Liver cancer
Liver cancer, also known as primary and metastatic hepatic carcinoma, is a rare form of cancer in the United States, with a high mortality. Most primary liver tumors (90%) originate in the parenchymal cells and are hepatomas (hepatocellular carcinoma, primary lower-cell carcinoma). Some primary tumors originate in the intrahepatic bile ducts and are known as cholangiomas (cholangiocarcinoma, cholangiocellular carcinoma). Rarer tumors include a mixed-cell type, Kupffer cell sarcoma, and hepatoblastomas (which occur almost exclusively in children and are usually resectable and curable). The liver is one of the most common sites of metastasis from other primary cancers, particularly colon, rectum, stomach, pancreas, esophagus, lung, breast, or melanoma. In the United States, metastatic carcinoma is over 20 times more common than primary carcinoma and, after cirrhosis, is the leading cause of liver-related death. At times, liver metastasis may appear as a solitary lesion, the first sign of recurrence after a remission.
Causes and incidence
The immediate cause of liver cancer is unknown, but it may be a congenital disease in children. Adult liver cancer may result from environmental exposure to carcinogens, such as the chemical compound aflatoxin (a mold that grows on rice and peanuts), thorium dioxide (a contrast medium formerly used in liver radiography), Senecio alkaloids, and possibly androgens and oral estrogens.
Roughly 30% to 70% of patients with hepatomas also have cirrhosis. (Hepatomas are 40 times more likely to develop in a cirrhotic liver than in a normal one.)
Whether cirrhosis is a premalignant state or alcohol and malnutrition predispose the liver to develop hepatomas is still unclear. Other risk factors are exposure to the hepatitis C virus and the hepatitis B virus.
Liver cancer accounts for roughly 1% of all cancers in the United States and for 10% to 50% in Africa and parts of Asia. Liver cancer is most prevalent in men (particularly men older than age 60), and incidence increases with age. It's rapidly fatal, usually within 6 months, from GI hemorrhage, progressive cachexia, hepatic failure, or metastasis.
Signs and symptoms
Clinical effects of liver cancer include:
❑a mass in the right upper quadrant
❑ tender, nodular liver on palpation
❑ severe pain in the epigastrium or the right upper quadrant
❑ bruit, hum, or rubbing sound if tumor involves a large part of the liver
❑ weight loss, weakness, anorexia, fever
❑ occasional jaundice or ascites
❑ occasional evidence of metastasis through venous system to lungs, from lymphatics to regional lymph nodes, or by direct invasion of portal veins
❑ dependent edema.
Diagnosis
CONFIRMING DIAGNOSIS The confirming test for liver cancer is liver biopsy by needle or open biopsy.
Liver cancer is difficult to diagnose in the presence of cirrhosis, but several tests can help identify it:
❑Serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, alkaline phosphatase, lactic dehydrogenase, and bilirubin all show abnormal liver function.
❑ Alpha-fetoprotein rises to a level above 500 mcg/ml.
❑ Chest X-ray may rule out metastasis.
❑ Liver scan may show filling defects.
❑Arteriography may define large tumors.
❑ Electrolyte studies may indicate an increased retention of sodium (resulting in functional renal failure) and hypoglycemia, leukocytosis, hypercalcemia, or hypocholesterolemia.
Treatment
Because liver cancer is commonly in an advanced stage at diagnosis, few hepatic tumors are resectable. A resectable tumor must be a single tumor in one lobe, without cirrhosis, jaundice, or ascites. Resection is done by lobectomy or partial hepatectomy.
Radiation therapy for unresectable tumors is usually palliative. Because of the liver's low tolerance for radiation, external beam radiation hasn't increased survival. However, radiolabeled antibodies have been used to selectively target cancer tissue; when used concurrently with chemotherapy, patients can convert from nonresectable to resectable.
