The Evolution of ERCP

Each year, 25 million Americans die from chronic liver disease (CLD) and cirrhosis — the 10th leading cause of death in the United States. CLD is particularly serious because it prevents the largest organ in the body from performing essential tasks that maintain health.

The term “chronic liver disease” encompasses a large number of conditions having different causes and existing

on a continuum between hepatitis infection and cirrhosis.1

Symptoms are many and varied, often including fatigue, exhaustion, and weight loss. The most common cause of liver disease is alcoholism. Alcohol-related disorders outnumber all other types of liver disorders by at least five to one.

Although CLD is irreversible, preventive care can be used to prevent further exacerbation of the disease. Experts recommend that patients with CLD take several actions:

• Eat a low-fat, “heart smart” diet
• Abstain from alcohol
• Avoid iron supplementation unless an iron deficiency is indicated
• Avoid liver-toxic medications
• Receive vaccinations against hepatitis A and B
• Once cirrhosis develops, get screened yearly with upper endoscopy to follow bleeding risk, and with ultrasound to detect liver cancer

Diet is the first and most important intervention in patients with CLD.3 A well-balanced diet is capable of reducing the complications of CLD and improving prognosis. Sodium, protein and even fluid intake are often restricted. Abstinence from alcohol is recommended to keep CLD from progressing to cirrhosis. “With patients with chronic liver disease, we look at the first stages as just staying healthy — getting adequate calories and protein — maybe even taking a multivitamin to make sure they get all the vitamins and minerals,” says Chris Senerote, MED, transplant dietitian at the Liver Institute at Methodist Dallas in Texas. “It is really all you have to do. As the liver disease progresses, then we need to really start focusing more on diet and prevention.”

Senerote points out that a multivitamin is the basic supplement that patients begin with; however, patients are continuously monitored to determine whether further nutritional supplementation is required. Micronutrient deficiencies typically encountered in alcoholics, such as for thiamine and folate, require specific supplementation.

Supplementation improves both nutritional status and survival in selected conditions. “There is a population out there that we look at which is approximately 60 percent moderately malnourished and 15 percent severely malnourished — that is the population that I’m seeing more of,” Senerote says. “My job is to work with these patients and prevent them from being more malnourished than they are when they see us and hopefully improve their nutrition status a little bit more.”

In addition to malnutrition, fatigue and muscle wasting are consequences of CLD which makes exercise training in this patient population difficult.5 One recent study, however, demonstrated the benefits of exercise. Investigators showed that maintenance of weight loss and exercise in overweight patients with CLD resulted in a sustained improvement in liver tests, insulin levels, and quality of life.6 “Most of our patients with liver disease, especially by the time we get to see them at the Liver Institute, are very tired,” Senerote says. “They don’t feel like exercising. We encourage them to be as active as they can possibly be.”

Most recommended dosages of medication are safe for patients with CLD despite affected liver function. However, patients may be at increased risk for idiosyncratic drug reactions and less able to tolerate hepatotoxicity when it occurs.7 Common drug classes for known hepatotoxicity include antidepressants, nonsteroidal anti-inflammatory drugs (NSAIDs, including cyclooxygenase- 2 inhibitors), muscle relaxants, psychotropics, anticonvulsants, lipid-lowering drugs, oral antidiabetic agents, estrogens, anabolic steroids and antituberculous agents.

Research supports vaccination against hepatitis A virus (HAV) and hepatitis B virus (HBV) in patients with CLD. Superinfection with either virus can lead to acute liver failure. In 2001, a combined hepatitis A and B vaccine became available. It is approved for use in people aged 18 and older and is given in three doses over a 6-month period.

The World Health Organization (WHO) reports that approximately 1.5 million clinical cases of HAV occur each year, whereas there are more than 2 billion carriers of HBV. Williams et al noted that death certificate data from 1989 to 1992 in the United States indicated a higher prevalence of CLD among persons who died of fulminant hepatitis A compared with persons who died of other causes.

Regular screening of cirrhotic patients is recommended to detect and treat complications of the disease. One such complication is variceal bleeding in which blood vessels become enlarged and burst, resulting in bleeding in the upper stomach or esophagus.

Endoscopy is not only used to screen for variceal bleeding but also as a therapeutic tool to directly inject the varices with a clotting agent or place a rubber band around the bleeding veins.

