Digestive Path Lecture 3 PDF

Diseases of the Gastrointestinal System Part 3 Lecture Outline: Diseases of the Liver Hepatitis MASLD (previously NAFLD) Cirrhosis Hepato...

Diseases of the Gastrointestinal System Part 3 Lecture Outline: Diseases of the Liver Hepatitis MASLD (previously NAFLD) Cirrhosis Hepatocellular Carcinoma (HCC) Dr. Kevin Tipper, ND Major Diseases of the Liver Hepatitis Viral Hepatitis Alcoholic Hepatitis Chronic Hepatitis Metabolic Dysfunction–Associated Steatotic Liver Disease (MASLD), formerly known as NAFLD Hepatocellular Carcinoma (HCC) Liver Failure Broad Categories of Hepatic Injury Abnormal conditions brought on by damage to the liver causes by, most likely, one of the diseases on the previous slide Cirrhosis PortalHypertension Esophageal Varices Hepatic Encephalopathy We will discuss this first as many complications from liver disease arise due to these secondary complications Cirrhosis Definition Irreversible replacement of normal liver tissue with non-functional scar tissue Thisdamage is typically irreversible Cirrhosis Etiology MC cause is alcoholic hepatitis Liver inflammation due to excessive alcohol consumption Viral hepatitis (Hep B and Hep C) Metabolic Dysfunction–Associated Steatotic Liver Disease (MASLD) Cirrhosis Epidemiology Twice as common in males Autopsy of livers in US reveal 5% of population has cirrhosis 25,000 deaths per year in the US Prognosis Once diagnoses, without transplant, patient usually dies within 5 to 15 years Usually due to complications of cirrhosis Cirrhosis Cirrhosis Complications Portal hypertension, which causes several complications: Esophageal varices May lead to mass hematemesis Rectal varices Ascites Kidney failure Hepatic encephalopathy Cirrhosis Complications Decrease in bile decrease in vitamin D absorption, possibly leading to osteoporosis Poor vitamin K absorption tendency for bleeding Splenomegaly platelets get trapped in spleen = tendency for bleeding Bleeding leads to anemia Cirrhosis Signs and Symptoms Many have no SSx for several years Recognizable symptoms of cirrhosis fall into two categories 1. symptoms related to declining liver function 2. symptoms related to portal hypertension MC SSx: weakness, malaise, fatigue, weight loss, ascites and loss of appetite Cirrhosis Signs and Symptoms symptoms related to declining liver function: Reduction in bile production results in decreased absorption of fat and fat-soluble vitamins Greasy, foul-smelling steatorrhea Fatigue, loss of appetite, loss of weight Dark urine Generalized edema Malabsorption Cirrhosis Signs and Symptoms symptoms related to portal hypertension: Jaundice Ascites Hepatomegaly and splenomegaly digital clubbing caput medusae, spider telangiectasia small yellow nodules (xanthelasma, especially around eyes) Cirrhosis Spider telangiectasia (spider angioma) Pathogenesis unclear Possibly a result of elevation in vascular endothelial growth factor and fibroblast growth factor or an altered estrogen/testosterone ratio Cirrhosis Digital clubbing Pathogenesis unclear Possibly a result of elevation in vascular endothelial growth factor and fibroblast growth factor or an altered estrogen/testostero ne ratio Cirrhosis Caput medusae Pathogenesis swollen veins around your umbilicus Due to portal hypertension Cirrhosis Xanthelasma Benign yellow growth that appears on or by the corners of your eyelids Cholesterol deposits build up under your skin to form a xanthelasma Pathogenesis Dyslipidemia and altered lipoprotein profiles Altered fat metabolism Association with metabolic disease Cirrhosis Signs and Symptoms Other Sx: Sarcopenia (and assoc. muscle atrophy) Palmar erythema Gynecomastia, testicular atrophy, and thinning of armpit hair Dupuytren’s contracture Cirrhosis Dupuytren's contracture Fibrosis of the palmar aponeurosis Pathogenesis exact mechanisms linking cirrhosis and Dupuytren's contracture are not fully understood Cirrhosis Diagnosis