take into account patient debility (or performance status), fluid accumulation (ascites), or confusion (encephalopathy). However, a low serum sodium, lower than 131-134, has been shown to increase the risk dying while waiting for a liver transplant. There is a good chance a measure of sodium will be added to MELD to determine the urgency of need for a liver transplant. Beyond a MELD of 25, patients have a higher risk of dying even should they receive a liver transplant. However receiving a liver transplant still offers the best chance of long term survival.
The liver is different from other organs because it has a double blood supply; an artery (hepatic artery) and a vein (portal vein). 75% of the blood flow comes from the portal vein and 25% from the hepatic artery. Liver cancers receive their blood supply from the hepatic artery.

In patients who are not eligible for surgery, hepatic artery embolization (HAE) or chemoembolization (HACE) blocks the arterial blood supply to a liver cancer and can destroy a large part of the cancer and lengthen patient survival. Liver cancers are mainly fed through the arterial blood supply. Hepatic artery embolization uses tiny particles injected into the arterial blood vessels supplying a liver cancer. These particles can be used alone or combined with chemotherapy.

Hepatic artery embolization is used for patients that will not tolerate surgery due to poor overall health, have cirrhosis, or if the cancer is located such that it is not technically possible to remove with surgery.

The pictures below show a catheter that is placed into an artery in the groin and goes to the liver. Once the catheter is in the liver, tiny beads and chemotherapy are injected into the arteries supplying blood the the cancer. The cancer is starved of its blood supply and killed with the chemotherapy.

HACE
The liver is different from other organs because it has a double blood supply; an artery (hepatic artery) and a vein (portal vein). 75% of the blood flow comes from the portal vein and 25% from the hepatic artery. Liver cancers receive their blood supply from the hepatic artery.

Selective Internal Radiation Therapy (SIRT) using
Yttrium-90 infusion is for patients who are not eligible for surgery with multiple or large liver cancers. Yttrium-90 therapy uses injection of tiny radioactive beads (microspheres) through the hepatic artery directly into the cancer. Yttrium-90 therapy has less side effects because the injection is only into the liver. Yttrium-90 therapy has 2 stages. The first stage is to map the hepatic artery blood supply to and in the liver. Patients are also tested to make sure minimal blood passes through the liver into the lung, "shunting into the lung". If the mapping is acceptable, patients return 2 weeks after for injection of Yttrium-90 microspheres into the liver cancer.



The pictures below show a catheter that is placed into an artery in the groin and goes to the liver (A & B). Once the catheter is in the liver, Yttrium-90 microspheres are injected into the arteries supplying blood the the cancer. (C)

sirspheresadmin

In patients not eligible for surgical removal, local ablation can be performed using Radio Frequency Ablation (RFA) or Microwave ablation (MA). RFA and MA can be performed using ultrasound guided laparoscopic surgery or directly through the skin (percutaneous). Cancers less than 5 centimeters in size are suitable for this type of treatment. For cancers less than 3 centimeters in size, injection of alcohol into the cancer can also be used. Radiofrequency ablation, Microwave ablation or alcohol injection are used for patients that will not tolerate surgery due to poor overall health, cirrhosis, or if the cancer is located such that it is not technically possible to remove with surgery. The cancer is usually located using ultrasound or CAT scan guidance. The nodule can be ablated directly through the skin or, if necessary, laparoscopically. The picture below shows use of a laparoscopic ultrasound to guide the ablation device or needle for alcohol injection. For cancers less than 2 centimeters in size, RFA is almost as good as surgical removal when patients are followed for up to 2 years.

ablation of liver lesion
Sorafenib tosylate (Nexavar®), a small molecule Raf kinase and VEGF receptor kinase inhibitor, is FDA approved for the treatment of patients with unresectable liver cancer. In large contolled clinical trials, sorafenib increased the life of patients with advanced liver cancer from an average of 7.9 to 10.7 months. Additionally, in patients with hepatitis C and liver cancer, sorafenib increased the life of patients from an average of 7.9 to 14.0 months. Given that hepatitis C cirrhosis is the largest cause of liver cancer in the United States, sorafenib may be particularly useful in these patients. Many studies are onging to increase the life of liver cancer patients using sorafenib with other methods of liver cancer treatment.

Sorafenib works by 1) blocking a cancer cell's machinery to divide and reproduce, and 2) blocking a cancer's ability to fool a patient's body to build a blood supply to feed the cancer. These actions combined block liver cancer growth. The figure below shows how sorafineb is believed to work.



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Surgical removal of cancer in the liver from the colon or rectum gives patients a 30-35% chance of being alive 5 years after surgery. Without surgery, most patients die within 12-18 months after diagnosis. Predictors of outcome include tumor size greater than 5 centimeters, having more than one tumor, having positive lymph nodes at the initial colorectal surgery, having a CEA greater than 200, and time between original colorectal surgery and development of metastatic tumor in liver less than 1 year. A patient without any of these risk factors has about a 7 out of 10 chance of being alive in 5 years. As a patient has more risk factors, their chance of surviving decreases. If a patient has all 5 risk factors, they have a 1 out of 10 chance of being alive in 5 years.

Although most patients receive chemotherapy before surgery, if the cancer is surgically removable, it should be removed then followed by chemotherapy. If a cancer cannot be removed with surgery, chemotherapy can be used to shrink the cancer to make it removable. In patients receiving a chemotherapy called irenotecan, the liver can be become "fatty" and develop inflammation. This is called "Chemotherapy Associated Steato Hepatitis" or "CASH".

In patients receiving a chemotherapy called oxaloplatinum, blood flow out of the liver is blocked, this is called "Sinusoidal Obstructive Syndrome" or "SOS". Both of these chemotherpies increase the risk of poor liver function, infection and pneumonia following surgery.

In patients receiving a drug called bevacizumab (Avstin), can have bleeding and wound healing complications.

