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Thursday, September 23, 2010

7.3 Splenectomy - Leukemia Cure/Liver/Pancreas


Physician's Notebooks 7  - http://physiciansnotebook.blogspot.com - See Homepage
3. Liver, Gallbladder, Pancreas & Spleen - Update 10 Feb. 2018
The following descending column are in order of their appearance in text to assist your view of this chapter and help you search & find or scroll to:
The Liver is 
Virus Hepatitis
Laceration of Liver
Cancer in the Liver
Liver Function Tests
Liver Transplant
Liver Imaging
Gallbladder
Pancreas
Spleen
Splenectomy for leukemia
A good screening imaging for Liver, Gallbladder, Pancreas,

The Liver is at base of right lung. Put heel of right hand on right lowest rib edge and extend 2nd finger around front of rib-cage for liver. It should not be felt below rib margin unless enlarged. Pain from liver is just below right rib margin, front and back, and is dull.
   You cannot live without Liver. I observed death from liver failure of cancer metastasis. It destroyed liver function by replacement and local pressure. Not a bad way to die; its worst is an increase of fluid, swelling the abdomen, which can be relieved by needle drainage. A painless coma may last days before death. Usually accompanied is jaundice, but if no tumor blocks major bile duct obstruction, it is only a mild yellowing of skin. Death is due to replacement of too many liver cells by tumor and when that happens, a major function of liver, the converting nitrogen waste product of metabolism to urea fails, and then blood ammonia goes up and the patient drifts into coma with characteristic liver failure smell. 
Functions of liver: 1) storage of excess carbohydrate as glycogen, which protects brain against hypoglycemia (low blood glucose); 2) the break down of nitrogen products (proteins) to ammonia; 3) production of bile which flows into Gall Bladder and is concentrated there and then squished out into duodenum after a meal to assist digestion and absorption of fat and also to excrete cholesterol; and it is a general metabolic organ that stores or converts many important chemicals in nutrition
   Liver detoxifies. Every chemical one eats goes directly from intestinal absorption to first pass through liver during which the chemical is neutralized and removed from blood. That makes liver vulnerable to toxins.
   Liver toxins divide into industrial chemical, poison mushroom, medication toxic effect, and ethyl alcohol (EtOH). Worst are the industrial like benzene, turpentine, carbon tetrachloride. Anything with that kind of smell is murder to your liver. Persons who work years in such an environment used to die of it. Today, gas mask is used in workplace, but do not forget at home removing shellac, and painting a house can kill your liver and you too. Keep away from fume or wear mask.
   Medicines that harm liver are dangerous in suicidal or chronic overdose. Most famous is acetaminophen (Tylenol). It is most dangerous in combination with opioid painkiller (Vicodin, Lortab, Percoset), where it is easy to chronically overdose the acetaminophen and after several years to discover your liver is destroyed and transplant needed. Good rule: do not use daily dose 1000 mg or more. Usual acetaminophen tablet is 325 or extra strength 500 mg. (But may work as low as one half tab under tongue)
   A common, often unrecognized medication with liver toxicity is the sex steroid hormone used by athlete and the estrogen used in birth control pill, both of which can cause blockage of bile flow in chronic dose and also cause liver cancer. For other medications, read labels.
   EtOH (alcohol drink) is well-known liver toxin at level of acetaminophen with which it should not be mixed since they have synergy as toxins. More than 2 standard drinks a day gives risk after 10-20 years to develop fatty liver then cirrhosis and then, if that has not killed, a liver cancer. Always drink lots of water with EtOH.
Virus Hepatitis
comes as hepatitis (Hep) A, B, C, D and E due to virus HAV, HBV, etc. The Hep A and E are the hepatitis we mostly get from feces transferred from anus to mouth by unwashed hand or unwashed, uncooked food. Both have similar incubation period of 2-8 weeks and 1% mortality and, usually, recovery with immunity. But hep A is much more common and its killed-virus vaccine gives permanent immunity and its gamma-globulin injection gives rapid temporary immunity. Hep B, C and D are mostly transmitted in contaminated blood or other injection, especially from re-used dirty needle such as drug addicts share. Hep B has 2%–7% chronic disease and its fatality rate 1%. Hep D, which is a super-infection from a Hep B case, is chronic 50% and fatality 2%–10%. 
Hep B killed-virus vaccine gives permanent immunity and its immune globulin injection rapid temporary protection for at-risk close associate of infected person. 
All the hep viruses may transmit by fecal-oral route, injecting, or more rarely from kissing. In chronic case, they cause liver cancer. All share symptom of jaundice developing from 15 days (A & C) to 150-180 days (B, C & D) after viral transmission. Hep B is big risk from male homosexual due to licking partner's anus in sex play.
   About jaundice in Viral Hepatitis, it is yellowing of body surface (eye white and skin) and darkening body fluid (especially urine but also blood plasma) due to combination of liver function failure and partial obstruction of small bile canal from swelling of liver. First you notice loss of color of feces (white or gray clay-color), next darkening of urine (amber to deep brown) then yellowing of eye whites and then yellow skin. The jaundice deepens as illness progresses with nausea, vomiting, right-sided liver soreness, low-grade fever and easy fatigue and mental depression. In worst case virus hepatitis, liver failure intervenes with high ammonia, coma and death. 