Based on Hx, SSx, PE, and blood tests Liver feels nodular and firm on palpation Advanced imaging (US or CT) Biopsy to confirm may be done Blood testing: LFTs (liver function tests) Liver enzymes are elevated (AST and ALT) Elevated bilirubin, decreased albumin CBC may show signs of anemia Blood work may be done to find underlying cause (hep B and hep C serology) Cirrhosis Treatment Eliminating of alcohol is crucial, especially if you have alcoholic hepatitis Improve diet and activity if caused by metabolic disease Review medications (Rx and OTC) and supplements with GP Some may be hard for the liver to process Diuretics Low sodium diet Liver transplant if liver failure occurs 80-90% of liver destruction by cirrhosis Cirrhosis Massage and Cirrhosis No contraindications Maywant to consider less pressure to avoid easy bruising Consider the patients overall comfort Portal Hypertension Definition Abnormally high BP in the branches of the portal vein Presentation: enlarged abdomen, abdominal discomfort, confusion, and internal bleeding MC cause: cirrhosis Portal Hypertension Etiology Cirrhosis Scarring leads to decreased blood flow through the liver Thrombosis in portal vein Parasitic infection called schistosomiasis Malignancy Portal Hypertension Signs and Symptoms Portal HT itself does not cause SSx, but creates consequences that do Ascites Telangiectasia and caput medusae Esophageal varices w/ potential mass hematemesis Splenomegaly Hepatic encephalopathy causing drowsiness, confusion, and coma Gastrointestinal bleeding Portal Hypertension Diagnosis Based on SSx, Hx, and PE Confirmed with US Treatment Most cases are irreversible (caused by cirrhosis) Medications to reduce portal BP (beta blockers) Managing complications If bleeding occurs, emergency Tx required Surgery to reduce bleeds Bypass shunt b/t portal venous system and general circulation Portal Hypertension Massage and Portal Hypertension No contraindications Any abdominal massage should be performed with very light pressure May want to consider less pressure to avoid easy bruising Consider the patients overall comfort Esophageal Varices Definition Engorged, tortuous, and fragile varicose vessels of the lower esophagus Etiology Portal HTN Retrograde flow into the lower esophageal vessels causes distention and eventually leads to varices Esophageal Varices Signs and Symptoms Hematamesis Mild to fatal Black, tarry or bloody stools Lightheadedness due to blood loss Treatment Betablockers to reduce blood pressure Bleeding = medical emergency Endoscope to confirm bleeding is from varices Banding off/chemical injections of veins Vasopressin given IV to constrict bleeding veins Transfusion to replace loss Esophageal Varices Massage and Esophageal Varices Possible CONTRAINDICATION Depends on severity of esophageal varices Some cases may be a medical emergency Hepatic Encephalopathy Definition Deterioration of brain fxn d/t buildup of toxic substances normally removed by liver reaching the brain Ammonia, end product of normal protein breakdown, plays large roll Etiology Portal hypertension Because of increased BP in portal vein, blood bypasses the liver Liver failure Can be trigged by an alcohol binge, drug intake, or other liver stressors in those with longstanding liver disorders Hepatic Encephalopathy Signs and Symptoms Decreased brain fxn w/ reduced alertness, increased confusion Early stages subtle changes in logical thinking, judgement, mood, personality, and behavior Late stages drowsiness, confusion, disorientation, asterixis, and sluggish movements and speech Uncommon sx: agitation, seizures Eventual lose of consciousness and coma Hepatic Encephalopathy Diagnosis Based on SSx, Hx, PE CT scan and EEG (electroencephalogram) Bloodtests for liver function and presence of ammonia Hepatic Encephalopathy Treatment Identify and eliminate triggers Reduce protein intake and other dietary restrictions Lactulose sugar in diet