Hepatitis is a viral infection that affects the liver. There are different types, but the two most common are Hepatitis B and Hepatitis C . The virus is spread through contact or contamination of blood.
If the disease has been left untreated for many years, hepatitis may lead to cirrhosis, cancer, or end-stage liver disease requiring liver transplant.
The first sign of hepatitis may be flu-like symptoms or yellowing of the skin and eyes (jaundice). In some cases no symptoms might be noted.
If a patient has risk factors for infection, hepatitis can be diagnosed with blood tests.
Sometimes patients may require further specialized imaging or liver biopsies to determine the extent of damage to the liver.
There are a number of FDA approved medications for hepatitis B and C. Newer medications are all-oral and have low side effects. After taking these medications, more than 95% of people are cured for life. Patients who develop liver cancer or cirrhosis may require surgery or transplant.
Fatty liver occurs when the liver begins to store fat at levels that are not normal. This usually occurs when a patient is at least 20 pounds overweight. In some individuals, the liver becomes fatty but no damage is done, this is called non-alcoholic fatty liver disease or NAFLD. In other people, the fat in the liver causes damage, and this is known as non-alcoholic steatohepatitis (NASH). NASH is the form of fatty liver that is very dangerous to your health.
NASH occurs when there is inflammation of the liver because of fat. This often occurs in people who are overweight, pre-diabetics/diabetics, those who have high cholesterol, or people who take certain medicines. Because of the damage being done to the liver, the “enzymes” become elevated, which is another way of saying your liver cells are dying faster than expected. As your liver cells die, they are replaced with scar tissue (fibrosis).
Fatty liver may not cause any symptoms in some people, others may complain of pain on their right side where the liver is. The liver actually does not have nerves to sense pain, but it has a capsule or skin around it that does have nerves. As the capsule stretches because of the fat, patients may experience a constant dull pain. If a patient’s weight increases 10% above the ideal amount, then probably fatty liver is present.
If fat is harming the patient would be to check a blood test, specifically measuring liver enzymes. If the AST and ALT are high, this may be a sign that the patient has NASH.
Fatty liver disease can be diagnosed by a ultrasound, MRI, CT or fibroscan, which can also tell your doctor if there is serious scar tissue present.
A liver biopsy can tell us what stage you are at and confirm the diagnosis of NASH.
Currently, the best treatment for fatty liver is diet and exercise, along with good control of other medical condition like diabetes and high cholesterol. Losing just 20 pounds brings most patients back to health. Vitamin E may help but increases risk of heart disease and prostate cancer, so we don’t recommend it.
No white bread or tortillas.
Cirrhosis occurs when the liver becomes “scarred,” oftentimes due to chronic alcohol use or infection with hepatitis virus.
Cirrhosis is inflammation and scarring of the liver. It can be a consequence of fatty liver disease, hepatitis, or heavy alcohol abuse. Both women and men who drink too much can have this condition. Some information suggests that genetics and problems with alcohol metabolism can make this condition worse. Cirrhosis can also occur at any age, but usually takes many years to develop.
Cirrhosis can be diagnosed by clinical exam. Patients with cirrhosis oftentimes can develop:
Cirrhosis can also be diagnosed by:
Patients will have low albumin and high bilirubin levels, both of which are markers of liver function. Additionally, as the liver becomes more scarred blood is shunted to spleen and platelets get trapped there, which causes patients to have very low platelet counts.
Cirrhosis can be diagnosed by a ultrasound, MRI, CT or fibroscan, which can also tell your doctor if there is serious scar tissue present.
A liver biopsy can tell us what stage of cirrhosis you are at.
Unfortunately there is no cure for cirrhosis. However, the ability to slow down the disease from getting worse is critical. Liver doctors are known as hepatologist, and they are usually the medical specialist best suited to handle complex cases of the liver.
In cases where cirrhosis progressed to end-stage liver disease, patients may need a liver transplant evaluation, which can be curative.
Liver cysts are usually benign, but can sometimes lead to problems which require treatment.
Cysts in the liver can be single or multiple. They usually contain fluid which is either consistent with serum or bile. Sometimes they can contain infectious materials.
The symptoms of liver cysts can be variable, but oftentimes include nausea, vomiting, pain, or jaundice. Some patients may not have any symptoms.
Cysts of the liver are best diagnosed by an imaging procedure. Common tests include:
Sometimes referred to as a “cat” scan, CT imaging uses x-rays to create very detailed black and white images of your insides. Oftentimes it is necessary to inject contrast dye into your veins during a CT scan to better visualize tumors.
