Hepatobiliary Services
Learn More About Your Liver
The body’s largest internal organ may not have the high profile of other vital organs such as the heart or lungs, but the liver has a complex range of functions that no mechanical or artificial substitute can duplicate. Take time to learn more about your liver and how you can keep it healthy:
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Bethesda North Hospital specializes in a wide variety of diagnostic and therapeutic interventions for conditions primarily affecting the liver, but also the pancreas and gallbladder.
The liver is a vital organ, located in the upper right abdomen beneath the ribcage, that has many unique and complex functions which are necessary to sustain life. The complexity of the liver’s function(s) cannot be duplicated by any devise or machine. This is different than other organs such as the heart, lungs, kidneys, and intestines. Although the liver is able to regenerate, this is dependent on the remaining liver being healthy. If the liver is severely diseased, it cannot regenerate adequately.
The functions of the liver can be divided into a few large areas:
- The liver is responsible for synthesizing a number of proteins, including those that aid in the clotting of blood and proteins which transport vitamins to different sites in the body.
- The liver is responsible for producing bile, which detoxifyies and excretes a number of injurious chemicals -- including drugs -- that would otherwise accumulate in the body into bile. Most of these chemicals first need to be converted to a different form in the liver before they can be excreted into bile.
- The liver also is responsible for the inter-conversion of most dietary nutrients from one form to another thus providing the brain, muscles, and other organs the proper proportion of nutrients necessary for their function.
There are a number of diseases that affect the liver. Many of these are called “hepatitis” because they affect the liver cells, causing inflammation and cell death. Hepatitis can be caused by a number of chemicals such as alcohol, solvents, or drugs. Hepatitis also is caused by a number of viruses. Additionally, there are genetic causes of hepatitis as well as autoimmune hepatitis.
A number of different diseases also affect the liver by causing obstruction to bile flow, while others are caused by obstruction to vessels leading into or out of the liver. If the liver disease is present over a long period of time, i.e. a chronic condition, severe scarring of the liver can cause a condition called cirrhosis. It is well known that alcohol is a cause of cirrhosis, but many other diseases can also result in a cirrhotic liver. Once cirrhosis is present a number of other problems start to develop and liver transplantation may be needed.
Other areas of our focus include:
- Portal hypertension
- Esophageal varices
- Inherited liver disease
- Gallstones
- Pancreatitis
- Pancreatic divisum
- Pancreatic duct stones
- Drainage of pancreatic pseudocysts/abscesses
- Pancreatic cancer (includes management of patients with a family history of pancreatic cancer)
- Bile duct strictures
- Complicated biliary strictures
- Cholangiocarcinoma
- Post-operative biliary complications
- Post cholecystectomy syndromes
For further information on these or other hepatobiliary disorders, please visit www.gi.org.
Team Approach
Our hepatobiliary service is a collaboration between various specialists. Together, gastroenterologists, surgeons, radiologists, oncologists, specially trained registered nurses, laboratory personnel and nutritionists work together as a team to meet the needs of our patients that require this level of care. This approach includes a dedication to safety and quality, which is an integral part of our mission.
We also recognize the patient as one of the most important members of this team and believe in a strong patient education program to support and improve our patients’ health. We understand that the more patients know about their disorder, the more likely there are to have a good response to therapy.
Specialized Services
We utilize the latest in technology to provide a safe environment in which we deliver excellent care to our patients and their families.
ERCP
Endoscopic retrograde cholangio pancreatography – or ERCP – is a technique that gives doctors the capability to gain access to the bile ducts and pancreas. It is performed with a flexible endoscope that is entered through the mouth and into the stomach and area of the upper intestine – called the ampulla – where the bile ducts and pancreas open. Through this technique, diseases of the bile ducts and the pancreas are diagnosed better and earlier than before.
There are several common uses for ERCP to treat the bile ducts. The most common is to detect the presence of stones within them. With ERCP, stones of almost any size and consistency now can be crushed and removed without having to open the abdomen.
ERCP also can be used to treat a bile duct injury after a gallbladder operation. Often, such injuries cause bile to leak into the abdomen. In the past, this very painful condition often required reparative surgery. ERCP allows doctors to place a stent in the bile duct to help it heal itself.
A stent also helps when cancers of the bile ducts cause obstructive jaundice. In these cases, placing the stent with ERCP helps bridge the obstruction and relieve the jaundice.
ERCP also is one of the best ways to access the pancreas for diagnostic purposes. It not only can help diagnose pancreatic cancer, but also help treat it by relieving jaundice and planning – if necessary – for major subsequent surgery.
ERCP also has a great use in accesses the pancreas for therapeutic purposes. Blockage of the pancreas leads to pancreatitis, which often is a debilitating condition. With ERCP, doctors can see the pancreas and determine the reason for such blockages and treat many causes of pancreatitis.
With referrals coming from a 200-plus-mile radius, Bethesda North Hospital is the regional leader in ERCP. The dedicated team of physicians, nurses and staff have come together to make Bethesda North the area’s preferred provider of treatment for bile duct and pancreas treatment.
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Liver biopsy
A liver biopsy is a valuable procedure used to diagnose and stage liver disease. With this procedure, a small piece of liver tissue -- about one inch to an inch and a half long and wide enough to fit into a needle -- is obtained and examined.
The biopsy can help establish a diagnosis, and therefore direct treatment if the cause of liver disease is uncertain. In other cases -- such as heaptitis C or nonalcoholic fatty liver disease -- the cause of disease may be obvious. Since the biopsy is used to help stage the disease it is therefore valuable in directing subsequent treatment. The quantity of iron found in the liver during the biopsy is also valuable in staging and directing therapy and follow-up for other diseases, such as hemochromatosis.