In patients receiving more than 6 cycles of either of these chemotherapies, the risk of complications rises dramatically and a waiting period of 6 weeks between the last dose of chemotherapy and the day of surgery is recommended.
Selective Internal Radiation Therapy (SIRT) using Yttrium-90 infusion is for patients who are not eligible for surgery with multiple or large liver cancers. Yttrium-90 therapy uses injection of tiny radioactive beads (microspheres) through the hepatic artery directly into the cancer. Yttrium-90 therapy has less side effects because the injection is only into the liver. Yttrium-90 therapy has 2 stages. The first stage is to map the hepatic artery blood supply to and in the liver. Patients are also tested to make sure minimal blood passes through the liver into the lung, "shunting into the lung". If the mapping is acceptable, patients return 2 weeks after for injection of Yttrium-90 microspheres into the liver cancer.

Please go to Yttrium-90 infusion for Hepatoma treatment to see how Yttrium-90 works.

The pictures below show a catheter that is placed into an artery in the groin and goes to the liver (A & B). Once the catheter is in the liver, Yttrium-90 microspheres are injected into the arteries supplying blood the the cancer. (C)

sirspheresadmin
In patients who are not eligible for surgery, hepatic artery embolization (HAE) or chemoembolization (HACE) blocks the arterial blood supply to a colon or rectal cancer in the liver and can destroy part of the cancer and lengthen patient survival. Hepatic artery embolization uses tiny particles injected into the arterial blood vessels supplying a liver cancer. These particles can be used alone or combined with chemotherapy. However, because the blood supply to the metastatic colon and rectal cancer is not from the artery, this method is less effective in stopping the growth of the cancer over a long period of time.

Hepatic artery embolization is used for patients that will not tolerate surgery due to poor overall health, have cirrhosis, or if the cancer is located such that it is not technically possible to remove with surgery.
In patients not eligible for surgical removal, local ablation can be performed using Radio Frequency Ablation (RFA) or Microwave ablation (MA). RFA and MA can be performed using ultrasound guided laparoscopic surgery or directly through the skin (percutaneous). Cancers less than 5 centimeters in size are suitable for this type of treatment. For cancers less than 3 centimeters in size, injection of alcohol into the cancer can also be used. Radiofrequency ablation, Microwave ablation or alcohol injection are used for patients that will not tolerate surgery due to poor overall health, cirrhosis, or if the cancer is located such that it is not technically possible to remove with surgery. The cancer is usually located using ultrasound or CAT scan guidance. The nodule can be ablated directly through the skin or, if necessary, laparoscopically.

Radiofrequency ablation is usually reserved for patients that will not tolerate surgery due to poor overall health, advanced age, or if the cancer is located such that it is not technically possible to remove with surgery.
FOLFOX is a chemotherapy combination for the treatment of colon and rectal cancer, made up of the drugs
FOL– Folinic acid (leucovorin) is a vitamin B derivative that modulates/potentiates/reduces the side effects of fluorouracil;
F – Fluorouracil (5-FU)
OX – Oxaliplatin (Eloxatin)

FOLFIRI is a chemotherapy combination for the treatment of colon and rectal cancer, made up of the drugs:
FOL – folinic acid (leucovorin)
F – fluorouracil (5-FU), a pyrimidine analog and antimetabolite which incorporates into the DNA molecule and stops synthesis; and
IRI – irinotecan (Camptosar), a topoisomerase inhibitor, which prevents DNA from uncoiling and duplicating.

Bevacizumab (Avastin) is a specialized protein called a monoclonal antibody that blocks the signals that lead to growth of new blood vessels (angiogenesis). By blocking angiogenesis this drug also blocks the blood supply to growing cancers. In patients with metastatic colon cancer, bevacizumab can be added the chemotherapy combination FOLFOX.

Cetuximab (Erbitux) is a monoclonal antibody that blocks signals that lead to cell growth (epidermal growth factor receptor). In patients who's colon cancer expresses the non-mutated form (wildtype) of the KRAS gene, cetuximab can be added to the chemotherapy combination FOLFIRI.

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Because neuroendocrine cancers spreading to liver are usually slow growing and occur without cirrhosis of the liver, most patients are eligible for surgical removal. In patients undergoing surgery, 5 out of 10 patients will be alive 5 years following surgery. Most liver surgery for removal of a metastatic neuroendocrine cancer in the liver can be performed laparoscopically

In patients with slow growing large cancer that are not removable by surgery, liver transplant is an option. Patients can have a prior site where the cancer was removed, such as the pancreas. However to be considered a liver transplant, there can be no cancer outside the liver or invasion of cancer into visible vessels in the the liver.

The liver is divided into compartments that can be used to guide surgery to remove a cancer. See picture below for description of liver compartments. Most liver cancers can be removed laparoscopically

Liver compartments

In patients with slow growing large cancer that are not removable by surgery, liver transplant is an option. Patients can have had a prior site where the cancer was removed, such as the pancreas. However to be considered a liver transplant, there can be no cancer outside the liver or invasion of cancer into visible vessels in the the liver.
In patients that have too much cancer in the liver that cannot be surgically removed or who cannot tolerate surgery, hepatic artery embolization of neuroendocrine metastasis to the liver can slow grow of the cancer and lengthen patient survival.

In patients who are not eligible for surgery, hepatic artery embolization (HAE) or chemoembolization (HACE) blocks the arterial blood supply to a neuroendocrine cancer and can destroy a large part of the cancer and lengthen patient survival. Neuroendocrine cancers are mainly feed through the arterial blood supply. Hepatic artery embolization uses tiny particles injected into the arterial blood vessels supplying a liver cancer. These particles can be used alone or combined with chemotherapy.