Using sound waves, ultrasound is a non-invasive and painless way to detect liver tumors. The procedure is typically performed by an ultrasound technician after application of ultrasound “gel” on your skin.
after being placed in a tube, a magnetic field is applied which can then be used to visualize your liver. Oftentimes it is necessary to inject contrast dye into your veins during a MRI to better visualize tumors. If you are claustrophobic or have metal implants, pacemakers, or shrapnel, please alert your care team prior to undergoing an MRI.
Once a liver cyst is diagnosed, the next step involves a treatment plan depending on a number of factors, including symptom, concern for malignancy, or infectious risk. The vast majority of cysts do not require any treatment, but sometimes may be treated with:
If cysts are thought to be benign on imaging or atypical for a simple cyst, sometimes your doctor may want to recommend close follow-up with repeat imaging or laboratory tests to make sure the cyst doesn’t grow or warrant treatment.
The goal of liver surgery is to either remove the cyst completely or “unroof” the cyst to allow it to drain freely into your abdomen. Surgery can be performed using an abdominal surgical incision (“open surgery”), laparoscopic “keyhole” surgery, or with the assistance of a robot.
If the cyst is suspected to be infectious, oftentimes antibiotics are started for control. If the infection resolves and the cyst becomes smaller, no further treatment is required. However, if the infection persists then sometimes percutaneous drainage or surgical drainage is performed.
Typically for infectious cysts that are not responding to antibiotics, patients undergo placement of a small drainage catheter through the skin to drain the cyst. The catheter is then removed after the cyst resolves. Percutaneous drainage is not performed for simple cysts because once the catheter is removed, the simple cyst usually reaccumulates!
Tumors in the liver can start in the liver or spread to the liver from other sites (“metastases”).
Tumors in the liver can either start in the liver (“primary”) or spread there from cancers that start in other parts of the body (“metastatic”). The symptoms of liver tumors can be variable, but oftentimes include weight loss, fatigue, jaundice (yellowing of the skin or eyes), itching, or pain. Some patients may not have any symptoms
Tumors of the liver are best diagnosed by an imaging procedure and confirmed with a biopsy once detected. Common tests include:
Sometimes referred to as a “cat” scan, CT imaging uses x-rays to create very detailed black and white images of your insides. Oftentimes it is necessary to inject contrast dye into your veins during a CT scan to better visualize tumors.
Using sound waves, ultrasound is a non-invasive and painless way to detect liver tumors. The procedure is typically performed by an ultrasound technician after application of ultrasound “gel” on your skin.
after being placed in a tube, a magnetic field is applied which can then be used to visualize your liver. Oftentimes it is necessary to inject contrast dye into your veins during a MRI to better visualize tumors. If you are claustrophobic or have metal implants, pacemakers, or shrapnel, please alert your care team prior to undergoing an MRI.
Because tumors are typically metabolically active, a special type of sugar is injected into your veins a few hours prior to the scan. Those areas of your body which use a lot of sugar (like tumors) will light up on the scan. It is important to not eat or drink anything before the scan for most accurate results.
After a tumor is identified, frequently a biopsy must be performed to confirm the presence of a cancer. A biopsy is a procedure where a needle is passed through your skin and a small piece of the tumor is removed for analysis. Biopsies usually require the assistance of ultrasound or CT scan to precisely guide the needle into the tumor. The majority of biopsies are outpatient procedures and patients can go home the same day!
Once a liver tumor is diagnosed, the next step involves a treatment plan after discussion of your case in a Multidisciplinary Tumor Board . Safe and effective treatment of liver tumors depends on the type of tumor, its location, your general liver health, and other underlying medical problems you may have.
If tumors are thought to be benign on imaging or atypical for cancer, sometimes your doctor may want to recommend close follow-up with repeat imaging or laboratory tests to make sure the tumor doesn’t grow or warrant treatment.
The goal of liver surgery is to either remove the tumor completely. Surgery can be performed using an abdominal surgical incision (“open surgery”), laparoscopic “keyhole” surgery, or with the assistance of a robot.
Depending on the type of tumor you have and size, sometimes liver transplant is the best option for long-term cure.
Liver ablation is a procedure which can be performed through your skin (percutaneously) or surgically via laparoscopic (“keyhole”) or open surgery. The goal of ablation is to destroy tumors with energy.
Most tumors have a dominant blood vessel which feeds it with nutrients. The goal of embolization is to block that vessel and prevent the tumor from receiving nutrients and oxygen. Sometimes at the same time, chemicals like chemotherapy or radiation are directed to the tumor as well to help destroy it. Access to the blood vessel is usually gained through an artery in your groin or leg.
For tumors that are advanced beyond the point of surgery, ablation, or embolization, sometimes chemotherapy is best option. Chemotherapy can be delivered through a pill form or intravenously depending on the tumor type. For some patients, chemotherapy may be offered before or after surgery, ablation or embolization to help control the tumor.