is helpful for decreasing blood ammonia Liver treatment Prognosis Reversible, complete recovery possible Chronic liver failure predisposes to future episodes Ongoing therapy is needed Acute hepatic encephalopathy, fatal in > 50% of cases Fatal in 80% of people who fall into coma Jaundice Definition excess amounts of bilirubin circulating in the blood stream dissolve in the subcutaneous fat (the layer of fat just beneath the skin), causing a yellowish appearance of the skin and the whites of the eyes Jaundice Etiology Prehepatic Conditions that affect the blood’s rate of breaking down blood cells cause bilirubin to overflow into bodily tissues Examples: sickle cell anemia, thalassemia Intrahepatic liver tissue becomes less effective at filtering out bilirubin from your blood Examples: hepatitis, cirrhosis, hepatocellular carcinoma Posthepatic (Obstructive) bilirubin filtered from the blood can’t drain properly into the bile ducts or digestive tract to be passed out of the body Examples: cholelithiasis, pancreatitis, pancreatic cancer Jaundice Signs and Symptoms Yellow skin and the white part of the eyes (sclera) Yellow colour inside the mouth Dark or brown-coloured urine Pale or clay-coloured stools Itching (pruritis) usually occurs with jaundice Jaundice Massage and Jaundice Treatmentmay or may not be indicated based on the cause and severity of jaundice Hepatitis inflammation of the liver that can result from a variety of causes, such as viral infections, heavy alcohol use, autoimmune disorders, drugs, or toxins. Types of hepatitis: Viral hepatitis hepatitis viruses A-E; varying severity and longevity Alcoholic hepatitis d/t over consumption of EtOH Both can lead to chronic hepatitis unrelenting liver inflammation Acute Viral Hepatitis Definition Inflammation of the liver d/t infection with one of the five hepatitis viruses (A-E) Hepatitis A virus is most common cause of acute viral hepatitis Followed by hepatitis B and hepatitis C Hepatitis D and hepatitis E are rare Sudden, rapid onset with a short duration (usually only a few weeks) SSx range from none to severe N/V, poor appetite, fever, RUQ pain, and jaundice are common Acute Viral Hepatitis Comparing Hepatitis Virus Types Usually no specific Tx necessary for hep A, hep B, and hep E Watch and wait Antiviraltreatments available for hep C and hep D Hep C is the most likely to become chronic Hep D can only be acquired if you have hep B Can be a serious form of hepatitis Vaccines for hep A, B (and therefore D) Hep E has a vax in China, but not approved in Canada and US Acute Viral Hepatitis Comparing Hepatitis Virus Types Severity depends on instigating virus and the host response Hep A and C are often mild, sometimes unnoticed Hep B and E are more severe Co-infection of hep B with hep D increases severity (has the highest mortality of all hepatitis infections)  Hep A Hep B Hep C Hep D Hep E Route Fecal-Oral Blood, body Blood Blood Fecal-Oral fluids Incu: 2-6 w Incu: 40-180d Chronic No Yes (5-7%) Yes (75%) Yes No (increases Cirrhosis in 20-30% of chance for those w/ chronic chronic B) infection - Can lead to LV CA Carrier No Yes Rare ----- ----- Vaccine Yes Yes No No (but can No only get D if already have B) Severity Mild Mild-severe Moderate ----- ----- MC cause of acute MC hep to have For unknown reasons, viral hep joint pain and 20% of persons with urticaria alcoholic liver disease develop hepatitis C Mild fever, N/V, loss of appetite, jaundice, cholestasis Acute Viral Hepatitis Common Signs and Symptoms SSx have sudden onset and include Prodromal: Poor appetite, N/V, fever RUQ pain Splenomegaly Hep B can cause joint pain Hep B and hep C can cause urticaria Acute Viral Hepatitis Common Signs and Symptoms Urticaria caused by hep B and hep C infections Acute Viral Hepatitis Common Signs and Symptoms ProgressiveSymptoms Progression causes dark urine and jaundice As other symptoms disappear, jaundice lingers for ~1 month