Hepatic artery embolization is used for patients that will not tolerate surgery due to poor overall health, advanced age, have cirrhosis, or if the cancer is located such that it is not technically possible to remove with surgery.
In patients not eligible for surgical removal, local ablation can be performed using Radio Frequency Ablation (RFA) or Microwave ablation (MA). RFA and MA can be performed using ultrasound guided laparoscopic surgery or directly through the skin (percutaneous). Cancers less than 5 centimeters in size are suitable for this type of treatment. For cancers less than 3 centimeters in size, injection of alcohol into the cancer can also be used. Radiofrequency ablation, Microwave ablation or alcohol injection are used for patients that will not tolerate surgery due to poor overall health, cirrhosis, or if the cancer is located such that it is not technically possible to remove with surgery. The cancer is usually located using ultrasound or CAT scan guidance. The nodule can be ablated directly through the skin or, if necessary, laparoscopically.

Radiofrequency ablation is usually reserved for patients that will not tolerate surgery due to poor overall health, advanced age, or if the cancer is located such that it is not technically possible to remove with surgery.
Well differentiated Neuroendocrine Tumors
The mammalian target of rapamycin (mTOR) controls multiple signaling pathways related to neuroendocrine growth. The mTOR inhibitor, Everolimus is approved by the US Food and Drug Administration for unresectable, locally advanced or metastatic pancreatic neuroendocrine tumors. Everolimus showed a 65% reduction in the risk of cancer progression.

The drug sunitinib blocks growth of new blood vessels. Sunitinib is approved by the US Food and Drug Administration for the treatment of progressive, well-differentiated pancreatic neuroendocrine tumors in patients that can not be treated with surgery or have metastatic disease. The most common side effects of treatment are diarrhea and insomnia.

Somatostatin has been shown to reduce symptoms and slow the growth of neuroendocrine tumors. This can be used in combination with local regional therapy.

Poorly differentiated Neuroendocrine Tumors
Patients with poorly differentiated neuroendocrine tumor tend to respond to a cisplatin and etoposide combination. About 50-67% of patients will show some response using cisplatin/etoposide with an average survival of 9-19 months.
Selective Internal Radiation Therapy (SIRT) using Yttrium-90 infusion is for patients who are not eligible for surgery with multiple or large liver cancers. Yttrium-90 therapy uses injection of tiny radioactive beads (microspheres) through the hepatic artery directly into the cancer. Yttrium-90 therapy has less side effects because the injection is only into the liver. Yttrium-90 therapy has 2 stages. The first stage is to map the hepatic artery blood supply to and in the liver. Patients are also tested to make sure minimal blood passes through the liver into the lung, "shunting into the lung". If the mapping is acceptable, patients return 2 weeks after for injection of Yttrium-90 microspheres into the liver cancer.

Please go to Yttrium-90 infusion for Hepatoma treatment to see how Yttrium-90 works.

The pictures below show a catheter that is placed into an artery in the groin and goes to the liver (A & B). Once the catheter is in the liver, Yttrium-90 microspheres are injected into the arteries supplying blood the the cancer. (C)

sirspheresadmin

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Breast cancer can spread (metastasize) to the liver. In patients having breast cancer spending to the liver, surgery to remove the cancer can increase survival in select patients. Patients most likely to benefit are: 1) hormone receptor positive (estrogen/progesterone receptor positive), 2) cancer has shrunk as a result of chemotherapy before evaluation for surgery, 3) cancer has not grown or is not growing at the time of evaluation for surgery, 4) small number of cancers in liver, 5) small size of cancer in liver, and 6) a long time period of over several years from the time the cancer was first diagnosed to the time the breast cancer was found to spend to the liver.

Patients with favorable characteristics on average lived 70-80 months compared to 20-30 months in patient without favorable characteristics.

Reference:
Abbott DE et al "Resection of liver metastases from breast cancer: Effect of timing of surgery and estrogen receptor status on outcomes" ASCO GI 2011; Abstract 288.
Occassionally germcell cancer can metastasize to the liver. In patients having germcell cancer metastasize to the liver with a time period of over a year from the time the germcell cancer was first diagnosed to the time the germcell cancer was found to metastasize to the liver, surgery can lengthen patient survival. The longer the time period between diagnosis of germcell cancer and metastasis to the liver, the longer the patient can be expected to live following surgery. Patients with a single liver metastasis do better than patients with multiple liver metastasis.


Occassionally kidney cancer can metastasize to the liver. In patients having kidney cancer metastasize to the liver with a time period of over a year from the time the kidney cancer was first diagnosed to the time the kidney cancer was found to metastasize to the liver, surgery can lengthen patient survival. The longer the time period between diagnosis of kidney cancer and metastasis to the liver, the longer the patient can be expected to live following surgery. Patients with a single liver metastasis do better than patients with multiple liver metastasis.

Occassionally melanoma can metastasize to the liver. In patients having melanoma metastasize to the liver with a time period of over a year from the time the melanoma was first diagnosed to the time the melanoma was found to metastasize to the liver, surgery can lengthen patient survival. The longer the time period between diagnosis of melanoma and metastasis to the liver, the longer the patient can be expected to live following surgery. Patients with a single liver metastasis do better than patients with multiple liver metastasis.

Occassionally ovarian cancer can metastasize to the liver. In patients having an ovarian cancer metastasize to the liver with a time period of over a year from the time the ovarian cancer was first diagnosed to the time the ovarian cancer was found to metastasize to the liver, surgery can lengthen patient survival. The longer the time period between diagnosis of ovarian cancer and metastasis to the liver, the longer the patient can be expected to live following surgery. Patients with a single liver metastasis do better than patients with multiple liver metastasis.



Occassionally prostate cancer can metastasize to the liver. In patients having prostate cancer metastasize to the liver with a time period of over a year from the time the prostate cancer was first diagnosed to the time the prostate cancer was found to metastasize to the liver, surgery can lengthen patient survival. The longer the time period between diagnosis of prostate cancer and metastasis to the liver, the longer the patient can be expected to live following surgery. Patients with a single liver metastasis do better than patients with multiple liver metastasis.

