Saga of a seventeen year old

 

What does a 17 year old normally do?

Hang out with friends, party and look forward to an enjoyable future.

Vishala, a 17 year old bright girl was doing just that, when she suddenly noticed that she had lost her appetite, not relishing her namkeens and snacks as she used to earlier. Slowly she found that her eyes have started turning yellow. Obviously this is a sign for worry and her parents got her investigated with the usual blood tests for jaundice thinking it is ‘hepatitis’. This was not hepatitis as ultrasound showed that the bile ducts were getting dilated (if there is jaundice, get sonography because it differentiates between hepatitis and obstructive jaundice). She was found to have obstructive jaundice and a series of investigations and imaging followed – CT Scan,MRI etc.

She was sent to Mumbai because she was found to have a tumour in the liver hilum a very delicate, complex area. As I tweeted earlier, we really had to plan carefully for this young girl. The team was determined to do our best for the girl and we spent nearly 7 weeks planning out the procedure and consulted a colleague from Japan. The procedure meant that we had to remove three-fourths of the liver from Vishala and the balance 25% would not be sufficient for carrying on the liver functions.

You may be surprised to know that 60% of normal liver can be removed and the liver regrows in just TWO weeks . Amazing !!

I had the privilege of knowing a Japanese surgeon,Prof Makuuchi, who first described a method of enhancing the volume of the liver which we applied in her case. We then proceeded to do the complex procedure which took almost 8 hours.

Things can go right or   horribly wrong especially in such complex surgeries. The family and the patient  had complete faith in us. We also said that we will do everything possible for getting her all right. Fortunately for us the recovery was relatively smooth and now you see that she is ready to go home.

I asked her what she wanted to do now and she said, “I want to learn dancing”, which is natural for a girl of her age. She with her doctor didis post a happy picture.

It is great to have a wonderful team and a faithful patient. Certainly in this case it makes us feel happy that we could save the life of this teenager. Wish and hope she has many years of bright life!

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World Hepatitis day – Test.Treat.Hepatitis

Today is world Hepatitis Day . The theme is Test.Treat.Hepatitis.

325 million people are affected with Hepatitis B and C which is root cause for liver cancer leading to 1.3 million deaths every year. Hepatitis B can be prevented and C is treatable.

As with my blogs, I want to share a true story and this time the story is about myself.

I have been operating patients with Liver cancer and Hepatitis B for the past 3 decades. Like many others, I was under the false notion that I was immunized for Hepatitis B. Hepatitis B immunization is done on Day 1, Day 30 and after 6 months. I vaguely remembered that I was immunized on Day 1 and Day 30 but was not sure on the 6 months booster which unfortunately is the case with many of us.

One of my doctor colleagues was looking for a job in another Institution and fortunately that Institution insisted on Hepatitis B and C testing. To his utter shock and disbelief he was tested positive for Hepatitis C, which must have been contracted from a patient. Fortunately there are drugs for treating Hepatitis C and also new drugs that reduces the treatment to just 3 months. He was cured completely from Hepatitis C and could join the job.

Then I thought, why not get tested for Hepatitis B & C and to my utter disbelief found that I had NO antibodies for Hepatitis B. In other words, I was at high risk for contracting the disease. This was because of inadequate immunization. So I was operating patient with Hepatitis B taking due precautions but I could have contracted Hepatitis B and C. There is effective immunization for Hepatitis B. I immediately took immunization again and now have adequate antibody titre.

This certainly is relevant and I urge my medical colleagues and friends to get tested for B and C. We do not know when get exposed. Hepatitis is a silent disease which goes on for a long time and can lead to cirrhosis or fibrosis of liver and then later  liver cancer.. This can be easily prevented.

In the US, the CDC has given directive that those born in the 50s and 60s are not immunized for Hepatitis B, as the vaccines were not part of the universal immunization programme as per today’s guidelines.  This is also  true for us.

Yes, we have risk of getting exposed. Hepatitis B spreads with body fluids, could be in hospitals, dentists, tattooing or unsafe use of injections. All this can be prevented. India has only constituted committees ( WHO infographic). This is the time for action and not just forming committees. Apart from the guidelines, WHO makes it amply clear that we can eliminate Hepatitis by 2030 . My own example is more than enough for anyone to be tested immediately.

If you do not remember that you are immunized, you can get immunized for Hepatitis B. This is partly true of those families who have patients diagnosed with Hepatitis B. Hepatitis C has no vaccine at this point of time but has good treatment.

Elimination of hepatitis reduces risk of liver cancer and cirrhosis. Saves lives.

Here’s an appeal by Dr. Tredos Adhanom Chebreyesus, Director General of WHO that calls for immediate action.