Hep A can causes cholestasis, resulting in pale stool and itchiness Progression to liver failure is rare, but MC w/ hepatitis B virus Acute Viral Hepatitis Diagnosis Initial suspicion is based on positive SSx Palpation of RUQ reveals tenderness and hepatomegaly in 50% of acute viral hepatitis LFT (liver function tests) blood work can indicate liver function and inflammation Varying ratios of blood tests can DDx viral infections from EtOH Antigen/antibody blood tests reveal the specific virus causing hepatitis Ultrasound of the liver to detect any changes If DDx is unclear, a biopsy is done (usually not indicated) Acute Viral Hepatitis Prevention Vaccines available for hepatitis A and B viruses No current vaccine for hep C, D, or E Hep D cannot occur without hep B infection present, therefore, hep B vaccine will reduce risk of hep D Other preventative measures: Washing hands thoroughly before handling food Not sharing needles Not sharing razors, toothbrushes, or items that could contain blood Practicing safe sex Acute Viral Hepatitis General Treatment and Prognosis of Acute Viral Hepatitis Typically, no Tx needed Diet and activity restriction unnecessary Vitamin supplementation not required Avoid alcohol and meds metabolized in the liver Return to most ADL after jaundice clears, even if LFT not WNL Severe cases may require hospitalization Acute viral hepatitis usually clears in 4-8 weeks Some cases can turn chronic Hepatitis A Transmission fecal-oral poor hygiene: food handlers, child care workers shellfish from water where raw sewage drains Diaper changing at childcare centers epidemics often linked to contamination of water supply Can also spread through blood Hepatitis A Hepatitis A Epidemiology Rare in Canada From 2011 to 2015, yearly average of 236 cases of hepatitis A reported Highest reported hepatitis A rates are in age groups 30-59 years Can be endemic in areas with poor water sanitation South Asia, Sub-Saharan and North Africa, parts of the Far East (except Japan), South and Central America and the Middle East Hepatitis A Signs and Symptoms Incubation period of 2-6 weeks Can be asymptomatic and infection goes unrecognized Mild fever, N/V, loss of appetite, jaundice Rare SSx: arthropathy, pancreatitis, renal failure Prognosis Complete recovery within days to months Does NOT result in chronic hepatitis No carrier state or chronic hepatitis from hepatitis A infections Hepatitis A Prevention Proper hand hygiene Avoiding contamination of water supplies Vaccination(Twinrix©) recommended for all children and for adults at high risk of exposure Hepatitis B Transmission Transmitted via blood and body fluids Sexual intercourse Through blood (highest risk), semen, vaginal fluids Needle sharing w/o sterilization Recreational drug use, tattoos, Rx medication Blood transfusion is a rare risk d/t increased screening procedures Birth (vaginal and cesarean) Usually d/t mother’s infected secretions or blood at the time of delivery Hepatitis B Epidemiology Rare in Canada In 2019, there were 178 reported acute hepatitis B cases in Canada since 2010, annual case counts have remained under 200 In 2019, there were 3,790 reported chronic hepatitis B cases in Canada Chronic hepatitis B rates have trended downwards since 2010 more common in some countries in Asia, Africa, South America and the Caribbean Hepatitis B Signs and Symptoms Incubation period of 40-180 days Generally more serious than hep A SSx range from mild to severe Illness followed by fever, jaundice and choluria Joint pain and urticaria more likely in hep B infection Occasionally fatal; especially in immunocompromised or with concomitant infection with hepatitis D Hepatitis B Diagnosis Blood tests confirm presence of infection, or immunity to hepatitis B Hepatitis B Surface Antigen Test (HBsAg) Tests for the presence of hepatitis B surface antigens in blood A positive test indicates acute or chronic infection Antibody