Stomach cancer can metastasize to the liver. In patients having stomach cancer metastasize to the liver with a time period of over a year from the time the stomach cancer was first diagnosed to the time the stomach cancer was found to metastasize to the liver, surgery can lengthen patient survival. The longer the time period between diagnosis of stomach cancer and metastasis to the liver, the longer the patient can be expected to live following surgery. Patients with a single liver metastasis do better than patients with multiple liver metastasis.

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This is usually a non-cancerous benign tumor of the liver. It is associated with use of birth control pills. Most adenomas have no symptoms. However, once an adenoma grows more than 5 centimeters in size, patients can describe a feeling of fullness. In up to 4 out of 10 patients, an adenoma can bleed. Patients can feel pain, loss of appetite, nausea, vomiting, fever, and sometimes shock. In 1 out of 10 patients, the adenoma can turn into a liver cancer. Once an adenoma reaches 5 centimeters in size, it should be removed.
These are non-cancerous benign tumors of the liver. They are also the most common tumors of the liver and occur mostly in people ages 30 - 50. Women are affected more and usually have bigger tumors than men. Most hemangiomas do not produce symptoms. But patient can feel fullness or a pressure type of pain. As hemangiomas increase in size, they can bleed; especially if greater than 10 centimeters in size.
Focal nodular hyperplasia (FNH) is a benign condition of the liver that is often discovered incidentally on radiological exam. FNH has no malignant potential, is rarely symptomatic and surgery is almost never required. FNH occurs most commonly in premenopausal women, but up to 10% of patients are men. Occassionally FNH can cause symptoms such as pressure, fullnes or pain, as well as demonstratng rapid growth. These findings can be indications for surgical removal. Prior to surgery, patients should have a thorough investigation to rule out other causes of symptoms, such as an upper endoscopy.
Liver cysts are thin-walled structures that are filled usually with clear fluid. Most are simple and single in number. Sometimes a cyst will increase in size, causing feeling of fullness, discomfort, or pain. On rare occassions, a patient can bleed into the cyst. This can cause sudden and severe right upperabdomen and shoulder pain. Simple liver cysts are not associated with cancer. If a patient suffers from discomfort or or pain, the best treatment is to remove a large portion of the cyst wall. This is called a marsupialization, and can usually be done with a laparoscope. This is usually a same day procedure. The risk of the cyst returning is 5-10%.

If the cyst is complex; meaning it has multiple divisions within or uneven wall thickening, a cystic tumor may exist. About 1-2% of cystic tumors contain a cancer. Cytstic tumors should be entirely removed surgically. If there is suspicion of a cystic tumor, the cyst fluid should be obtained and sent for testing of tumor markers.

In very rare cases, patients can have clusters of cysts that spread through out the liver. This is called polycystic liver (PLD) disease. Over many years, patients can develop massive liver enlargement, causing abdominal swelling and pain. Although PLD does not cause liver failure, in extreme cases, the patient may needs a liver transplant.

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All patients being considered for treatment for hepatitis B need to be tested for the presence of liver cancer and cirrhosis.

Blood tests necessary to determine how best to treat patients include: surface antigen, e-antigen, e-antibody, viral load and genotype.

Drugs for HBV treatment fall mainly into two categories: immune modulators (interferons) and those that inhibit HBV replication. Responses to therapy are described as “initial response”, measured at 6 months or 12 months into treatment, “maintained response” when the response is still present at the patients last visit, and a “sustained response” when the response is still present 6 months after the completion of therapy. A resolved infection or "response" is a sustained loss of HBsAg.

Immune Modulators
pegylated interferon (Pegasys, Roche)
pegylated interferon (Peg-Intron A, Merck)

Inhibitors of HBV replication
tenofovir, (Viread, Gilead Sciences)
entecavir (Baraclude,Bristol-Myers Squibb)
adefovir dipivoxil (Hepsera, Gilead Sciences)
telbivudine (Tyzeka, Novartis)
lamivudine (Epivir-HBV, GlaxoSmithKline)

Of these, tenofovir is the most potent with no reported viral resistance reported after 3 years on treatment. Entecavir also has low reported resistance after long term use. Advantages over interferons include a more rapid response, oral administration, and a good tolerability with fewer adverse effects. The disadvantages of these drugs include uncertainty about the durability of HBeAg seroconversion and development of antiviral resistance. The 3-year relapse rate has varied between 38% and 77%.
Chronic Hepatitis C infection is the leading cause of cirrhosis, liver failure and cancer in the United States. Recent breakthroughs in therapy enable up to 90% of patients to eradicate viral infection without need for interferon. As the guidelines are rapidly changing with new agents please click on link below to go to The American Association for the Study of Liver Disease updated guidelines for chronic hepatitis C infection.

American Association for the Study of Liver Disease HCV Guidelines

Often called a pyogenic abscess, is a pus-filled area in the liver. Common causes of liver abscesses include abdominal infection such as appendicitis, diverticulitis, or a perforated bowel, trauma that damages the liver, infection in the blood, recent endoscopy of the bile draining tube, infection of the bile draining tubes.

Treatment usually consists of surgery or going through the skin with a needle or tube to drain the abscess and the use of antibiotics for about 4 - 6 weeks. Sometimes antibiotics alone can cure the infection.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001307/
Echinococcus is an infection caused by the Echinococcus granulosus or Echinococcus multilocularis worm. Echinococcus is common in: Africa, Central Asia, Southern South America, The Mediterranean, and The Middle East.

Humans become infected when they swallow eggs in contaminated food. The infection is carried to the liver, where cysts form. Cysts can also form in the brain, bones, kidney, lungs, skeletal muscles, and spleen

Most often, echinococcosis is found when an imaging test is done for another reason. The cysts may break open (rupture) and cause severe illness, including fever and shock
The cysts may also spread throughout the body. The main treatment are with the drugs albendazole or mebendazole. These medications are often used for up to 3 months. Another drug, praziquantel, may be helpful combined with albendazole or mebendazole.