Liver cancer is also screened for in cirrhotic patients. The most commonly used screening tests are ultrasound and the measurement of a-fetoprotein (AFP) in the blood. The choice of treatment for liver cancer depends on the condition of the liver; the number, size, and location of the tumors; and whether the cancer has spread outside the liver.

Joining the ranks of more standard forms of treatment, such as surgery, radiation therapy, chemotherapy and percutaneous ethanol injection, is radiofrequency ablation (RFA). With RFA, a special needle electrode is placed in the tumor under the guidance of an imaging method such as ultrasound, computed tomography (CT) scanning, or magnetic resonance (MR) imaging.10

A radiofrequency current then is passed through the electrode to heat the tumor tissue near the needle tip and ablate or eliminate it.11 RFA may be done as an outpatient procedure. Stephen Pedroff, vice president of marketing communications at RITA Medical says the procedure spares healthy tissue, only affecting a small margin of tissue surrounding the tumor.

Many studies have shown that more than half the liver tumors treated by RFA have not recurred. In a recent study, the overall survival of the patients treated with RFA as the sole first-line of treatment was 97 percent at one year, 89 percent at two years, 71 percent at three years, 57 percent at four years, and 48 percent at five years.12 Pedroff says, “Many of the practitioners we work with believe that radiofrequency ablation is the most promising new therapy for managing or destroying tumors in primary liver cancer patients with cirrhosis.” (See sidebar below)

For a complete list of works cited, visit www.endonurse.com.

Diseases That Affect the Liver

Alagille Syndrome — An inherited disorder characterized by a progressive loss of the bile ducts within the liver and narrowing of bile ducts outside the liver over the first year of life.

Alpha 1 - Antitrypsin Deficiency — A hereditary disease that may lead to hepatitis and cirrhosis.

Autoimmune Hepatitis — A progressive inflammation of the liver associated with an abnormality of the body’s immune system and related to the production of antibodies.

Biliary Atresia — An infant’s disease, resulting in inflammation and obstruction of the ducts.

Cancer of the Liver — The most common primary malignant tumor of the liver is hepatocellular carcinoma.

Chronic Hepatitis — An ongoing injury to the cells of the liver with inflammation which lasts longer than six months.

Cirrhosis — A group of chronic liver diseases in which normal liver cells are damaged and replaced by scar tissue, decreasing the amount of normal liver tissue.

Cystic Disease of the Liver — A number of diseases, including choledochal cysts, Caroli’s Syndrome, Congenital Hepatic Fibrosis, and Polycystic Liver Disease.

Fatty Liver — An accumulation of fat cells in the liver, common in patients who are overweight or who have diabetes.

Galactosemia — A rare hereditary disease caused by elevated levels of galactose, a sugar in milk, in the blood resulting from a deficiency of the liver enzyme required to break it down.

Gallstones — This condition can cause severe and intermittent pain in the right upper abdomen, as well as chronic indigestion and nausea.

Gilbert’s Syndrome — A relatively common and benign congenital liver disorder, found more frequently in males.

Hemochromatosis — A genetic condition that causes the body to absorb and store too much iron.

Hepatitis A — This inflammation of the liver is usually caused by eating food or drinking water that has been contaminated with human excrement.

Hepatitis B— One of the most serious forms of hepatitis, which is more common and much more infectious than AIDS.

Neonatal Hepatitis — Inflammation of the liver that occurs only in early infancy, usually between one and two months after birth.

Porphyria — A disease in which a chemical compound in the body called porphyrins does not successfully perform its task of forming heme, a substance that makes blood red in human beings.

Primary Biliary Cirrhosis — A chronic liver disease that causes slow, progressive destruction of bile ducts in the liver.

Primary Sclerosing Cholangitis — A disease in which the bile ducts inside and outside the liver become narrowed due to inflammation and scarring.

Reye’s Syndrome — A rare complication of childhood respiratory infections characterized by vomiting that begins three to seven days after the onset of flu or chickenpox.

Sarcoidosis — A systemic disease of unknown cause, in which nests of cells appear in many tissues, including the lung, lymph nodes and liver.

Tyrosinemia — A genetic inborn error of metabolism associated with severe liver disease in infancy.

Type I Glycogen Storage Disease — A deficiency of the enzyme glucose - 6 - phosphatase which helps in maintaining normal blood glucose during fasting.

Wilson’s Disease — An inherited disorder of copper secretion by the liver.