Serology Antibody serology tests check for the presence or level of specific antibodies in the blood Certain antibodies will Hepatitis B Prognosis Most cases self resolve in 4-8 weeks 5-7% of adults develop chronic hepatitis B Inverse correlation b/t age and risk (ie ~ 90% of neonates) The estimated 5-year survival rates were 97% for patients with chronic persistent hepatitis 55% for those with chronic active hepatitis with cirrhosis Can have carrier state Hepatitis B Healthy Carriers 10% of infected become healthy carriers Surface antigen present months, years, or sometimes for life but otherwise healthy and unaware of status Must have had infection in order to be a carrier 70% of carriers develop chronic persistent hepatitis B Most do not appear to be ill. Hepatitis B Phases of Hepatitis B Infection 1. Pre-icteric (days to weeks) Mild fever, N/V, anorexia, myalgia, malaise, weakness 2. Icteric (one to two months) Jaundice, hepatomegaly w/ tenderness, urticaria w/ pruritis Pre-icteric SSx abate 3. Convalescent (up to six months) Resolution of SSx Viral Ag disappear and immune Ab appear Hepatitis B Prevention Vaccination Recommended for everyone < 18 ( 3 doses, usually given at birth), but especially for those at risk of exposure Immunocompromised, cirrhosis, and those on dialysis may need booster Avoid needle sharing Engage in safe sex practices If exposed, persons are given a hep B immunoglobulin and the vaccine combination prevents chronic hep B in most. Hepatitis C Transmission Transmitted via blood Needle sharing w/o sterilization Transmission via profusion is rare d/t screening Transmission via sex is more rare than hep B, d/t spread through blood, not body fluids Transmission via pregnancy and birth is rare Hepatitis C Signs and Symptoms Unpredictable course of SSx Initial infection (acute) is usually mild and w/o SSx Clinical presentation indistinguishable from hep B, but often less severe Illness followed by fever, jaundice and choluria urticaria more likely in hep C infection LFTs ebb and flow for several months or years Hepatitis C Prognosis Chronic infection results in 75% of cases Usually mild for decades, but can eventually lead to steatosis Cirrhosis in 20-30% of those w/ chronic infection Cirrhosis can lead to liver CA Carrierstate in a small portion of healthy people Hepatitis C Prevention No vaccine currently available Avoid high risk behaviour needle sharing Hepatitis D and E Hepatitis D can only infect people who are also infected by the hepatitis B virus (HBV) HDV can cause severe symptoms and serious illness that can lead to liver damage and even death Hepatitis E Fecal-oral transmission Usually mild disease, but especially dangerous to pregnant women Fulminant Hepatitis Rare, life-threatening complication of acute hepatitis Marked by the presence of massive liver necrosis Viral hepatitis can progress to fulminant hepatitis if it’s of the B, D or E strain Hep E infections are more likely to become fulminant in pregnant women S&S include encephalopathy (including edema), GI bleeds,  Hep A Hep B Hep C Hep D Hep E Route Fecal-Oral Blood, body Blood Blood Fecal-Oral fluids Incu: 2-6 w Incu: 40-180d Chronic No Yes (5-7%) Yes (75%) Yes No (increases Cirrhosis in 20-30% of chance for those w/ chronic chronic B) infection - Can lead to LV CA Carrier No Yes Rare ----- ----- Vaccine Yes Yes No No (but can No only get D if already have B) Severity Mild Mild-severe Moderate ----- ----- MC cause of acute MC hep to have For unknown reasons, viral hep joint pain and 20% of persons with urticaria alcoholic liver disease develop hepatitis C Mild fever, N/V, loss of appetite, jaundice, cholestasis Viral Hepatitis Massage and Viral Hepatitis Appropriatenessof massage is determined by patient’s symptoms Treatment is CONTRAINDICATED if a fever is present Until 24 hour fever free without the use of antipyretics Alcoholic Hepatitis Definition Liver inflammation due to excessive