No antibiotic can cure but most cases recover and serious case is best treated in hospital with IV fluid and, typically, improves while jaundice is still deepening.
   Type of virus can be determined by blood test, and the severity is monitored by the blood test ALT (AL transaminase). Infectious status can be determined by blood test for viral particle. All persons with virus hepatitis jaundice are infectious via body fluid, feces and sexual kissing. It is a common disease of male homosexuals. Some continue chronically infected. Blood test is sole arbiter of infectiousness.
   It is best for everyone to be immunized against HAV and HBV from childhood, not only to prevent acute and chronic illness but to prevent liver cancer, most of which comes from chronic Hep B infection.
   Chronic hepatitis is most frequent with Hep C, and Hep D (D is always combined with Hep B infection). Symptoms may be few or none but liver is being slowly destroyed as blood test will show, and eventually liver failure ends life. Alpha interferon, given as 24-week course of injection has cured up to 20% bad cases but anyone who tries that must seek out expert because of complexity of treatment.
Laceration of Liver
is not infrequent because of the liver edge being exposed to trauma being just under right lower rib border. Falls, forward on face, and sudden car stops with seat belt tight are the usual causes. Pain is initial sign and then faintness due to the internal hemorrhage. Get to ER fast!
Cancer in the Liver
is from metastases more than from a primary cancer because liver has much blood and lymph connection with cancer-prone organ like breast, stomach, colon, and pancreas. Oral contraceptives increase risk of liver cancer in young women and anabolic-steroid increases the risk in athlete. No good treatment exists but if one can prove a localized area of metastasis and no other, the liver metastasis can be cut out as part of curative treatment. In isolated liver cancer, a liver transplant can cure.
Liver Function Tests
When using a liver toxin like EtOH or acetaminophen or working with industrial toxin, you need a screening test to tell if liver is being affected badly. Liver damage can creep up with no sign or symptom and then one day one is dying. In fact right now (Feb. 2018) I am taking acetaminophen rather promiscuously because of my severe hip arthritis pain and I worry about that so on my next set of blood tests I plan to get a gamma-glutamyl transpeptidase(GGT) a good screener for early liver cell damage.
   The transaminase blood tests, ALT and AST (serum level normally <40 IU/L) measure early liver cell damage by mild elevation. ALT is more specific for liver-cell damage. Bilirubin the liver pigment should normally be <1.0; if elevated and mostly of direct type it is sign of liver duct obstruction; when the elevation is mostly indirect and no blood disease, it indicates liver cell failure or hemolysis of red blood cell as in malaria. The prothrombin time (INR) test is dependent on vitamin K and factors made in liver. It is a sensitive test, being prolonged (>22 sec also reported as INR > 2.0) in early liver disease. Alkaline phosphatase (AP) is an enzyme that goes high (>85 IU/L) when cancer hits liver and with any source of bile obstruction; it should be done with gamma-glutamyl transpeptidase (GGT), to make sure AP rise is coming from liver and not bone. Serum albumin is a measure of liver function, low (<3 g/dL) in liver malfunction, but also low in starvation. Serum ammonia and BUN measure the liver ability to metabolize nitrogen product: in liver failure the ammonia rises (>45 microgramN/dL) and BUN becomes abnormally low (<6 mg%).
Liver Transplant
for liver failure due to infectious or toxic hepatitis, cirrhosis or localized primary liver cancer (20% 3-yr survival selected liver cancer cases) 4500 transplants a year in the year 2000, with 1-yr all case survival >90% and 10-yr, 70%. As with kidney transplant, the availability of donor is the rate-limiting factor so early consideration and referral is important where irreversible liver failure looms large. Donor selection is based on ABO blood type and body size compatibility. Large adult liver is more available than small, a reflection of high fatal accident rate for vigorous young men compared to women and frailer men. In child transplant, a living donor, usually parent can successfully give left lateral segment of liver, and new work is succeeding in using lobe of liver from living donor for adult. Similarly, liver of dying donor is being split between 2 recipients successfully. Immunosuppression with cyclosporine or tacrolimus helps successful transplantation and drug must be taken for life along with corticosteroid.
   When it comes to liver transplant, the patient (or close family if child or less competent adult) must aggressively seek out care at world-beater institution and not sit back and allow local HMO to do work just because it is at convenient rate and place.
Liver Imaging
Ultrasound (US) scan is best imaging method for liver cancer, cyst and cirrhosis due to low cost, safety and accuracy. The US scan can be repeated safely and inexpensively in short interval, in contrast to MRI or CT scan or radioactive scan. If you must have highly accurate imaging, MRI is best because most accurate and no x-ray. 
Gallbladder
 is nestled in a niche under the liver with which it connects via the cystic duct (via common bile duct from liver) and excretes bile into duodenum via the common duct. A stone in the duct or a gallbladder, an infection-inflammation, and painless enlargement from obstructing cancer are its diseases; and ultrasound is its best imaging. The GB is a non-vital structure. But if you need to cut it out, choose an expert surgeon at a world-beating institution because it is easily botched surgery.