In patients failing medical treatment, the cysts need to be removed with surgery. For further information, go to:

http://www.cdc.gov/parasites/echinococcosis/

or

http://www.nlm.nih.gov/medlineplus/ency/article/000676.htm
This infection can cause scarring and portal hypertension. Go to the link below for Center For Disease Control Guidelines

http://www.cdc.gov/parasites/schistosomiasis/health_professionals/index.html#tx
Amebic liver abscess is a collection of pus in the liver brought on by an intestinal parasite. Amebic liver abscess is caused by Entamoeba histolytica, the same organism that causes amebiasis, an intestinal infection also called amebic dysentery. The organism is carried by the blood from the intestines to the liver. The disease spreads through ingestion of amebic cysts in food or water contaminated with feces (sometimes due to use of human waste as fertilizer), and through person-to-person contact.

The infection occurs worldwide, but is most common in tropical areas where crowded living conditions and poor sanitation exist. Africa, Latin America, Southeast Asia, and India have significant health problems associated with this disease.

An antibiotic medicine called metronidazole (Flagyl) is the usual treatment for liver abscess. A medication such as iodoquinol must also be taken to get rid of all the amebas in the intestine, to prevent the disease from coming back. This can usually be delayed until after the abscess has been treated. In rare cases, the abscess may need to be drained to help relieve some of the abdominal pain.

For further information, go to http://www.cdc.gov/parasites/amebiasis/faqs.html

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Pancreas cancer remains a deadly disease. Over 9 out of 10 people with pancreas cancer will not live longer than 5 years from the time they were first diagnosed. At surgery, 4 out of 10 patient will be eligible for a curative surgical resection. Of patients surgically resected, 8 out of 10 will have have their pancreas cancer reoccur. Only 2 out of 10 patients surgically resected for cure will be alive 5 years after surgery.

Any patient with pancreas cancer should strongly consider enrolling in a clinical trial.

At the National Cancer Institute patient treatment information web site, clinical trials listed are possible treatment options for patients with pancreas cancer.

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If the tumor is located in the head of the pancreas, a pancreaticoduodenectomy, also known as a Whipple procedure, is the surgery most commonly used. This involves removing the pancreas head, duodenum, gallbladder, portion of the bile duct,and part of the stomach as shown below.

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If the tumor is located in the body or tail of the pancreas, the procedure of choice is a distal pancreatectomy. The can usually be performed laparoscopically. (see below)

Though some chemotherapy combinations, such as Abraxane/Gemcitabine or , improve survival, they are not curative. As a result, the National Cancer Institute strongly recommends, all patients with pancreas cancer be encouraged to participate in a clinical trial.

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A pancreatic neuroendocrine tumor (NET) may also be called a pancreatic endocrine tumor (PET), islet cell tumor, islet cell carcinoma, or pancreatic carcinoid. Pancreatic NETs are much less common than pancreatic exocrine tumors and have a better prognosis. Pancreatic NETs make different kinds of hormones. Symptoms can be caused by the growth of the tumor and/or by hormones the tumor makes. however, some tumors may not cause symptoms.

Go to the link below for further details

http://www.cancer.gov/cancertopics/pdq/treatment/isletcell/Patient/page1
These are cysts in the pancreas that make a thick fluid called mucin. Left alone (surgically not removed), Mucinous cyts can turn into a cancer called a cystadenocarcinoma, a potentially fatal disorder.

It is important to separate these tumors from a condition called pancreatic pseudocyst. Cystic tumors are often misdiagnosed as pancreatic pseudocyst and inappropriately treated.
Intraductdal Papillary Mucinous Neoplasm (IPMN) are tumors that grow within the pancreatic ducts. These tumors make a thick fluid called mucin. IPMN is important because it can turn into to cancer. If found early, IPMN can be removed before it turns into a cancer. Once IPMN turns into cancer, it is much more difficult to treat and patient survival is much shorter. IPMN can form in the main pancreatic duct (main duct type) or in a branch off of the main pancreatic duct (branch duct type). Branch duct type IPMNs are less likely to turn into cancer than are main duct type IPMNs.

The most common signs of IPMN are yellow jaundice, weight loss, and acute pancreatitis. IPMNs become more common with older age. The diagnosis is comfirmed with computerized tomography (CT), endoscopic ultrasound (EUS), or magnetic resonance cholangiopancreatography (MRCP). These tests show an abnormally large main pancreatic duct or one of the branches of the pancreatic duct. A fine needle aspiration (FNA) biopsy using endoscopic ultrasound or through the skin using a needle guided by ultrasound or CT scanning can be used to confirm the diagnosis. Having an IPMN can also increase the risk of colon and rectal cancer.

Treatment of Main Duct Type IPMN
Up to 7 out of 10 patients with main duct type IPMN have cancer. in general, most main duct type IPMN should be surgically removed if the patient can safely tolerate surgery. If a main duct type IPMN is in the body or tail of the pancreas, usually a procedure called a “distal pancreatectomy" is used to remove the tumor. IPMNs in the head or uncinate process of the pancreas are usually resected using a Whipple procedure (pancreaticoduodenectomy). A total pancreatectomy (removal of the entire gland) may be indicated in the rare instances in which the IPMN involves the multiple sites along the length of the main duct of the pancreas.

Treatment of Branch Duct Type IPMN
Most branch duct type IPMNs will not turn into cancer. However, surgery is necessary when a patient has 1) signs or symptoms as described, 2 ) the IPMN is more than 3 centimeters in size, 3) IPMN is associated with an enlarged (balloonning) main pancreatic duct, or 4) contains a solid mass (mural nodule). Sometimes branch duct type IPMNs less than 3 cm need to be removed because they are growing fast, or preferences of the patient and surgeon. Branch duct IPMNs that are not surgically removed should be followed with an imaging study to make sure they do not grow. Acceptable imaging studies include computerized tomography (CT), endoscopic ultrasound (EUS), and magnetic resonance cholangiopancreatography (MRCP). Branch duct IPMNs smaller than 1 centemeter in size should be imaged every year. IPMNs with a change in size should be imaged more frequently, some as often as every three months.