alcohol consumption over an extended period of time Alcohol is toxic to hepatocytes and therefore damages the liver, causing inflammation Mild damage from alcohol can heal Excessive/prolonged alcohol consumption inhibits regeneration Females who consume high amounts of alcohol are more at risk of developing alcoholic hepatitis compared to males Alcoholic Hepatitis How much is too much? 1 drink = 14g of pure alcohol < 3 standard drinks/week Heavy drinkers can develop early symptoms during their 30s and tend to develop severe problems by their 40s Aside: Canada recently changed recommendations on alcohol uptake to 2 drinks per week Alcoholic Hepatitis Epidemiology Typically between 30-50yo, most patients presenting < 60yo Hx of daily heavy alcohol use (> 100g daily) > 20yrs Pathologic Findings Histological examination shows fatty liver (steatosis) Fatty appearance of hepatocytes d/t focal necrosis of cells Can be reversed with alcohol cessation Alcoholic Hepatitis Signs and Symptoms Anorexia Jaundice RUQ/epigastric abdominal pain Ascites Tender hepatomegaly Alcoholic Hepatitis Treatment Only effective treatment is alcohol cessation Consider formal recovery programs Liver transplant if necessary Prognosis Alcohol cessation: semi-reversible damage w/o further damage (ie. steatosis/steatohepatitis) Continued use: progression to cirrhosis, liver failure and possibly liver CA Combined with systemic damage, it is fatal Nervous System (encephalopathy) Cardiovascular System (alcoholic cardiomyopathy) Urinary System (renal failure) Alcoholic Hepatitis Massage and Alcoholic Hepatitis Appropriatenessof massage is determined by patient’s symptoms No general contraindications Chronic Hepatitis Definition Inflammation of the liver lasting longer than 6 months Cause: most common are hepatitis B and C viruses and medications Hepatitis C is responsible for 60-70% of chronic hepatitis cases ~75% of Hep C cases become chronic ~5-7% of Hep B become chronic Hep A and E do not become chronic Use/overuse of certain drugs (such as Tylenol) Alcoholic hepatitis Metabolic Dysfunction–Associated Steatotic Liver Disease (MASLD) Chronic Hepatitis Signs and Symptoms Usually mild sx with no significant liver damage for years Some have low-grade fever and RUQ discomfort Jaundice is rare and typically only much later in the disease Insome, continued inflammation can result in cirrhosis, liver failure, and/or liver cancer Chronic Hepatitis Signs and Symptoms Complications: Cirrhosis leading to portal hypertension Splenomegaly d/t increased venous pressure from portal HTN Ascites (fluid accumulation in abdominal cavity) d/t portal HTN Spider angioma, caput medusae, palmar erythema Deterioration of peripheral nervous system and brain fxn d/t demyelination and increased serum toxins (hepatic encephalopathy) MC w cirrhosis caused by Hep C Chronic Hepatitis Signs and Symptoms (cont’d) For most, chronic hepatitis does not progress for years Certain hepatitis viral strains will cause gradually worsening SSx. Outlook depends on the cause. Chronic hep C leads to cirrhosis in 15-25% of those infected Hep C is r/t increased risk of liver CA if cirrhosis is present Chronic hep B tends to worsen, sometimes rapidly, and is linked to increased risk of liver CA Chronic co-infection with hep B and D cause cirrhosis in 70% Chronic hepatitis caused by drugs may completely resolve if drug is stopped Chronic Hepatitis Diagnosis May suspect hepatitis in people who present with typical SSx, abnormal blood LFT, or Hx of hepatitis. definitive with biopsy Lab work helps to determine severity and identify the cause, but biopsy is essential for definitive dx. Biopsy also confirms severity of disease process and the cause Thosewith chronic hep B require annual ultrasound and blood work to screen for liver CA. Hep C patients are only screened if it has turned to cirrhosis. Chronic Hepatitis Treatment Eliminate noxious substance and/or