Friday, December 3, 2010

One Tattoo Too Many

I was seeing patients in my hepatitis clinic as usual, when I walked into an exam room to see a new patient.  He was a 45 year old Hispanic male who needed to be seen due to a lesion in his liver which needed to be biopsied. 
He was slightly overweight, worked as a factory line worker and lived in a small 2 bedroom house in the northeast part of the city.  He had a wife who had gone through surgery, radiation and chemotherapy for breast cancer two years prior.  She was standing next to him. 
Before I could begin asking my usual questions of the patient, his wife immediately stated, “I can’t live without him.  I don’t know what I would have done without him by my side during my breast cancer treatment.  He can’t die!”
“I see here on the intake sheet that your primary care physician has sent you to the hepatitis clinic due to a lesion in your liver which needs to be biopsied.  Is this correct?”
“Well, before I explain to you the procedure and what to expect, let me ask you a few questions.  Okay?”
“Do you have a history of any sort of viral hepatitis, such as chronic hepatitis B or C?
“Yes.  I was told that I have chronic hepatitis C.”
“How long have you had it?”
“I don’t know.”
“Okay, well then do you know what your risk factor was for hepatitis C?  Did you ever receive a blood transfusion, inject street drugs, or have a tattoo put on, for instance?”
“Yes, I had this tattoo here on my right forearm done about 25 years ago as a way of showing my love for my wife.  It’s a heart with our initials in the middle of it.”
“Is that your only risk factor?”
“The only one I know of.”
“Okay, well then I can pretty well assume that you acquired hepatitis C from that tattoo, which means that you’ve had it for 25 years and this is a long enough time to have ended up with cirrhosis, or end stage liver disease.  One of the complications from hepatitis C is that it can cause liver cancer in patients who have end stage liver disease, which maybe the problem with you right now.”
With that, his wife erupted, she viscously started physically pounding her fists into his chest, and screaming at him that he better not have cancer.  Then she started screaming at him about how stupid he was to have put a tattoo on his forearm.  I was totally taken aback by her action.  I immediately stood up and tried to grab the patient’s wife’s arms and hold them down.  But the patient’s wife was too determined and she kept breaking free of my hold.  Meanwhile, the patient was just sitting mute, unmoving on the exam table, as he continued to just let her beat on his chest.
Finally, after several minutes of her physical beating of her husband, she had used up enough of her physical energy that she was finally worn out and sat down in the exam room chair. 
I was still shaken up from the whole incident, sat back down warily keeping my eye on the patient’s wife.  Whereas the patient continued to have a blank face, empty of any emotion.
“Okay, I have some more questions for you.”
“Okay,” the patient answered.
I proceeded to ask him the rest of the questions I needed an answer to, which included his past medical history, family history, current medications, allergies, alcohol intake, etc.  I then did my physical exam and found that he had a small liver (understandably due to his having cirrhosis or end stage liver disease).  Other than that I didn’t find anything else on his physical exam that was alarming.

I went on to explain to him what the liver biopsy would entail, gave him his laboratory request for the necessary blood work and scheduled him for the biopsy as well as a return clinic appointment in one week’s time when the biopsy results would be known.  After I completed all of this, I asked the patient whether he had any questions, which he didn’t, and then ended the patient encounter.

Chronic hepatitis C is a disease that is caused by a virus which infects the liver.  Over time (usually around 20 years or longer) it can cause liver failure, liver cirrhosis (end stage liver disease), or liver cancer.  If patients are treated for their chronic hepatitis C prior to their acquiring the end stage complications (whether that is cancer, cirrhosis, or failure) they can be cleared of their virus with medications which include a long acting alpha interferon and ribavirin.  Patient’s clearance of the virus is based on the patients genotype, there are at least eleven different subtypes of the virus and they respond differently to the medications, hence they have different long-term response rates. 

Chronic hepatitis C is acquired through different mechanisms.  These risk factors include: blood transfusions prior to1991, intravenous drug abuse, tattoos, sexual encounters, and occupational needlestick injuries.   Most patients who have acquired this infection do not have any symptoms during the immediate period after they have acquired the infection, so patients typically don’t know they have been infected.  Patients usually find out they have the infection if they are tested for it by their physicians based on the risk factors they have, or if they are found to have elevated liver function tests. 

