The TriHealth Digestive Institute is a one-stop provider of coordinated care for patients with disorders of the pancreas, liver and biliary system.
Common Hepatobiliary Disorders We Treat
- Space occupying liver lesions
- Liver tumors
- Gall bladder tumors
- Gallstone disease
- Bile duct tumors
- Inflammatory disease of the biliary tract
- Pancreatic tumors
- Endocrine tumors
Our hepatobiliary diagnostic techniques include:
Endoscopic Retrograde Cholangiopancreatography (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 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 accessing 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.
Performing an average of 450 cases per year, Bethesda North is Greater Cincinnati's leader in ERCP and ranks within the top five in Ohio.
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 hepatitis 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, aspirin, 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 considerable 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.
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 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 hepatic 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.
The Bethesda North Center for Digestive Health specializes in hepatobiliary treatments that, because of their complexity, cannot be performed in a physician office or an ambulatory facility. They include:
- Therapeutic ERCP
- Laparoscopic surgery
- Hepatic chemoembolization
- Radiofrequency ablation
Procedures are performed by the Center's multidisciplinary team of gastroenterologists, surgeons and interventional radiologists.