SAVED
File name
.JPG
File alt. text
Image should be
px wide x
px tall.
Select Image
Select Image
L
O
G
I
N
EXISTING USERS
NEW USERS
password:
Forgotten your password?
password:
LOG IN
REGISTER
The Gastroenterology Training Handbook
For Specialist Registrars
HOME
OESOPHAGUS
•Gastro Oesophageal Reflux Disease
•Oesophageal Cancer
•Oesophageal Dysmotility
•Benign Oesophageal Lesions
•Miscellaneous
•Dysphagia
STOMACH
•Obesity Surgery
•Clinical Presentations of Gastric Conditions
•Gastric Cancer
•Gastric Polyps and Masses
•Peptic Ulcer Disease
•Gastritis and Gastropathy
•Miscellaneous
SMALL BOWEL
•Coeliac Disease
•Small Bowel Infections
•Small Bowel Masses
•Miscellaneous
COLON
•Colorectal and Anal Cancer
•Diagnostic Pathways for Colonic Disease
•Colonic Vascular Disorders
•Anal Diseases
•Various Colitides
•Colonic Motility Disorders
•Miscellaneous
•Colonic Infection
LIVER
•Alcohol
•Liver Failure
•Miscellaneous
•Ascites
•Bilirubin Metabolism
•Vascular Problems
•Clinical Presentations
•Liver Masses
•Hepatitis B
•Hepatitis C
•Autoimmune Conditions
•Metabolic Conditions
•Treatments
•Various Viruses
•Hepatopulmonary Disorders
•Liver Imaging
BILIARY
•Gallstone Disease
•Biliary Cancers
•Biliary Parasites
•Miscellaneous
NUTRITION
•Nutrition Therapy
•Minerals
•Proteins, Fats and Sugars
•Vitamins
•Clinical Conditions and Nutrition
PANCREAS
•Pancreatitis
•Pancreatic Masses and Cysts
•Pancreatic Cancers
•Other
IBD
•Epidemiology
•IBD Diagnosis
•Extra Intestinal Manifestations
•Surgery
•Treatment
MISCELLANEOUS
•Bleeding
•Rheumatological Disease
•Infection
•Vascular Lesions
•Other
home -
Liver -
Miscellaneous -
Hepatocellular Carcinoma
search
Ask a question in the forum
Written by Dr Sebastian Zeki
MCQs for this page
What the Curriculum Says
Knowledge
Recognises the importance of sepsis as a complication
Aware of the differential diagnosis and management of sepsis and its
possible sequelae
Knows the appropriate use of the appropriate antibiotics and their
complications Aware of prevention of nosocomial infection
Skills
Understands the principles and practice of diagnosis and treatment of
sepsis
Behaviours
Prepared to involve and liaise with specialist sepsis support
Also....
Knowledge
Knows the importance of clinical nutrition and its disturbances in
patients with acute and chronic liver disease
Appreciates indications for enteral or parenteral support and
understanding of limitations of these interventions
Skills
Shows ability to make careful nutritional assessment
Behaviours
Can liaise with nutritional support team where appropriate
Also...
Knowledge
Understands prognostic scoring systems including Child - Pugh
MELD UKELD Maddrey and disease-specific scoring systems where
they exist
Skills
Builds the use of accredited quantitative scoring systems into routine
clinical liver practice clinical colleagues and junior staff
Behaviours
Shows consistent application of evidence-based in the
evaluation of liver disease and the determination of prognosis
Hepatocellular Carcinoma
View large version
Embed image
paste this code into your webpage / blog to share.
Choice of staging system
Primary staging for all patients with
HCC should be clinical staging, and
the CLIP system was preferred.
They also recommended secondary
staging with the AJCC/UICC (TNM)
staging system for patients
undergoing surgery (liver transplan
-
tation, resection).
Other Factors Influencing Survival:
High versus low-incidence regions:
Survival shorter
in high-incidence regions.
Tumor histology:
Well-differentiated, clear cell and
fibrolamellar tumors and the presence of tumor
encapsulation have been associated with a better
prognosis.
Serum AFP level:
Correlates with tumor size and
extent.
Increase when mass > 3 cm; Rise to 1000 -10,000
ng/mL as tumour >5 cm diam.
Serum AFP level is independent predictor of
survival; High AFP levels assoc. with poorly
differentiated tumors.