If patients chose to be treated for their viral disease they undergo numerous blood tests to follow up on their liver enzyme tests, and blood counts.  They are seen frequently by a gastroenterologist/hepatologist (physician who specializes in abdominal problems and/or liver disease).  After they complete their treatment they are then followed for  another six months to make sure that they have cleared their virus long-term. 

One week later the patient came back into clinic.  He was accompanied by his wife.  I was prepared.  I had alerted hospital security and they had sent up a security guard who was sitting in the nearby conference room, ready if I needed them.  This was based on what had happened with the patient last week with his wife.  I was afraid that his wife  was really going to lose it when the patient was told the news of his biopsy.   I had also alerted the clinic social worker who knew the patient’s wife from her previous cancer treatments and was on stand-by in case the patient’s wife needed someone to discuss the situation with.

I walked into the exam room and the patient was sitting on the exam table.  His wife was sitting in one of the chairs.  I was hoping she would stay in control of her feelings.  I sat down and told the patient that the biopsy showed what we expected and that he did indeed have liver cancer.   Instantly, the patient’s wife flew into a rage and started running between the clinic exam room walls and hitting them with her fists.  Surprisingly she wasn’t hitting her husband. 
Screaming enraged she said, “you can’t die, you can’t die.  This isn’t fair, I need you here, hear me, I need you here.”
I quickly slid out of the room and grabbed the security guard.  He came in and physically restrained the wife.  The patient during this episode again was totally unmoved.  He was emotionless sitting on the exam table.  With the security guard in the room, I proceeded to explain to the patient that I would immediately refer him over to the oncology (cancer) service.  I advised him that his options would include either surgery, chemotherapy or both. 
I left the exam room, leaving the security guard in the exam room.  I went and told the social worker that she was needed and to come back with me.    Pam, the social worker came with me and followed me into the exam room.
Pam asked the patient’s wife, “why don’t you come with me into my office, I have several things to talk to you about and we can discuss a plan of action for you so that you get the necessary support you need.”
The patient’s wife meekly followed Pam into her office. 
Relieved of his explosive wife, the patient finally turned to me and asked a few questions.
“When is my appointment with the oncology service?”
“I’ve scheduled it for two days from now.  I’ll be presenting your case before tumor board tomorrow.” (This is a gathering of physicians who work in oncology, radiation oncology and surgery who all work with cancer patients.  It’s during these meetings that a coordinated plan of action is determined for each patient).
“How extensive is my liver cancer?”
“Well based on your radiology scans at least one of your lobes of your liver is involved, it looks as though the other two are clear of disease.  But whether you are a surgical candidate will be based upon what the surgeon says, who will see your scans tomorrow at tumor board.”
“Any other questions?”
With that the patient left to walk over to find his wife in the social worker’s office. 

Over the next two years the patient received surgery, and chemotherapy.  His wife continued to need time with the social worker almost every week, she had a high amount of anxiety over her husband’s disease.
Then I heard that the patient had been put into hospice care and after several weeks, he died.  The patient’s wife continued to see the social worker and six months later she relapsed with her breast cancer.  Six months later she died. 

Once a patient is diagnosed with hepatocellular cancer it is a terminal disease, with a life expectancy of about 12 months.  Usually by the time that it is discovered it has already spread to other parts of the liver and/or to the surrounding lymph nodes.    
 Risk factors for the disease includes having chronic viral hepatitis B, chronic viral hepatitis C, chronic alcoholic liver disease or non-alcoholic steatohepatitis (fatty liver).  All of these risk factors are present within the patients for about twenty years prior to the patient being diagnosed with hepatocellular cancer.  There are many options available to patients to treat their disease long before they are diagnosed with liver cancer.

For patients with chronic hepatitis B they have treatment options of several anti-viral medications which include epivir, hepsera, and tenofovir to name a few.  For patients with chronic hepatitis C they also have treatment options of pegylated interferon with ribavirin.  For those who have alcoholic liver disease, their option is to quit drinking alcohol.  Lastly, for those patients who have fatty liver, usually due to obesity, patients need to lose weight and keep it off. 

Overall, hepatocellular cancer is one of the most preventable cancers there are.  By treating the risk factors for it, clearing the patients of their chronic viral hepatitis, helping the patients quit drinking alcohol or helping them to lose the excess weight would go a long way to prevent this disease.   

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