Hemangiomas are the most common benign tumors of the liver. They have no malignant potential and may occur in a person with or without underlying liver disease. The name hemangioma derives from the fact that these tumors are filled with heme (blood). They resemble the small bright red spots that people commonly get on the skin of their chests and abdomens as they age. These spots, referred to as senile hemangiomas, are also benign. Hemangiomas occur in the liver in approximately 7 percent of the population, but some studies have reported ranges of from 1 to 20 percent. About 10 percent of people with a hemangioma will have more than one of them. Some people will also have hemangiomas in other areas of the body such as the skin, lungs or brain. Hemangiomas are more common in women, but can also be found in men, and can occur at any age.
There are many types of benign liver tumors and I will discuss five of the most common types: hemangioma, hepatic adenomas, focal nodular hyperplasia (FNH), the solitary liver cyst, and nodular regenerative hyperplasia (NRH). For a discussion of malignant liver tumors please refer to www.liverdisease.com.
In general, they occur more frequently in women than in men. They are usually discovered by chance during the evaluation of nonrelated symptoms. Liver function tests (LFTs) are usually normal in people with benign liver tumors. In rare circumstances, these benign tumors can become so massive that a person may go to the doctor for abdominal discomfort caused by an enlarged liver. In these uncommon circumstances, results from blood tests occasionally reveal mildly elevated AP or GGTP levels.
There are no blood tests that specifically indicate that a tumor is in fact benign. Thus, the doctor may be uncertain as to whether the tumor is, in fact, benign. While malignant liver tumors may metastasize (spread to other organs, most commonly the lungs), benign liver tumors are always confined to the liver. Diagnosing the specific nature of the tumors can generally be done using a variety of radiological techniques (imaging studies) combined with the patient's medical history. When the diagnosis remains uncertain, a liver biopsy is generally performed. Since many of these tumors have an abundance of blood vessels, liver biopsy in some cases carries an increased risk of bleeding. A smaller than normal needle, or an aspirate of liver fluid, can be used to decrease the occurrence of this potential complication. Treatment of benign lesions is generally conservative. Surgery is considered primarily in cases where the tumor is causing significant abdominal pain, or if there is a high risk of rupture of the tumor. Furthermore, surgery should be done if the benign nature of the tumor cannot be confidently established, or if it is felt that the tumor has a risk of progression to a malignancy.View Thread
There are many different kinds of doctors who evaluate and treat people with liver disorders.
A gastroenterologist is an internist who has completed specialty training in the treatment of digestive disorders. Digestive disorders include disorders of the esophagus, stomach, small and large intestines, pancreas, gallbladder, and liver. In order to become board certified in gastroenterology, the doctor must first become board certified in internal medicine. In order to become eligible to even take the examination for board certification in gastroenterology, a gastrointestinal (GI) fellowship lasting an additional two to three years beyond an internal medicine residency must be completed.
During the course of their two to three years of training in gastroenterology, some gastroenterologists have little exposure to patients with liver disease. On the other hand, some gastroenterologists have a great deal of exposure to patients with liver disease during the course of their gastroenterology specialty training. Thus, the level of experience and expertise among gastroenterologists in diagnosing and treating liver disease varies greatly. It is important for the patient to determine the gastroenterologist's level of expertise in liver disease prior to establishing a long-term medical relationship with this type of doctor.
A hepatologist is the most experienced and qualified type of doctor to treat people with liver disease. There are specialized training programs for doctors who are focused solely on liver disease, - known hepatology fellowships and typically last from one to two years. Over the course of a hepatology fellowship, a doctor receives comprehensive training in the diagnosis and treatment of liver disease. This specialty training typically includes extensive exposure to all liver diseases, including those that are rare and infrequently seen. This intense training in liver disease is rarely matched in a gastroenterology fellowship.
A physician who successfully completes a hepatology fellowship is considered a hepatologist. Most hepatologists, although not all, are also gastroenterologists. These doctors have successfully completed both a hepatology and a gastroenterology fellowship. Occasionally, gastroenterologists who have not completed a fellowship in hepatology nonetheless focus their medical practice primarily on the diagnosis and treatment of people with liver disease.