Hepatitis B is a virus that can lead to liver damage, cancer and even death. Hepatitis B can be transmitted from birth or person-to-person, for example from sex or sharing needles.
If you are concerned that you may have hepatitis B you may be referred to a hepatologist. The first sign might be flu-like or from yellowing of the skin and eyes (jaundice). In some cases no symptoms might be noted. If the disease has been left untreated for many years, cirrhosis can develop.
Yes blood tests are recommended and your doctor may also recommend a liver biopsy. All patients with hepatitis B infection should be assessed for their risk of liver cancer. Some may need an ultrasound of the liver every 6 months.
A liver biopsy is the best test to determine the amount of damage to the liver. When examined under a microscope, the biopsy can be graded for the amount of scar tissue. Stage 1 and 2 indicates mild amounts of scar tissue. The highest amount of scar tissue is stage 4, which indicates cirrhosis of the liver. Cirrhosis is a very serious medical diagnosis. In some cases we can determine the stage of liver damage with a picture of the liver known as the fibroscan.
Medicines for hepatitis B are available in pill form or shots. Your doctor can discuss which are right for you. Additionally, patients with hepatitis B should avoid alcohol and receive vaccinations for hepatitis A. Sexual partners and other household members should receive the hepatitis B vaccine.
What is Hepatitis C?
Hepatitis C is a viral infection that affects the liver. We believe that 5 million Americans have been exposed the virus through blood transfusions before 1992, tattoos and sharing needles. There may be no symptoms of hepatitis C, and patient would not know they had it unless they were specifically checked for it.
Who should get tested for Hepatitis C?
The virus is spread through contact or contamination of blood. All persons born between 1945 and 1965 should get checked since they have the highest risk. Anyone who had a blood transfusion before 1992, received medical care in Mexico, has a tattoo or history of sharing needles should get checked. In some cases, we do not know how a person was infected.
How is Hepatitis C diagnosed?
Hepatitis C is first suspected if a patient has a positive hepatitis C antibody. This may be checked if liver tests are abnormal or if a patient has risk for HCV infection. The test is confirmed by measuring the amount of virus in the blood. This test is known as the HCV RNA. The next important test to know is the genotype of the virus, and there are 6 different strains of the virus. The most common genotype in the US is genotype 1a. An additional test known as “resistance testing” can be done to see how the new Hepatitis C medications will work best against the patient’s virus.
How can my doctor tell how much damage has been done to my liver?
A liver biopsy is the best test to determine the amount of damage to my liver. When examined under a microscope, the biopsy can be graded for the amount of scar tissue. Stage 1 and 2 indicates mild amounts of scar tissue. The highest amount of scar tissue is stage 4, which indicates cirrhosis of the liver. Cirrhosis is a very serious medical diagnosis. In some cases we can determine the stage of liver damage with a picture of the liver known as the fibroscan.
Can Hepatitis C be treated?
Yes, Hepatitis C is highly treatable! There are a number of FDA approved medications for hepatitis C and none of them require injections or interferon. New hepatitis C medications are all-oral and have low side effects with short durations of therapy. After taking these medications, more than 95% of people are cured for life.
Depending on the size and location of your tumor, you may need a “wedge resection” (or removal of a small part of your liver) or a “lobectomy” (or removal of a large part of your liver). In most patients, it is safe to remove up to 60-80% of the liver because the liver can regenerate! Liver surgery can be performed using an open incision or sometimes Laparoscopically.
In order to safely get to your liver, your surgeon typically makes incisions under the ribcage on the right side. Sometimes it is necessary to make a “Chevron” or “Mercedes-Benz” incision if your tumor is in a hard to reach spot!
Since these surgeries are performed “minimally invasively,” your incisions are oftentimes smaller and located lower in your abdomen. You may have one incision that is larger than the others because that is used to remove the tumor specimen from the body.
After your operation, you will need to recover in the hospital anywhere between 2-7 days depending on the extent of your operation. During this time we will repeatedly encourage and assist you with walking and deep breathing exercises.
Some patients will be transferred immediately to the Intensive Care Unit (ICU) for recovery. Usually after 1-2 days they will be transferred to the inpatient floor to continue the recovery process.
All rooms at St Vincent are private and you will not share your room with another patient.
Yes, we encourage family to visit and keep patients company during the day. Family are not discouraged to stay overnight, however, so that patients can receive adequate sleep.
Yes, once approved by your care team it is allowed and encouraged to bring home-cooked meals. However, if you are on a special restricted diet (for example, low sodium), we ask that family do not bring food from home.
Unfortunately since smoking has been shown to inhibit wound healing, we prohibit smoking in our patients. Additionally, because of the fire danger with smoking and oxygen cannulas (which most of our patients have!) any smoking is prohibited. We will prescribe you nicotine patches or gum when appropriate.