There are several precautions you must take into consideration before your biopsy. You generally are asked to fast the night prior to the biopsy. Also, it is important for you to undergo clotting studies before the biopsy to ensure that your blood clots properly and that the procedure is safe to perform. If you take a blood thinner such as Coumadin, Plavix, Ticlid, Persantine, Aggrenox, asprin, or non-steroidal anti-inflammatory drugs it is important that you stop taking them before the biopsy is performed.
When you arrive to the hospital, you will receive an IV in the outpatient procedure area. An ultrasound then will be used to identify the position of the liver and to identify the safest location within the liver to perform the biopsy. A sedative is usually given, although it is important that you be conscious enough to follow simple commands.
The biopsy site is generally along the right chest wall in between the ribs. The site is carefully cleaned and then a local anesthetic is administered with a small needle. The remainder of the procedure is generally painless. You will be asked to breathe a certain way. The biopsy needle then will be quickly inserted and tissue will be extracted in a fraction of a second. This tissue will then be placed in a fixative and sent to the laboratory for staining and examination using a microscope.
You will then be asked to lie on your right side for two hours, with your pulse and blood pressure monitored periodically for two to four hours. If pain occurs at the site of your biopsy or in the right shoulder, a medication will be given to relieve the pain. Generally any pain occurs within the first hour or two following the biopsy. When you go home, there is only some mild soreness at the biopsy site. Detailed instructions will be given in terms of resuming activity and an appointment will be made to discuss biopsy findings and treatment recommendations.
While liver biopsy it is often met with considerably anxiety, it is a procedure with a low risk and a low incidence of inconvenience. Patients are generally relieved and surprised at how easy and quick the procedure is.Liver biopsy is generally a very safe procedure, however complications can occur as is with any medical procedure. These include internal bleeding, perforation of the gallbladder or lung, introduction of infection, and prolonged pain. While all of these problems are rare, they may require readmission to the hospital or an overnight stay in the hospital.
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Liver diagnostics
Blood test in the diagnosis and management of liver disease
Patients with liver disease often are asked to have their blood drawn because blood tests are so useful in following and understanding liver disease. A number of blood tests are general measures of liver function or liver cell damage and they are useful in assessing the severity of disease and the type of disease.
For example, the transaminases (AST and ALT) are elevated when there is primarily inflammation and damage to the liver cells (or hepatocytes). This is the pattern of injury most often seen with hepatitis. Another enzyme called the alkaline phosphatase generally measures obstruction to bile flow and is more elevated than the transaminases if there is primarily an obstructive problem within the liver. Bilirubin is a yellow pigment that becomes elevated in blood if the liver fails to excrete this pigment. A number of other proteins found in blood are used to measure the liver’s ability to synthesize these proteins. We therefore measure the prothrombin time as a measure of the liver’s ability to produce clotting factors and serum albumin is roughly a measure of the liver’s capacity to synthesize this particular protein. Changes in the levels of liver enzymes, proteins synthesized by the liver, and bilirubin help to determine improvement or deterioration in liver function and response to therapy.
A number of other blood tests will specifically identify the cause of liver disease. There are blood tests to determine the activity of a number of hepatitis viruses. Measuring the levels of nucleic acids of hepatitis B and C is very useful in assessing a response to therapy given to treat these viral diseases. Other blood tests will specifically identify metal storage disease as seen with abnormal accumulation of iron (hemochromatosis) or copper (Wilson’s disease). Antibody tests will help identify autoimmune diseases affecting the liver.
Radiology in the diagnosis and management of liver disease
Various tests done in the radiology department help us to understand and treat liver disease. They are particularly useful in determining the size and shape of the liver, determining whether cirrhosis is present, and identifying tumors within the liver. They can tell us if a liver is particularly fatty and they are especially useful to define the bile ducts and the hepatic vessels that surround the liver. These tests are rarely useful to tell us the reason for of the severity of hepatitis.
Ultrasound is a useful and relatively inexpensive technique that has no unwanted side effects. It is able to show a fatty liver and is useful in determining whether there is an obstruction to bile flow because it reveals if there is a dilation of the hapatic ducts. Ultrasound also can determine whether there is adequate flow to the liver through hepatic vessels -- the hepatic artery and portal vein, which send blood to the liver, and the hepatic veins, which take blood away from the liver. It also is very useful in localizing fluid that can accumulate in the abdomen (ascites) in patients with more advanced cirrhosis and it is commonly used to define the optimal site for a liver biopsy.
Computerized axial tomography or CAT scanning is generally more expensive and uses x-rays to identify lesions within the liver, the general shape of the liver to determine whether there is likely to be an obstruction of the bile flow, and to tell us whether the vessels are open. Patients generally receive dye taken both by mouth and intravenous injection to optimally image the liver and surrounding structures. It often offers more detail than an ultrasound concerning any mass or tumor within the liver and it is generally able to pick up tumors at an earlier stage. Cirrhosis often can be identified using this technique because the liver appears nodular, the spleen enlarges, and the portal vessels leading to the liver become engorged. Patients with cirrhosis generally have a scan performed at least yearly using either ultrasound or CAT to screen for the development of hepatocellular cancer. This cancer unfortunately develops commonly in patients with long standing cirrhosis and a favorable prognosis depends upon finding tumors at an early stage.
Magnetic resonance imaging or MRI scan also is useful in imaging the liver. These scans generally are more expensive and patients are placed in a very confined space, which is difficult for anyone who suffers from claustrophobia. This technique avoids using x-rays and intravenous dye that is used during CAT scanning which can injure the kidneys. MRI scanning is therefore particularly useful in patients with preexisting renal disease. MRI scanning can give a detailed and clear picture of the entire length of the bile duct and can give additional information about the nature and extent of tumors within the liver. It is also very useful in providing information about the vessels surrounding the liver.
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