For many reasons, it is to the patient's advantage to choose a hepatologist to treat his liver disease. The patient can be virtually assured that the hepatologist will have substantial experience in the diagnosis and treatment of the full range of liver diseases. Furthermore, hepatologists are likely to be the first to learn about the most up-to-date therapies—both FDA-approved and experimental—and to incorporate them into their practices. However, whether someone chooses to see a gastroenterologist or a hepatologist, it is important to find a doctor who is willing to work with him or her as an equal partner in the healing process.
10/27/2010 - Time gap could appear between protease inhibitor approval and creation of new AASLD practice guidelines, committee member says - Managed care might ask for testing at week 4 and 12, may interrupt treatment regimens - IL-28B genotype testing to possibly play a role in reimbursement algorithms - If a patient displays eRVR, then SOC would likely be sufficient, some physicians said Merck's (NYSE: MRK) boceprevir and Vertex's (NASDAQ: VRTX) telaprevir, first generation protease inhibitors in development for HCV, will necessitate both professional treatment algorithms to be updated and managed care reimbursement algorithms to be created to define eligibility criteria for triple therapy, physicians said. The current treatment regimen for the treatment of hepatitis C (HCV) involves a 24 or 48-week course of a combination of pegylated alpha interferon and ribavirin. There is concern that there will be a disconnect between the time when these protease inhibitors become available, the next annual review of the American Association for the Study of Liver Diseases (AASLD) practice guidelines, and the implementation of managed care reimbursement algorithms, according to Dr Nancy Reau, a member of the AASLD Practice Guidelines Committee and associate professor of medicine at the University of Chicago. The annual review is typically not a complete overhaul, said Reau, but there is concern that the association will have to change the whole algorithm. This might include four week viral load testing, which the European Association for the Study of Liver (EASL) guidelines currently indicate, she said. In practice, this means that the current EASL guidelines are set up to "use week four as a decision making point, but ours are not," she said. The lack of a four week testing point conflicts with the four week assessment to see if a patient has achieved early rapid virologic response (eRVR), which might indicate that a patient is eligible for response guided therapy as is done in some clinical study protocols, according to Reau. "We don't think our practice guidelines are going to mirror [clinical> practice the day this becomes available. We think these are going to come out, and our guideline review will lag a bit," said Reau. However, she said she remains confident that academic institutions will be able to adequately treat patients with triple therapy until the guidelines are updated. Although there are currently guidelines for the use of interferon and ribavirin, use is not uniform - as it is tailored to an individual patient, Reau said. The lag time in the guideline review will be most difficult for physicians who are less experienced in the treatment of HCV, like virologists and gastroenterologists, she said. Reau has previously had to show 12 week viral load data to managed care companies demonstrating sufficient viral load in order for them to continue authorizing even SOC treatment, she said. "That's probably going to become more common with triple therapy, because it's going to be so much more expensive," she said. "You could see some treatment interruptions," as a result of possibly needing four week or 12 week data, she said. The appropriate tests need to be performed and analyzed, with results then sent to a managed care company to review. The company then needs to reauthorize treatment and appropriately notify the physician, who will then need to reorder the proper therapy. It will be "nearly impossible" for this to happen in a timeline 11 W 19 Street, 2 nd Floor, NY 10011 USA tel: +1 212-500-1384 www.pharmawire.com 1 which will not interrupt the proper time course of therapy, said Dr Paul Gaglio, medical director of the Liver Transplant Center at Montefiore Medical Center and professor of clinical medicine at Albert Einstein College of Medicine. Gaglio said he would like to use protease inhibitors in all of his patients - regardless of whether an individual presents with a positive prognostic profile who would likely achieve SVR with SOC. The improved SVR results in a patient like this would merit use of triple therapy, he said. Another option outlined by Gaglio was the use of a four week SOC lead-in and subsequent viral load test to then determine if a patient should receive triple therapy, which is the protocol used by Merck in its boceprevir trials. If a patient displays eRVR, then SOC would likely be sufficient, whereas if the viral load still remained high, the patient would be eligible for triple therapy, he said. If managed care mandates these four week and 12 week decision making points, it might "mandate a minimum standard," said Reau, with practitioners ordering these tests because they have to for reimbursement purposes. The IL-28B genotype test may also be used to guide treatment selection, said Gaglio. Dr Andrew Muir, director of gastroenterology and the hepatology research program at Duke, and co-author on the article in Nature which reported on the predictive value of the