All patients will have their pain controlled after the operation. This is typically achieved by using a combination of oral medications, epidural pumps, and patient controlled anesthesia (PCA) pumps. Be aware though: narcotic medications can cause constipation and if your bowels are not moving after surgery, then sometimes it is necessary to decrease the amount of pain medications we give you.
The goals for discharge include:
Sometimes patients will require the assistance of physical therapy at home or may even need to be discharged to a rehabilitation facility. Our social workers will work with you to arrange this care.
Once you are cleared to go home, the safest option for you is to leave the hospital. Because the hospital is full of other sick patients, you have a greater chance of exposure the longer you stay.
On the day of discharge, a member of your care team will review your discharge paperwork, medications, and follow-up instructions with you and your family. In the case of emergencies, please call (213) 484-5551. If you feel the emergency is life-threatening, please call 911!
Typically, stitches and medical “Super-Glue” will be used to close your incisions, and there is no need to take out the stitches afterward because they will dissolve. If you have surgical staples, these will need to be removed by your doctor approximately 5-15 days after the surgery. Taking out the staples is painless for most patients!
surgical staples stitch removal
We prefer that you shower after surgery, and that can be done as soon as the first day after surgery! We recommend against baths, jacuzzis, or submerged water. You do not need to cover your incision when you shower.
It will be safe to resume full exercise by about six weeks postoperatively. Between 1-6 weeks you are at high risk for a hernia developing in your incision, so please do not lift anything heavy (anything more than a milk jug!) Please discuss with your doctor before resuming activity.
Driving a car or operating heavy machinery is safe when you are no longer taking pain medications and are able to have appropriate reaction times.
Drinking alcohol after liver surgery is not advised, because your liver is still healing.
When a cancer starts in the liver, it is most commonly a type of cancer known as hepatocellular carcinoma (HCC). Unfortunately, this is the 3rd most frequent cause of cancer in the United States. Liver cancer is a highly treatable form of cancer and can be controlled with different types of procedures performed by interventional radiologist and special medicines. In some patients with early cancer, it can be cured with a liver transplant.
The reason patient get liver cancer is cirrhosis. As chronic damage happens in the liver that leads to cirrhosis, it also causes changes in the cells that lead to cancer. In the United States, the most common causes of cirrhosis that can lead to liver cancer are hepatitis C, hepatitis B and fatty liver.
Unfortunately, liver cancer does not cause many symptoms until it is very advanced. In those cases, it may cause pain on the right side or yellowing of the eyes and skin or jaundice. Since liver cancer is highly treatable and there are no warning signs, it is recommended that patients with advanced liver disease or cirrhosis get a picture of the liver with ultrasound, MRI or CT every 6 months. Doctors know that finding a liver tumor early can save lives.
Once it is suspected that a patient has a liver tumor, a special MRI or CT scan is done to understand the quality, number and size of the tumors. There are also blood tests that can be done that sometimes detect liver cancer as well. The most common blood test used is the alpha-fetoprotein (AFP). All patients with cancer of the liver should be seen by a hepatologist and then referred to a special team of doctors that review the patient’s case together known as a tumor board. This expert panel of doctors includes liver doctors, liver surgeons, cancer doctors, and radiologists. The team will evaluate the patient’s case together and come up with an expert recommendation about the plan of care.
Yes, there are many treatment options for liver cancer. The best way to way to decide on a treatment plan is to review the patient’s case at tumor board. Most often, the first line treatment is to perform a locoregional therapy. A locoregional treatment is when a special kind of doctor known as an interventional radiologist delivers a treatment to the cancer either by bringing the chemotherapy right to it or burns it with microwave. The medicines that these doctors use include chemotherapy or radiation therapy, known as a TACE or Y90.
Some patients cannot get locoregional therapy and they are better candidates for medicines like sorafenib, regorafenib, or nivoluminab. Occassionally, there are limited options for a patient, and in those cases we offer clinical trials.
On the other hand, if the tumors are able to be controlled and are not too big the patient may be a candidate for liver transplantation, which is a cure for cancer.
If you have liver cancer, we are equipped to quickly evaluate your case with state of the art technology in a multidisciplinary approach. Liver cancer is highly treatable and even curable. If you don’t have liver cancer but think you are at risk, then ask.
A Multidisciplinary Tumor Board is a team of doctors and nurses who discuss your individual case to recommend the best treatment options for you based on your specific information. The members of Tumor Board include:
Usually once a week
The Tumor Board needs to have the latest imaging available to make accurate recommendations. Patients are typically presented after all of the appropriate tests are completed.
Because multiple patients are presented at a single Tumor Board, having patients attend is discouraged for privacy concerns. However, you will learn the recommendations of the Tumor Board at your next clinical appointment.