While patients who have an IPMN removed that is not an invasive cancer are “cured” of their tumor, patients with an IPMN are at risk for developng a many tumors. These patients need to be followed over many years.

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The pancreas is organ located deep in the back of the body (retroperitoneal space) in the upper part of the abdomen. It is almost completely covered in front by the stomach and duodenum. The pancreas may be divided into five major regions—the head, neck, body, tail and uncinate process. Acute pancreatitis refers to an acute inflammatory process of the pancreas, usually accompanied by abdominal pain, nausea, vomiting and elevations of serum pancreatic enzymes. Eighty percent of the cases of acute pancreatitis in the United States are related to alcohol use or biliary stones. Pancreatitis may be classified as mild, moderate, or severe based on physical findings, laboratory values, and radiological imaging. Mild disease is not associated with complications or organ dysfunction and recovery is uneventful. In contrast, severe pancreatitis is characterized by pancreatic dysfunction, local and systemic complications, and a complicated recovery.



Gallstones are the most common cause of pancreatitis in the United States. It is believe that obstruction of the major papilla by a stone causes reflux of bile into the pancreatic duct

Alcohol is the second leading cause of acute pancreatitis. In many patients, however, chronic pancreatitis is already present. The cause of alcohol related pancreatitis is believed to result from abnormal major papilla function, direct toxic and metabolic effects, and small duct blockage by protein plug formation.

Drugs: are a well-recognized cause of pancreatitis. These drugs may be divided into those that have a definite association and probable association with the development of acute pancreatitis.
Clearly linked drugs include:
Azathioprine, 6-mercaptopurine, Trimethprim-sulfamethoxazole, Pentamidine, 2',3'-Dideoxyinosine, Asparaginase, Methyl-dopa
Likely linked drugs:
Sulfasalazine, Captopril, Alfa-interferon, Estrogens, Aminosalicylic acid,Corticosteroids, Corticotropin, Acetaminophen, Sulindac, Tetraclcline, Metronidazole, Thiazide diuretics, Furosemide, Isotretinoin, Valproic acid

Pancreas Divisum: The most common congenital anomaly of the pancreas, occurs in approximately 10% of the population, and results from incomplete or absent fusion of the dorsal and ventral pancreatic ducts during embryological development.

Microlithiasis: Many patients with acute pancreatitis of unknown cause will have microlithiasis. This may be diagnosed either as gallbladder sludge on ultrasound (ultrasound of gallbladder sludge) or as crystals on microscopic examination of bile

Metabolic Causes: Hyperlipidemia and hypercalcemia can cause acute pancreatitis. In patients with hyperlipidemia, triglyceride levels are usually greater than 2,000mg/dl. It is believed that lipase present in the pancreatic capillaries metabolizes the levels of triglyceride generating toxic free fatty acids. Hypercalcemia has been shown to induce experimental pancreatitis, probably by increasing pancreatic duct permeability. Its mechanism for the development of clinical pancreatitis is not clear.

Sphincter of Oddi Dysfunction: In a few patients with recurrent pancreatitis of unknown cause, pressure studies of the sphincter of Oddi show abnormal motility. Endoscopic or surgical sphincterotomy directed to the sphincter of Oddi, may be beneficial in these patients. Use of nitrates or calcium channel blockers may also provide short-term relief.

Other Causes: Viral, bacterial, and parasitic infection may cause pancreatitis, mumps and Coxsackie B virus infection being the most common. The human immunodeficiency virus (HIV) may cause elevation of serum pancreatic enzymes but rarely leads to severe pancreatitis. Bacterial infections that can cause acute pancreatitis include Salmonella, Shigella, Campylobacter, Escherichia, Legionella, Leptospira, and even brucella.
Patients chronic pancreatitis can suffer from scarring within the pancreatic duct in the pancreas or formation of pseudocysts. These are both basically caused by blockage of the pancreas duct. The basic procedure is to correct the blockage and let the pancreatic juices flow into the intestine.

Pseudocysts:
Communicating pseudocysts
Sphincteroplasty drainage: If the pseudocystcyst connects to the main pancreatic duct, use of endoscopic sphincterotomy via Endoscopic Retrograde CholangioPancreatography (ERCP) is usually the first option to try to fix a blocked pancreatic duct and let the pancreatic juices drain from the psedocyt.



Non-communicating pseudocysts
Transgastric Endoscopic Pseudocyst Drainage: Using endoscopy, if the pseudocyst is next to stomach, a plastic tube can be placed through he stomach wall into the cyst to



Pseudocyst Drainage: the cyst is drained into the stomach or a segment of small intestine



Longitudinal Pancreaticojejunostomy (Puestow Procedure): The pancreatic duct is opened from the tail to the head of the pancreas and attached to the small bowel.

Distal Pancreaticojejunostomy (Du Val Procedure): The pancreas is divided transversely at the neck, and the body and tail are drained via attachment to the small bowel.
Pancreas divisum is the most common congenital anomaly of the pancreas, and occurs in approximately 10% of the population. This anomaly results from incomplete or absent fusion of the dorsal and ventral ducts during embryological development. In pancreas divisum, the ventral Duct of Wirsung empties into the duodenum through the major papilla but draining only a small portion of the pancreas (ventral portion). Other regions of the pancreas, including the tail, body, neck and the remainder of the head, drain into the duodenum through the minor papilla via the dorsal duct of Santorini. Obstruction of the minor papilla can cause acute pancreatitis or chronic pancreatitis in patients with pancreas divisum when most of the pancreas drains through the minor dorsal duct (hence the term dominant dorsal duct syndrome).