treat the cause Antiviral drugs PO or SQ medications given to those with chronic, progressive hep B and C SQ injections are most effective for hep C and stopping inflammation After 6-12 months, 45-75% of cases improve with no further issue Chronic hep B (only ~5% of cases) tends to recur once drug therapy ends Antiviral treatment may be indefinite Family members and close contacts of those with hep B should receive vaccine and immunoglobulin Corticosteroids Advanced disease may require a liver transplant Chronic Hepatitis Massage and Chronic Hepatitis Appropriatenessof massage is determined by patient’s symptoms No general contraindications Metabolic Dysfunction–Associated Steatotic Liver Disease (MASLD) Previously nonalcoholic fatty liver disease (NAFLD) Definition Steatosis in the absence of significant alcohol consumption Most common cause of liver disease in US Estimate of 25% of adults worldwide with NAFLD Forms include: Simple hepatic steatosis (NAFLD) (has little clinical relevance) MASH - Metabolic dysfunction–associated steatohepatitis formerly known as Non-alcoholic steatohepatitis (NASH) Progresses to cirrhosis in 10 – 20% of cases Metabolic Dysfunction–Associated Steatohepatitis (MASH) Pathologic Findings Initially hepatocyte ballooning, lobular inflammation, and steatosis With progressive disease there is steadily more fibrosis, eventually leading to cirrhosis Strongly associated with obesity and the metabolic syndrome Pathophysiology “two-hit” model, involving hepatic fat accumulation and increased oxidative stress Free radicals cause lipid peroxidation of the accumulated intracellular fat Metabolic Dysfunction–Associated Steatohepatitis (MASH) Signs and Symptoms Usually asymptomatic until overt hepatic failure clinical findings are usually due to atherosclerotic disease/diabetes that accompany NASH Fatigue and right-sided abdominal pain can occur in some, though Cardiovascular disease is a frequent cause of death in those with NASH Increased risk of hepatocellular carcinoma Metabolic Dysfunction–Associated Steatohepatitis (MASH) Metabolic Dysfunction–Associated Steatohepatitis (MASH) Treatment Losing weight Medication to reduce cholesterol or triglycerides Medication to reduce blood pressure Medication to control diabetes Limiting OTC drugs Avoiding alcohol Metabolic Dysfunction–Associated Steatotic Liver Disease (MASLD) Massage and MASLD Appropriatenessof massage is determined by patient’s symptoms No general contraindications Hepatocellular Carcinoma (HCC) AKA hepatoma Definition Most common primary liver tumor, most commonly caused by cirrhosis Usually presents with vague signs of abdominal pain, fatigue, loss of weight and appetite Results in late stage Dx and therefore poor prognosis Hepatocellular Carcinoma (HCC) Signs and Symptoms Early signs: abdominal pain, fever, weight loss, and palpable mass in RUQ Persons with cirrhosis may have unexpected increase in illness Rupture of tumor can cause sudden abdominal pain and shock Diagnosis Blood tests PE looking for palpable liver mass Advanced imaging (US, CT, MRI) Biopsy to confirm unclear cases Hepatocellular Carcinoma (HCC) Prevention Hepatitis B vaccine Treatment of chronic hepatitis C Alcoholism treatment and cessation programs Screening for earlier diagnosis Treatment Chemotherapy, radiation, and tumor embolization Surgical resection High rate of recurrence If no metastasis, transplant can be performed Hepatocellular Carcinoma (HCC) Prognosis Vague SSx cause late stage Dx with poor prognosis 5 year survival rate is ~18% Other Primary Liver Cancers Other primary tumors are rare and have poor prognosis Metastatic Disease Far more common than primary liver cancer Commonly from breast, colon, kidney, lung, stomach, pancreas, ovaries/uterus Hepatocellular Carcinoma (HCC) Massage and Hepatocellular Carcinoma (HCC) Appropriatenessof massage is determined by patient’s symptoms No general contraindications