Saturday, March 4, 2023

Liver Cancer

                      Liver Cancer.

                     PKGhatak, MD


Liver Cancer is a deadly disease. Cancers of the liver are of two main categories namely, Primary Liver cancer and Metastatic or Secondary liver cancer.

Primary Liver Cancer:

The liver is made up of about 15 thousand individual lobules. Each lobe is a structural and functional unit of the liver. Liver cells, Hepatocytes when turn cancerous called Hepatocellular cancer. The liver has a dual blood supply - portal and systemic circulatory systems and in addition, a bile duct network to drain the bile from the liver. The endothelial cells of the blood vessels and bile duct cells can turn cancerous. Cancers of different cell lines differ from each other in many aspects. In addition, the liver is richly supplied with immune cells and malignant tumors may develop from immune cells also.


 A. Hepatocellular cancer.

Hepatocellular cancer is by far the most common cancer of the liver. The annual incidence of hepatocellular cancer in the USA is 35,000. Native Americans have the highest incidence among all the ethnic groups. Older Americans have more cancers than the younger age group. The incidence of hepatocellular cancer in East Asian countries is the highest in the world. A very rare form of cancer is occasionally seen in very your children in the hepatic stem E-MB  and MEM-HB cells.

Risk factors.

Hepatitis B and hepatitis C are proven causes of liver cancer. A fungal toxin Aflatoxin is carcinogenic. Alcoholic liver cirrhosis and Non-alcoholic fatty liver disease (NASH) can turn cancerous. Cigarette smoking and alcohol are risk factors. Muscle-building androgenic steroids and oral contraceptive pills are also additional risk factors. Liver cysts and cysts associated with polycystic disease of the kidney are risk factors also. Very rarely, cancerous cysts in the associated use of anabolic steroids and birth control pills are seen

In addition, hereditary metabolic diseases like Hemochromatosis (iron), Wilson disease ( copper), alpha 1 antitrypsin deficiency ( enzyme), porphyria cutaneous tarda, and glycogen storage disease are known to cause Hepatocellular cancer.

Symptoms.

A small size liver cancer does not produce any symptoms. Patient with growing cancer develops loss of weight, loss of appetite, upper abdominal fullness and abdominal pain. At this stage, the diagnosis of liver cancer leads to a better outcome. But most patients come to the doctors when they develop jaundice and dark-colored urine at this stage the disease has progressed too far for a good outcome.

Diagnostic tests.

Alpha fetoprotein in serum is elevated, and Liver function tests show elevated ALT over AST and high bilirubin. Ultrasound is a very useful tool to detect tumors, CT scans and needle biopsies under ultrasound guidance give a definite diagnosis.

Treatment.

In most instances, a complete resolution of liver cancer is not possible because of the advanced stage of cancer at the time of diagnosis. In suitable cases local, or regional resection of the liver is possible. The liver is a remarkable organ in its capacity to grow back to full size if cancer free. In selected cases, a lobectomy or total hepatectomy followed by a liver transplant produces are done. Immunotherapy, chemotherapy and several ablative therapy methods are available.

Prognosis:

In general, this is most disheartening. 5-year survival is less than 20%, and in advanced cases, it is less than 3 %.

 Carcinoma of Bile ducts.

The medical term for bile duct cancer is Cholangiocarcinoma (CLC). CLC is less common than hepatocellular carcinoma. However, people who have habits of eating raw fish have an alarmingly high rate of CCL. 


The diagram above shows bile ducts inside the liver and also outside. The outside bile duct for this discussion is dealt with into two separate categories namely Hilar and  Common bile duct cancers.

The life cycle of a Liver Fluke.

CLC (cholangiocarcinoma) is the second most common liver cancer in the world but the incidence in the USA is much less than hepatocellular carcinoma but over all CLC is increasing in all countries including the USA. In the USA, the Hispanic ethnic group has a higher CLC. In the world, Thailand has the highest rate of  CCL about 40 in 100,000 people, followed by China, Japan and other East Asian countries, with a clear association with Liver fluke infestation of the biliary system. In the Mekong River basin countries Liver fluke infestation is in between 30 to 70 % of the population and the death rate from CCL is 3% of all deaths.