“World Hepatitis Day is an opportunity to highlight one of the world’s most pressing public health issues. Globally, viral Hepatits B and C affect 325 million but only 1in 10 of those people have been tested and only one in 5 have received appropriate treatment. Viral Hepatitis slowly and silently degrades a person’s health leading to liver cancer and cirrhosis which results in 1.3 million deaths every year. The good news is that we have new medicines that can cure Hepatitis C in 3 months or less. WHO’s new recommendations call for treating everybody with Hepatitis C aged 12 years or older with these new drugs. That’s about 70 million people. While testing and treatment are key to eliminating Hepatitis, we also need strong focus on prevention. We have a clear vision for elimination and we have the tools to do but we must accelerate our goal of eliminating Hepatitis by 2030.”

 

This is what keeps us going….

My Secretary said there is a little girl waiting to see me.

The ‘little girl ‘walked into my room. I said “Hello” . I have never seen this girl before. Then the parents walked in. I immediately recognized the parents. The mother was nursing the baby who had a liver tumour.   It was about a month after the surgery, when we had a fund raising event and Sachin Tendulkar was so moved by the story that he came and gave a personally signed bat to the family.sachin and child

The girl is now 5 years old and they had come to see Mumbai. I asked her what she liked about Mumbai. She said ‘shopping malls’. Yes of course, for a girl from a small town the shopping malls of Mumbai are the big attraction.I asked her if she had gone to the new aquarium and she said “yes, there are a lot of fish and  I liked the gold fish”. She was bubbly, full of life. She does not remember me and perhaps she does not even remember that she has been treated with chemotherapy and later undergone surgery for 12 hours and then recovery for another 12 days.child 2

It is a moment of immense satisfaction to see the little girl and the grateful family.

I was lucky that day. Shravan, a young software engineer who was diagnosed with Stage IV gastric cancer, was practically given 6 months and asked wind up his affairs. He was treated with chemotherapy and then, rather unconventionally, we went in for surgery followed by radiotherapy. I was pleasantly surprised and happy that it is now about 3 years and he is having a productive career . In spite of being a middle class professional he had been generous to donate a substantial sum towards ‘Crusade Against Cancer Foundation’ always saying that he is grateful for this gift of life.

All of them say they are grateful for their ‘second’ life. I am truly modest to reply that it is their courage and God’s will that brought about this happy outcome. I am just doing whatever I can do to the best of my capabilities.

In cancer you have two choices, either to give up or to fight. Giving up is very easy.  Fighting for the patient needs time, effort and multidisciplinary planning by many individuals. First and foremost, the patient has to muster courage and literally lift the weapons. We can only render our shoulders to fire.

Meanwhile I can only say that if you, by God’s grace succeeded in your fight, do help others. The only thing they need is a message that there are many victors in this world who have also battled and won.

God be with you!

Can you ‘change my Liver’ and get rid of the Tumour

 

Mehta, a 50 year old accountant is an anxious patient with a very anxious family. He was diagnosed with Liver Cancer.  As I said in my last blog, due to undetected and untreated Hepatitis B, he had multiple tumours of the liver and it seems very logical for the family to opt for a ‘change of liver’ or liver transplantation. The family was prepared to donate half a liver as cadaver donations are rare. I thought I would clarify some of the issues related to this.

First, let’s  see how the normal liver looks like.  A normal liver is a huge organ situated largely in the right rib cage and well protected.

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It is a phenomenal metabolic factory, a filtration and manufacturing plant. Nearly 5 litres of blood goes through it every 5 minutes. The liver purifies the blood from all the toxins, food indulgences, alcohol and all the insults we subject our body to.  It also has important functions of synthesizing proteins and also storing extra energy for utilization in the periods of starvation.  Though the liver looks like a single organ, it is actually made up of 2 lobes, right and left.  Advances in surgery have made it possible to remove nearly 60% of the liver.  Its remarkable that the remnant liver regrows in just 2 weeks to its original volume.  So, liver resection or removing part of the liver can be easily be done for liver tumours leaving a healthy normal liver to regrow.

What about ‘change of liver or liver transplantation’. 

It is an entirely different procedure, first initiated by Thomas Starzl.  It is actually done in diseases where the liver fails when practically 80% of liver stops functioning.  Also in children where bile ducts are not formed and some genetic defects leading to rare metabolic diseases. In these conditions  liver transplantation works like magic.

However when it comes to tumors, the picture is not always rosy.  There are many tumors and cancer cells are in circulation and are not just confined to Liver. The transplanted liver is immediately infected by the cancer cells.  So we have to be cautious in selecting and advising patients on liver transplantation for tumours.  Some scientific criteria have been developed, so called Milan criteria. In large tumors or multiple tumors, liver transplantation will not be beneficial.  I advised Mr. Mehta against transplantation.

It should not to be taken as an emotional decision but a rational approach.  So the next time that you ask for change of liver, ask the doctor and also ask yourself  if the major procedure would  actually give  an extension of lifespan with good quality of Life.  That is the key question.