Variant estrogen receptors:
Some aggressive HCC
have variant oestrogen receptor with
constitutive
transcriptional activity.
Hepatitis C-
Prognosis worse if compared to Hep B
Okuda system (
Tumor size +
Severity of cirrhosis )
Does not stratify patients by
vascular invasion or nodal mets
Because most patients staged
according to this system are not
candidates for resection, it is a
purely clinical scoring system.
The Cancer of the Liver Italian Program score
(CLIP)
Combines tumor-related features (macroscopic
tumor morphology, serum AFP, and the presence of
PV thrombosis)
+
Severity of cirrhosis
Prognostic score ranges from 0-6.
CLIP better at predicting survival compared to the
TNM, Okuda, or Child-Pugh systems, esp with
nonsurgical therapy (eg, transarterial chemoemboli
-
zation, TACE).
The French prognostic classification
5 prognostic factors:
-Karnofsky performance status
-Serum bilirubin >50 micromol/L (>2.9 mg/dL)
-Serum alkaline phosphatase a>2x
ULN.
-Serum AFP >35 ng/mL
-Ultrasonographic portal obstruction
Patient put in 3 groups with 1yr survival of 72, 34,
and 7 %, respectively.
The Barcelona staging classification
Based on extent of primary lesion, performance status, the
presence of constitutional symptoms, vascular invasion and
extrahepatic spread, and Okuda stage.
Early stage (A) - Asymptomatic with tumors suitable for radical
therapies;
Intermediate stage (B-) Asymptomatic with multinodular HCC
Advanced stage (C)- Symptomatic, vascular invasion and/or
extrahepatic spread.
Stage D - Either Okuda stage III tumors or ECOG performance
3/4.
Stage B and C patients candidates for palliative/ clinical trials
Stage D - symptom control only
Tumor, node, metastasis
(TNM) staging
5yr survival: Stage I – 55 %;
Stage II – 37 %; Stage III – 16 %
If have cirrhosis, liver function
dominates prognosis so Okuda
and CLIP more useful.
Prognostic Scoring Systems
Median survival following diagnosis
ranges from 6 to 20 months.
Epidemiology
The M:F ratio is 4:1.
The mean age of onset is 50-60 years.
It’s most common in SEAsia
(35/100,000).
Hepatitis B
0.47 % per year get HCC.Higher in Asians.
Much higher if HBeAg +ve/with higher HBV DNA levels/ co-infected with HCV
Environmental toxins
Aflatoxin-
mycotoxin in corn/soybeans/peanuts p53 gene mutator
The blue-green algal toxin Microcystin (pond-water contaminant).
Betel nut chewing
also for oesophageal and head/neck SCC
Hepatitis C-
HCC in HCV only if advanced fibrosis
Risk factors with HCV:Genotype 1b;Concomitant heavy alcohol use, DM, and obesity; Cirrhosis; HBV
coinfection
Cirrhosis
Compensated cirrhotics-4 % annual incidence of HCC
Chronic hepatitis-1% annual risk . Higher if AFP (<20 µg/L).
Chronic hepatitis/cirrhosis who have hepatitis B, hepatitis C, or hereditary
hemochromatosis
(HH) have
the highest HCC risk-HCC in HH with cirrhosis only
Tobacco and alcohol abuse-
Both are a risk factor
NAFLD and DM-
DM risk x2.5 tho may be because of
NAFLD,
also a HCC risk factor.
+
Risk reducers:
Coffee Consumption(>2
cups/day - 43 % risk reduc
-
tion).
Statins-possible but
unproven as yet.
-
HCC growth patterns:
Large solitary mass.
Multi-focal ACC with dominant mass and satellite lesions.
Diffuse infiltration.
Fibrolamellar HCC (non-cirrhotic).
Forms:
1) Nodule
2) Solitary
3) Diffuse
HCC manifestations:
Hepatomegaly.
Hepatic impairment.
Bloody ascites.
Fever.
Increased ALP.
Polycythaemia/Leukocytosis.
Hypoglycaemia/hypercalcaemia.
Radiology
USS shows- HCC<3 cm - hypoechoic.
Vascular invasion is common (PV>HV).
CT shows hypodensity on non-contrast in
PV imaging.
CT can also show a central necrotic area.
On MRI-T1:hypodense;T2:Hyperintensive.
MRI angiography can be useful.
PET can be useful.
Risk Factors
Written by Dr Sebastian Zeki