Another method of treatment is chemotherapy with I.V. fluorouracil, mitomycin, or doxorubicin, or with regional infusion of fluorouracil or floxuridine (catheters are placed directly into the hepatic artery or left brachial artery for continuous infusion for 7 to 21 days, or permanent implantable pumps are used on an outpatient basis for long-term infusion).
Appropriate treatment for liver metastasis may include resection by lobectomy or chemotherapy with mitomycin or fludarabine (results similar to those in hepatoma). Liver transplantation is now an alternative for a small subset of patients.
Special considerations
The patient care plan should emphasize comprehensive supportive care and emotional support.
❑Control edema and ascites. Monitor the patient's diet throughout. Most patients need a special diet that restricts sodium, fluids (no alcohol allowed), and protein. Weigh the patient daily, and note intake and output accurately. Watch for signs of ascites (peripheral edema, orthopnea, or dyspnea on exertion). If ascites is present, measure and record abdominal girth daily. To increase venous return and prevent edema, elevate the patient's legs whenever possible.
❑Monitor respiratory function. Note any increase in respiratory rate or shortness of breath. Bilateral pleural effusion (noted on chest X-ray) is common, as is metastasis to the lungs. Watch carefully for signs of hypoxemia from intrapulmonary arteriovenous shunting.
❑Relieve fever. Administer sponge baths and aspirin suppositories if there are no signs of GI bleeding. Avoid acetamino-phen, because the diseased liver can't metabolize it. High fever indicates infection and requires antibiotics.
❑Give meticulous skin care. Turn the patient frequently and keep his skin clean to prevent pressure ulcers. Apply lotion to prevent chafing, and administer an antipruritic such as diphenhydramine for severe itching.
❑Watch for encephalopathy. Many patients develop end-stage signs or symptoms of ammonia intoxication, including confusion, restlessness, irritability, agitation, delirium, asterixis, lethargy and, finally, coma. Monitor the patient's serum ammonia level, vital signs, and neurologic status. Be prepared to control ammonia accumulation with sorbitol (to induce osmotic diarrhea), neomycin (to reduce bacterial flora in the GI tract), lactulose (to control bacterial elaboration of ammonia), and sodium polystyrene sulfonate (to lower potassium level).
❑If a transhepatic catheter is used to relieve obstructive jaundice, irrigate it frequently with prescribed solution (normal saline or, sometimes, 5,000 units of heparin in 500 ml dextrose 5% in water). Monitor vital signs frequently for any indication of bleeding or infection.
❑After surgery, give standard postoperative care. Watch for intraperitoneal bleeding and sepsis, which may precipitate coma. Monitor for renal failure by checking urine output, blood urea nitrogen, and creatinine levels hourly. Remember that, throughout the course of this intractable illness, your primary concern is to keep the patient as comfortable as possible.
❑When all treatments have failed, concentrate on keeping the patient comfortable and free from pain, and provide as much psychological support as possible. If the patient is going home, discuss continuing care needs with the caregiver or refer the patient to an appropriate home health care agency or hospice. Encourage the patient and caregiver to express their feelings and concerns. Answer their questions honestly, with tact and sensitivity.
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
Other Book Chapters Related to Liver symptoms
Read excerpts from these other book chapters related to Liver symptoms:
Medical Books Excerpts
- JAUNDICE
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
- [ read ]
- JAUNDICE
- "Differential Diagnosis in Primary Care" (2007)
- [ read ]
- Jaundice
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Jaundice
- "A Pocket Manual of Differential Diagnosis" (1999)
- [ read ]
- Fatty liver
- "Professional Guide to Diseases (Eighth Edition)" (2005)
- [ read ]
- Hepatomegaly
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Hepatomegaly
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Jaundice
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Jaundice
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Hepatomegaly
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
- Jaundice
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
- JAUNDICE
- "Differential Diagnosis in Primary Care" (2007)
- [ read ]
Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Liver symptoms
» Next page: Hepatomegaly (Professional Guide to Signs & Symptoms (Fifth Edition))
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