Today is Organ Transplant Day.  Yes, we need to promote cadaver donation as so many kidneys are going waste when today patients are on life long  dialysis.  I really do not think it is a cultural issue as there is nothing in any religion against this form of donation, of one’s organ.  It is just that we need to go cut through a bureaucratic red tape and develop the right kind of infrastructure for organ sharing. Co-operation between public and private hospitals with motivated transplantation coordinators is the key of success in organ transplantation as in Spain. It’s more of motivation of society than a medical issue.

A B C of Hepatitis

 

28th July is declared as ‘World Hepatitis Day’.  I thought I will share some information with you to help and prevent major illness affecting the liver causing nearly 1 million deaths annually world wide.

Hepatitis is a viral infection of the liver.   There are Hepatitis viruses A,B,C,D,E, but the most relevant are A, B & C.

Hepatitis A is relatively an innocuous viral infection, normally spreads by contamination of food and water and can be prevented by good hygiene. Nearly 1.4 million people across world get Hepatitis A.  Many of us including me, had mild jaundice in childhood and in a week’s time cleared off.  The infection occuring once, provides immunity for the rest of our life.  Hepatitis A vaccination is available and if one member of family has Hepatitis A, then others can take vaccine. Good hygiene and sanitation are most effective measures for  prevention.

Hepatitis B, on the other hand is a much more sinister virus.  More than 240 million people have chronic (long-term) liver infections. About 600 000 people die every year due to the acute or chronic consequences of hepatitis B.

This is actually a preventable disease.  Now an effective vaccine is available and  has been made mandatory as part of immunization program for neonates.  But in earlier days it was not mandatory.  You may not be sure whether you had Hepatitis B immunization in your childhood and it is worthwhile particularly if you are active and are likely to sustain some injury etc., to go in for a booster dose of Hepatitis B.

The biggest risk is that Hepatitis B spreads by body fluids through skin and mucosal injuries just like the AIDS virus but it is nearly 50 times more resistant than AIDS virus.  In fact, the AIDS virus is a very fragile virus which can just die on drying up.  But Hepatitis B, on the other hand, can stay on in moist surfaces for a period of atleast a week.  That is a big risk. There are so many places that can lead to spread- hospitals, clinics, unsafe sex, sex workers etc.

Hepatitis B virus does not enter through intact skin or mucus but if there is injury, there is all the more reason that you need to have protection.  Also when you go in for a procedure, you have to insist on the healthcare worker on wearing gloves while handling your wound or doing any examination.  Blood, body fluids, contaminated needles, unnatural sex are high risk factors for Hepatitis B.

So the best way to prevent is  vaccination or booster dose appropriately.

Please vaccinate the newborn and if you don’t know your immunization status, take a booster.

Hepatitis B, once it enters, can linger on in the liver and can be detected by a blood test called HBsAg.  So in case an adult gets jaundice and it clears off, it is definitely both Hepatitis B and C infections are to be tested for.

Sequelae of Hepatitis B: What happens to Hepatitis B or C when they infect the liver ? They produce cell necrosis.   When the liver cells die, there is always scarring, just like a scar forms after a wound on the skin.   The repeated internal scarring produces  ‘fibrosis or cirrhosis’ of the liver.  The liver becomes firm and fibrotic.  This takes a long time of may be even 10 years and can be detected. Nowadays cirrhosis can be easily picked up by Scans including CT, Ultrasound or Fibro Scan and one can limit the progress of the cirrhosis.

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Liver Cancer The big risk of Hepatitis B & C viruses unfortunately is development of liver tumors.  Given enough time, at least a third of them develop liver cancer ,which are aggressive involving a large part of the liver.

Unlike kidneys, liver is a single large organ, a huge organ of the body to metabolize all the nutrients, drugs, etc.  So nearly 80% of the liver has to be damaged before there are any signs outside and that is a big reason why most liver diseases are silent and can only be detected much later when the damage is extensive.  So it is very very important for us to make sure that we undergo appropriate diagnostic measures to identify them in the early stage.

Hepatitis C also has a similar mode of transmission as Hepatitis B.  The most unfortunate thing however, is that Hepatitis C has no vaccine so far developed though there have been attempts on that.  But Hepatitis C has effective treatment.

Recently, a rich philanthropist who has been harboring Hepatitis C virus almost 30 years came to me with cirrhosis and liver cancer. Many told him that Hepatitis C has no treatment.  Fortunately it is not true.  Hepatitis C has effective treatment now  and should be treated.  This will prevent further progression into cirrhosis and liver  tumours and also chronic liver disease.

In brief, therefore, Hepatitis A is self-limiting, Hepatitis B is preventable and Hepatitis C is treatable.  So it is all good news for you – provided you take adequate care in your life.

WHO fact sheet on Hepatitis : http://www.who.int/mediacentre/factsheets/fs204/en/