Normal pancreas: main and accessory ducts joined


Pancreas Divisum: main and accessory ducts do not join


Endoscopic minor papilla sphincterotomy is an effective treatment for patients with recurrent pancreatitis and pancreas divisum. Good long-term results are found in about 70% of patients but may be significantly less if there are changes of chronic pancreatitis. Surgical sphincteroplasty of the minor pancreatic sphincter is indicated for unsuccessful or failed endoscopic minor papilla sphincterotomy in patients with pancreas divisum.

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Bile duct cancer is called a cholangiocarcinoma. It is a cancer that grows from the lining of the bile ducts. Conditions that increase the risk of this cancer are:

1) Primary Sclerosing Cholangitis (PSC), which is an autoimmune disease of the large bile ducts. PSC is common in people with the inflammatory bowel disease ulcerative colitis.
2) Parasite infections (liver flukes: Clonorchis sinensis or Opisthorchis viverrini) of the bile bucts from eating raw fish.
3) Cyts of the bile ducts (choledochocyst) 10-20% of people who have a choledochocyst for many years will develop bile duct cancer
4) Having multiple gallstones over many years.

Common factors for all of these causes include:
1) blocked flow of bile, a liquid made by the liver used to digest fatty foods
2) inflammation of the bile ducts
3) scarring (fibrosis) of the bile ducts

Cholangiocarcinoma is either central (A. bile ducts outside the liver) or peripheral (B. bile ducts inside the liver)

Symptoms depend on if a cholangiocarcinoma is central or peripheral.

Patients with a central cholangiocarcinoma may have yellow jaundice, itching, pain, fever, weight loss or weakness.

Patients with a peripheral cholangiocarcinoma may only have vague abdominal pain, weight loss, weakness and fatigue. Patients with a peripheral cholangiocarcinoma usually have more advanced cancer when diagnosed.
Often an ultrasound or CAT scan may find a mass in the bile ducts. This is usually confirmed with an Magnetic resonance cholangiopancreatography (MRCP).

In patients with suspected blockage with stones or in need of a stent (small plastic tube) to bypass the blockage, Endoscopic retrograde cholangiopancreatography (ERCP) is used to obtain scrappings/brushing from inside the bile duct as well as place the bypass stent.

A technique called Spyglass may also be used to look directly inside the bile duct to identify a tumor directly as well as obtain a biopsy specimen.

In patients with complete blockage of the bile duct such that ERCP is not possible, a plastic catheter may need to be placed through the skin, liver and into the bile duct. This is called Percutaneous transhepatic cholangiography (PTC).

In addition to these imaging studies, blood test can also be helpful. The most common blood tests used are CA19-9, CEA and CA-125. CA 19-9 is elevated in up to 85% of patients with cholangiocarcinoma. CA-125 is elevated in 40–50% of cholangiocarcinoma patients. Carcinoembryonicantigen(CEA) is raised in approximately 30% of patients with cholangiocarcinoma.
Bile duct cancer outside the liver can be proximal (hilar), mid, and distal (usually as the bile duct passes through the pancreas). If a patient is a surgical candidate, removal of the cancer is performed with removal of the lymph nodes in and around the liver. As the number of lymph nodes found to have cancer increases, so does the chance that the cancer will return.

Proximal bile duct cancers are challenging to remove. It is necessary to remove the right or left half of the liver with the involved bile duct and connect a portion of intestine to the remaining bile duct. It may also sometimes be necessary to remove and reconstruct a large vein located behind the bile duct called the portal vein.

Mid bile duct cancers can be particularly difficult to remove because of early local invasion to the portal vein or spreading into the liver as well as the pancreas. It maybe sometimes possible to remove that portion of the bile duct involved. However sometimes the cancer spreads to the pancreas or to the liver, or even both.

Distal bile duct cancer have the best chance for surgical removal and long term survival. Surgery usually involves removing a portion of the stomach, pancreas and duodenum. This is call a pancreaticoduodunectomy or "Whipple Procedure"

When the cancer is not removable, percutaneous transhepatic cholangiography (PTC) is used to place a catheter to bypass the blockage. This may be used in combination with external beam radiotherapy and chemotherapy such as fluorouracil (5-FU), cisplatinum and capecitabine.

This is cancer of the bile ducts within the liver. If the cancer is well localize, surgical removal is indicated. However, these patients are at high risk for recurrent cancer at a different site in the liver.
In patients with primary sclerosing cholangitis who develop a central bile duct cancer, the "Mayo Protocol" has shown up to 6 out of 10 patients transplanted are alive after 5 years.

Eligible patients have the following:
1. locally advanced unresectable disease with, positive intraluminal brush cytology, positive intraluminal biopsy, or CA19-9 < 100 in the setting of a radiographic malignant stricture.
2. primary sclerosing cholangitis with resectable disease
3. absence of medical contraindications for liver transplant.

Reason why patient are not eligible include:
1. extrahepatic disease including regional lymph node involvement
2. uncontrolled infection
3. prior attempt at surgical resection
4. prior treatment with radiation or chemotherapy
5. previous malignancy within 5 years.

The protocol includes.
1. External beam radiotherapy to a target dose of 4,500 cGy with concomitant fluorouracil (5-FU).
2. Transcatheter Iridium-192 brachytherapy with a target dose of 2,000 to 3,000 cGy
3. Patients receive oral capecitabine as tolerated until transplantation.
4. Staging laparotomy before transplant. Finding perihilar lymph nodes, any lymph nodes or nodules with tumor excludes eligibility.

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Injury from cholecystectomy: Injury to the common bile duct during laparosopic cholecystectomy occurs in 1 in 1000 patients. The type of injuries are classified as shown below. Patient's with a bile duct injury have the best outcome when repaired by a surgeon experienced with hepato-pancreato-biliary surgery.



The repair usually involves complete removal of the injured bile duct and reconstruction using a segment of intestine to reconnect the bile to. This procedure is called a hepatico-jejunostomy with roux-en-y limb.