Pancreas
is located in mid upper abdomen, behind duodenum. It makes digestive enzymes that enter duodenum via the common duct through the sphincter of Oddi and produces insulin in the islets of Langerhans cells. Typical symptom of its developing cancer is from wrapping around and constricting the duodenum leading to vomiting 4-7 hours after eating (This was the symptom of the late Japanese Emperor Hirohito in 1989). Pancreatitis (not necessarily cancer) is a disease of alcoholics, and causes severe vomiting and mid-abdominal pain that require IV feeding by central vein catheter for weeks. Best test for pancreas is mid-abdominal UltraSound scan or when question of cancer, an MRI. Pancreas transplantation is now available. It works well when done well but technically difficult because of small size. Problem of donor and immunity suppression treatment are like with kidney and liver transplants. Combined liver-pancreas transplant is possible but donors rare.
Spleen
is a kind of miniature liver under left rib margin. It filters blood of abnormally shaped or old cells and it fosters immunity by producing lymphocytes for blood and antibodies against capsular gram-positive bacteria like pneumococci. Without it, immunity gets low. Spleen enlargement may be a sign of leukemia especially Chronic Lymphatic Leukemia (CLL) but also from malaria, infectious mono, even from flu shot. Main problem is its occasional laceration or rupture from being poked or traumatized when enlarged.
   Removal of spleen has side effect of high platelet count (up to 1-million per microLiter) risking blood clot in legs that passes to lung and can kill. Low-dose aspirin reduces clot risk.  
Splenectomy for leukemia is a good option and in Chronic Lymphocytic Leukemia may result, alone, in a long-lasting complete remission from the leukemia. The post-splenectomy side effects – lower immunity and high platelet count causing risk for internal blood clots – have in my observation in a case I have watched closely for 10 years now have been manageable. In the case mentioned the splenectomy has arrested the course of a CLL that had reached white blood cell counts upwards of 150,000 per microLiter, platelet counts below 30,000 and hemoglobin below 10 grams per dL. A virtual cure and no bad effects!
         ENDNOTE: A good screening imaging for Liver, Gallbladder, Pancreas, Spleen, and Kidneys too is an ultrasound scan of upper and mid abdomen and flank. It avoids dangerous radiation that one gets from CT scan; it is not expensive and complicated to do, as MRI is, and thus can be repeated as frequently as one needs; and it picks up cancer, cysts and benign tumors and all enlargements and malfunctions. It is worthwhile doing at one to five yearly interval depending on risk factors. A certified radiologist in a University HMO should supervise the imaging. 
END OF CHAPTER. To read next now, click 7.4 GI Tract Scopies/Hands On View

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