Risk factor.

Primary sclerosing cholangitis is a precancerous condition, a congenital bile duct disease called Choledochal cyst disease has a high rate of CLC. Ulcerative colitis and Crohn's disease have a higher incidence of CLC. Infestation of the liver fluke is a risk as mentioned above. Both liver cells and the bile duct system developed from the same progenitor cell in the embryonic stage of development. As a result, the non-specific risk factors mentioned under hepatocellular cancer (alcoholic liver cirrhosis, NASH, diabetes, etc.) are also risk factors for CLC.

 A. Intrahepatic CLC.

Intrahepatic CLC is the least common among the three CLCs. Initially, CLC  is not distinguishable from hepatocellular carcinoma, the diagnosis is made only after a liver biopsy. Patients remain asymptomatic in the early stage. Occasionally diagnosed by chance when ultrasound or abdominal CT scans are done for other reasons. The prognosis at this stage is very good with surgery and chemotherapy. However, the majority of patients seek medical attention because of the development of jaundice. Diagnosis is relatively easy by ultrasound and fine needle biopsy. A standard care protocol in the USA hospitals uses a multidisciplinary approach and provides partial or complete removal of liver and liver transplantations.

B. Hilar CLC.

Hilar CLC is the most common of CLC, accounting for about 70% of CLC. Pathologically these are adenocarcinomas. Because of their location jaundice develop earlier than other liver cancers. The patient seeks medical attention because of worsening jaundice, dark urine and light stool, loss of appetite and weight loss. Laboratory tests confirm obstructive jaundice. CEA and alpha-fetoprotein are positive. Diagnosis requires a fine needle biopsy. Curative surgery is not possible in the majority of cases. Initial therapy is draining bile by inserting a stent in the common bile duct draining into the duodenum done during an ERCP examination, however, transcutaneous bile duct stent can be done also. 

C. Common bile duct CLC.

The risk factors are the same as the above group and an additional risk factor is an abnormal opening of the pancreatic ducts.

Abnormal Pancreatic Duct.

Anatomical variations of pancreatic ducts are common. Occasionally one or both pancreatic ducts may join the common bile duct, rather than opening into the ampulla. In this circumstance, chemical inflammation of the duct from pancreatic enzymes leads to fibrosis and stricture, and also carcinoma

Obstructive jaundice is the presenting symptom of common bile duct CLC. In clinical practice, obstructive jaundice is common. The causes of obstructive jaundice are as follows.


                                                   Taken from NIH publication.

Among the benign causes, gallstone and bile duct inflammation are most common, followed by common bile duct stricture, and Mirizzi syndrome. Gallbladder cancer leads the malignant causes followed by cancer of the periampullary region. 12 % of cases are due to cholangiocarcinoma.

                              Mirizzi syndrome in a diagram.

Diagnosis and treatment. 

Initial diagnostic workup is no different from other types of CLC. Initial treatment is a stent placement during ERCP or can be placed transcutaneously. The definitive treatment is the Whipple procedure or a modified Whipple operation. The prognosis is encouraging with hepatic transplants and immune therapy.

 [ See Chronic pancreatitis blog, dated April 9, 2022]. 

Childhood Liver Cancer, Hepatoblastoma, is seen in children less than 3 years of age. It is more common in premature and underweight newborns. The primary cause of it is unknown. Several inherited conditions are associated with hepatoblastoma. Resection of the liver when performed early produces the best outcome.

************************************************


                                                                                      



Sunday, February 26, 2023

Food Poisoning

 


                            Food Poisoning

                            PKGhatak, MD

Food and drinks can be contaminated with microorganisms if not handled properly. Certain bacteria grow in the leftover food kept outside the refrigerator and produce toxins. When people eat leftover food, these toxins produce an illness which is called food poisoning.