Factors that effect a success repair are surgeon experience, injury to the artery supplying blood to the bile duct, and local infection.
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Cysts of the blie duct are called choledochocysts. There are several types located in different parts of the common biliary and hepatatic ducts. Over many years, there is a 10-20% chance a bile duct cancer will grow within a choledochocyts. It is generally recommended that choledochocysts be removed to avoid the risk of developing cancer.

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Type I choledochal cysts - These are the most common, representing 80-90% of cysts. Type I cysts are dilatations of the entire common hepatic and common bile ducts or of segments of each.

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Type II choledochal cysts - These are relatively isolated protrusions or diverticula that project from the common bile duct wall. They may be either sessile or connected to the common bile duct by a narrow stalk.

Type III choledochal cysts - Also called choledochoceles, these are found in the intraduodenal portion of the common bile duct.

Type IVA cysts - These are characterized by multiple dilatations of the intrahepatic and extrahepatic biliary tree. Most frequently, a large, solitary cyst of the extrahepatic duct is accompanied by multiple cysts of the intrahepatic ducts.

Type IVB choledochal cysts - These consist of multiple dilatations that involve only the extrahepatic bile duct.


Type V choledochal cysts - These are defined by dilatation of the intrahepatic biliary radicles. Often, numerous cysts are present with interposed strictures that predispose the patient to intrahepatic stone formation, obstruction, and cholangitis. The cysts are typically found in both hepatic lobes. Occasionally, unilobar disease is found and most frequently involves the left lobe.

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Scaring of the common bile duct can result from stones in the gallbladder passing through the duct into the intestine.

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Portal Hypertension is abnormally high pressure in the vein that delivers blood to the liver from the intestine (portal vein). The increase in portal vein pressure is caused by a blockage in the blood flow through the liver. The blockage can be caused by severe scarring of the liver (cirrhosis) or formation of a blood clot in the portal vein. Increased pressure in the portal vein requires the veins of the esophagus and stomach to bypass the blockage. The abnormally high blood flow and pressure in the veins of the esophagus and stomach cause increased tension in the wall and increased size, forming varices that become fragile and can bleed easily. The increased portal vein pressure also causes sweating from the liver and intestine resulting in an accumulation of fluid in the abdomen. The is called ascites.

Cirrhosis is the leading cause of portal hypertension. Historically a surgical procedure called a mesocaval shunt was performed to relieve increased pressure to lower the risk of bleeding. With advances in interventional radiology, a procedure called a Transjugular-Intrahepatic-Portalsystemic-Shunt or TIPS procedure is now used in most patients with portal hypertension. In patients with a completely blocked portal vein, TIPS is usually not possible. In these patients a surgical shunt is usually the procedure of choice. The most common shunt used is called a mesocaval shunt. Patients who have a completely blocked portal vein commonly have an abnormally high tendency to form blood clots, otherwise known as a hypercoagulable state. These patients also need to take blood thinners to prevent future blood clots in their TIPS or surgical shunt.






Initial treatment for ascites is a low-sodium (salt) diet with no more than 2 grams of sodium per day. Reduced protein intake will also help avoid confusion (encephalopathy). Medical treatment also include the use of water pills (diuretics). The most common medications used are furosemide (Lacix) and spironolactone (Aldactone). To further reduce the pressure in the portal vein, patients are also started on medications to lower blood pressure. The most common medications are "beta blockers", these include propanolol, nadolol, or atenolol. Patients that fail medical management maybe eligible for a "shunt" procedure.

Normal Esophagus compared to Esophagus with varices



Life threatening bleeding can occur from esophageal varices. Patients diagnosed portal hypertension should have an endoscopy to determine if varices are present. Patients with significant varices can be treated with "banding" or "sclerotherapy". To further reduce the pressure in the portal vein, patients are also started on medications to lower blood pressure. The most common medications are "beta blockers", these include propanolol, nadolol, or atenolol. Patients that fail endoscopic management maybe eligible for a "shunt" procedure.
In patients with cirrhosis, a procedure called a Transjugular Intrahepatic Porto-systemic Shunt (TIPS) is usually the treatment of choice because many of these patients ultimately need a liver transplant. In patients without cirrhosis, a surgical shunt offers better long term function. The most common complication from a TIPS is confusion and disorientation (encephalopathy).



Transjugular Intrahepatic Portosystemic Shunt, or better known as a TIPS procedure, is usually performed by an interventional radiologist. A hollow needle is used to access the internal jugular vein in the neck. A wire is passed through the needle into the vein, down to the liver. A ) The wire is passed usually through the right hepatic vein, and a connection is made with the portal vein. B) Through the connection a wire mess tube is placed. C) The wire mesh tube expanded to allow blood to flow directly from the portal vein to the hepatic vein.
Since a TIPS procedure has become the leading treatment for portal hypertension, surgical shunts are used in patients with cirrhosis who have failed TIPS or who have a completely blocked portal vein. In patients without cirrhosis, a surgical shunt offers better long term function when compared to TIPS. Most patients in need of a surgical shunt have a blood disorder where clot forms too easily in the portal vein. When a patient goes on to suffer from bleeding varices or ascites, a surgical shunt can relieve these complications.

The most common surgical shunt used is called a mesocaval shunt. In patients with cirhosis, the most common complication from a mesocaval shunt is confusion and disorientation (encephalopathy). In patients already having encephalopathy, a surgical shunt called a distal splenorenal shunt is an option. However because most candidates for a surgical shunt do not have cirrhosis, a distal splenorenal shunt is rarely needed. A distal splenorenal shunt also does not usually improve control of ascites.

elow are the types of shunts to treat patients with portal hypertension: 1) portal-caval, 2) meso-caval, and 3) meso-renal



In patients with portal hypertension suffering from bleeding with extended clot formation, such that a TIPS or surgical shunt is not possible or has failed, it is necessary to tie off of the blood supply to most of the stomach.

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