IL-28B genotype and a patient's likelihood of responding to the SOC, said "IL-28B appears to be the strongest predictor of your response to standard of care." The test is available from LabCorp (NYSE: LH) after it licensed the technology from Merck. Current turnaround time on the test is usually around 10 days, said Muir. Gaglio outlined a possible scenario of how IL-28B genotyping could be used in a managed care algorithm. If IL-28B testing is favorable, a patient will get SOC first, he explained. If patients have a lack of response or an unfavorable genotype to start, then they will start on triple therapy, he added. "I think IL-28B testing might be the way that companies stratify which way patients are treated," he said. The "worst case scenario," according to Gaglio, would be one in which managed care only pays for triple therapy if a patient is a null responder or relapser, he said. Muir also cautioned, however, that IL-28B is neither the only predictor of response, nor always a predictor of response. Other predictive indicators beyond IL-28 genotype include race, viral load, and degree of fibrosis. "As with many other tests, it could be misused," said Dr Melissa Palmer, medical director of hepatology at New York University Hepatology Associates. Virologic response to treatment is still a stronger indicator than IL-28B, Reau added. IL-28B data could be used to truncate the treatment window of patients with an unfavorable genotype if they do not demonstrate a reduced viral load on therapy, she said. Additional studies are currently being done to verify that the IL-28B genotype is also predictive of a patient's response to therapy with a protease inhibitor, said Muir. This data is expected around EASL next year, said Reau. "Boceprevir seems like it will cost more because in trials it was in continuous therapy for longer than telaprevir," said Dr Silvia Degli Esposti, director of the Center for Women's Gastrointestinal Services at Women and Infants Hospital of Rhode Island. Additionally, the side effect profile associated with boceprevir, namely anemia, may limit the extent of its managed care reimbursement and thus use in patients, as a patient may require erythropoietin stimulating agents (ESAs) in addition to their triple therapy regimen, she said. This could confer an advantage to the use of telaprevir, she noted. "I have the feeling it is too complicated for managed care to tackle, because it's too complicated for us, as individualized therapy is very difficult," said Degli Esposti. "I don't think they want to know about patient details to decide what should be reimbursed. I think they will just go for a general guideline," she said. 895 Broadway #4, New York, NY 10003 USA tel: +1 212-500-1384 www.pharmawire.com 23 When historically presented with only guidelines, patients have a hard time receiving reimbursement without a defined algorithm, as there is often no rationale behind an insurance provider's choice for wView Thread
The average person requires between 7-8 hours of sleep per night. However, some people require as much as10 hours of sleep per night and others require only 4 hours of sleep per night. No matter what your personal requirement is, the main objective is to feel rejuvenated upon awakening. People with liver disease often suffer from sleep disturbances. In fact, approximately 35 to 50 percent of people with cirrhosis report having sleep-related difficulties. Some people have trouble falling asleep and others have difficulty staying asleep. Many people complain of being tired all day and awake all night. Others complain of erratic sleeping habits characterized by days of excessive sleep (a condition known as hypersomnia) alternating with days of lack of sleep (a condition known as insomnia). Still others state that they experience delays of their usual bedtimes and wake-up times. For most people suffering from these sleep disorders, the sleep they do get is not refreshing. Sleep disturbances may cause decreased concentration, poor coordination, excessive fatigue, anxiety and depression. It may affect personal relationships, work performance, and physical appearance. These symptoms and consequences of sleep disorders are magnified in people with liver disease as they may already be suffering from one or more of the aforementioned symptoms. The cause of sleeping disorders in people with liver disease is unclear, but most likely it relates to alterations in the body's production of melatonin—a hormone that is produced by the pineal gland and is involved in the sleep cycle. Sometimes, sleep disturbances stem from medications used for the treatment of liver disease. For example, interferon, ribavirin, prednisone, and propanolol all may cause insomnia. Pruritus (itching) can sometimes cause a sleeping disorder. People suffering from intense itching (discussed on page xx) may find themselves awake half the night scratching. People on interferon therapy for chronic hepatitis may be drinking up to a gallon a day of water to diminish the side effect of dehydration. Therefore, they may be awakening throughout the night to go to the bathroom. Discontinuation of water or fluid intake 2-3 hours prior to retiring, along with urinating before bedtime, may alleviate this problem. Caffeine, nicotine, and alcohol consumption may disturb sleep habits. Abstaining from these substances will likely assist in the quest for a good night's sleep. Note that sleep disturbances may also be a sign of impending encephalopathyView Thread
Since this is understandably such a frequent question, I am leaving up this information.