In general, such a definition of food poisoning is not universally followed. Viral gastroenteritis, cholera, amebiasis, typhoid fever and others are also included in food poisoning. It is better to address those illnesses as food borne illnesses rather than food poisoning.


Bacterial Toxin.

Bacteria can grow over a wide range of temperatures, from 4 degrees C to 60 degrees C,  provided moisture and nutrients are present. A growing bacterial colony produces toxins.

Toxins produced by bacteria are in two groups-

A. Exotoxin. Endotoxins are secreted by bacteria in the food. Exotoxins can be heat resistant or destroyed by heating.

B. Endotoxin. Endotoxins are present in the bacterial bodies and released in food when the bacteria die or are killed by antibiotics.

Preformed toxins in food produce symptoms in 1 to 6 hrs. after ingestion, whereas, bacterial infection and toxin generation take over 8 hrs. and then symptoms develop. Bacteria commonly responsible for food poisoning are Staphylococcus, Bacillus, Clostridium, E.coli and Vibrio species.


Staphylococcus aureus food poisoning.

S. aureus readily grows when food is left on the kitchen countertop. Symptoms start within 1 to 6 hrs. after eating food. Reheating food before eating does not destroy the bacterial toxin. Nausea and vomiting are common symptoms and start abruptly. Campy abdominal pain and diarrhea follow. The illness is self limited and patients recover in 24 hrs.


Bacillus cereus.

Reheated fried rice is often the source of poisoning. Intense nausea and vomiting start within 1 to 8hrs after eating food. The toxin can be detected in stool and leftover food.

Symptoms last for 12 hrs. It is also a self limited illness.


Clostridium botulinum.

Clostridium botulinum is a soil bacteria. Canned vegetables not properly washed and low oxygen environment in a sealed can are ideal for the production of toxins. Another source is natural honey. The ingested toxin produces nerve paralysis and the illness is known as Botulism. Though the symptoms start days after ingestion of the poison, botulism is due to the toxin present in food and not a bacterial infection.

Botulism. The sudden onset of fluctuant and intermittent but severe muscle paralysis in a healthy person should alert the physicians of botulism. Botulism toxin prevents the release of a neurotransmitter, Acetylcholine, at the neuromuscular junctions.

Symptoms generally develop 3 days after ingestion of the toxin and continue to progress further for another 3- 4 days. Paralysis of eye muscles produces double vision, and eyelid paralysis causes drooping eyelids. Muscles of swallowing and speech muscles are also paralyzed producing difficulty in eating and drinking, and nasal voice. In severe cases, the muscles of limbs may be paralyzed. Identifying the toxin in unused portions of food and serum helps in the diagnosis. An electroencephalogram(EEG) is also useful.

Ant-toxins are available to reverse the effects of toxins. Hospitalization and close monitoring of respiration and blood oxygen and CO2 are essential parts of the management of botulism. Public health authorities must be informed.


Clostridium perfringens.

This spore-forming Clostridium is found in soil and feces. Uncooked beef, poorly cooked poultry and fish are the source of toxins. Between 6 to 24 hours after eating symptoms of severe diarrhea and abdominal cramps develop. The illness can last one to several days. The initial onset may be from preformed toxin but subsequently, the bacteria multiply in gut epithelium and continue to generate enterotoxin and produce symptoms.

Enterotoxin producing E. coli.

This entity falls in between preformed toxin and bacterial infection and perhaps, both are operative.

Animals and humans harbor E. coli in their large guts. When food and drinks are contaminated with feces, severe watery diarrhea and abdominal cramps develop within a day or two after ingestion. It is a common cause of food poison among international travelers. Antibiotic fluoroquinolones are effective therapy.

Vibrio parahaemolyticus.

This vibrio usually contaminates shrimps, carbs and shellfish. Eating raw oysters or lightly cooked seafood produces a sudden onset of abdominal pain and diarrhea within 2 to 48 hrs. Nausea, vomiting and diarrhea last for 2 to 5 days.

Proper hydration is required to prevent dehydration.


************************






Leprosy

                                                  Leprosy                                              P.K.Ghatak, MD It is the perception ...