Sexual contact, whether it is genital, oral, or anal, appears to be an extremely inefficient means of HCV transmission. In fact, many studies evaluating this route of transmission have failed to detect the presence of HCV in either the saliva, semen, or urine of HCV-infected people—except when these body fluids have been contaminated by the person's blood. However, it is important to emphasize that HCV has the potential to be transmitted through intimate contact if there are breaks in the skin or in the lining of the mouth, vagina, or anus. This may occur for a variety of reasons including the presence of active, bleeding herpes sores; an inflamed and infected prostate gland, known as prostatitis; or as a result of traumatic or rough sex, especially anal intercourse.
HCV has been detected with greater-than-average frequency among people who have a history of sexual promiscuity. While there is no exact definition for sexual promiscuity, one study published in the New England Journal of Medicine defines it as a "history of a sexually transmitted disease, sex with a prostitute, more than five sexual partners per year, or a combination of these." Of interest is that it appears to be easier for a man to transmit HCV to a woman than vice versa.
A person who is in a long-term monogamous relationship with an HCV-infected person rarely contracts this virus. Only approximately 2 percent (a range of 0 to 6 percent) of sexual partners of HCV-infected people also test positive for HCV. However, it is important to note that this statistic is based on indirect evidence only. Therefore, whether these people became infected through a sexual act or by another route is unclear. For example, people in long-standing relationships generally care for one another in times of illness or injury. During such times, HCV may be transmitted to the spouse or partner as blood-barrier precautions may not always be taken into consideration—even among the most cautious of couples.
Household Contact Transmission of HCV among family members or other people living together may occur. This potentially can happen through the sharing of razors, toothbrushes, or any sharp instruments that carry HCV-infected blood. Therefore, it is crucial to keep all personal items, such as toothbrushes, in a separate part of the bathroom or specifically labeled. In this manner, the accidental use of a potentially HCV-infected household item will be decreased. The incidence of contracting HCV from accidental household contact in the United States is unknown. However, data from other countries indicate that it is low—approximately 4 percent.View Thread
BLUEBERRIES Studies conducted in an HCV subgenomic replicon cell culture have demonstrated that blueberry leaves contain a potent inhibitor of HCV replication known as proanthocyanidan. Further study on this provocative natural agent is anticipated. GRAPEFRUIT Naringenin, a flavanoid contained in grapefruit and other citrus fruits, has numerous beneficial properties that potentially can prevent and/or treat NAFLD/NASH. Naringenin has been reported to be an antiinflammatory, an antioxidant, and a lipid-lowering agent, and may act as a promoter of carbohydrate metabolism. Studies have demonstrated that naringenin may decrease insulin resistance and glucose intolerance, in addition to preventing obesity and the development of fatty livers in mice independent of total energy intake. Trials will need to be conducted to confirm these finding in humans. Furthermore, it appears that dose of naringenin required to correct metabolic disturbances associated with insulin resistance is much higher than the amount capable of obtaining from grapefruits. Thus, a more concentrated supplement will need to be produced, or intravenous administration may be necessary in humans for comparable efficacy to be acheived. It should be kept in mind that compounds in grapefruit juice — furanocoumarins, inhibit intestinal first-pass metabolism of many medications, resulting in increased systemic drug exposure and enhanced drug toxicity. A fatty liver develops in some patients with chronic HCV. This is believed to be due to the interaction of the virus with cholesterol and fatty acid metabolism. One step in the HCV life cycle involves attachment of the virus to very low density lipoprotein (vLDL) prior to secretion. The grapefruit flavanoid naringenin has been found to inhibit secretion of HCV from hepatocytes in cell culture in part by inhibiting vLDL secretion. Dosages of naringenin up to 1000 µM have been found to be nontoxic to hepatocytes in cell culture. Studies will need to be conducted on humans confirming these intriguing results and defining the role of naringenin in HCV treatment.View Thread