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Can you have cirrhosis if your liver is normal sized and has smooth surface contour?
I have been a stealth reader here for many months & finally got my nerve up to ask this question. Sorry in advance for writing a novel. This stuff is so hard to understand and I have been trying to make sense of it for months.
My husband's doctor's "gut" thinks that he may be borderline cirrhosis. MD is hepatologist at major transplant hospital.
The doc keeps referring to a "borderline spleen" and platelets being low (though still in the normal range) and stiffness from the elastography.
The doc did not want to do a biopsy prior to triple treatment with Incivek as he feels the biopsies can be very inaccurate & feels the elastography is more reliable.
Last August 2011, he started triple tx (Incivek) und at 4, 8, & 12 week and he is trying to decide if there is any evidence to support the 48 week treatment?
Exposed to Hep C in 1981. Diagnosed 1992.
Genotype 1 subgroup not identified
Il28B CC
Previous tx:
1996 Intron-A 3xweek x 5 months non responder
1998 Interferon & ribavirin daily for 28 days non responder
2008 Pegasys & Copegus x 11 months und @ 12 wks & till end of tx but virus came back 6mth after tx completed. So the doctor is considering him a relasper.
Other:
2007 Jaundice - resolved on own. No reason identified
2007 Biopsy grade 1 stage 2
2011 CT - Spleen normal size. Esophageal varices identified (EGD done in response to this found no varicies). Mildly enlarged peripancratic & periportal lymphnodes.
2011 MRI Abd & Elastography - Borderline spleen. Liver normal sized and with smooth surface contour. Mild fatty infiltration. Calculated mean hepatic shear stiffness is elevated at 5.50 kPascals.
2011 Labs (Before triple tx)
Protime 14.6
INR 1.16
Platelets 195
Alk Phos131
ALT 76
AST 49
AFP 1.9
Many thanks if you have made it this far in my ramblings. I realize that not even my husband's doctor can definitely say whether he has cirrhosis. I do appreciate all the expertise based on everyone's own experiences and would like to get your input on if you think he could have cirrhosis and therefore should continued the extra months of treatment of pegasys & ribavirin following the completion of the incivek.
Mckinzie
My husband's doctor's "gut" thinks that he may be borderline cirrhosis. MD is hepatologist at major transplant hospital.
The doc keeps referring to a "borderline spleen" and platelets being low (though still in the normal range) and stiffness from the elastography.
The doc did not want to do a biopsy prior to triple treatment with Incivek as he feels the biopsies can be very inaccurate & feels the elastography is more reliable.
Last August 2011, he started triple tx (Incivek) und at 4, 8, & 12 week and he is trying to decide if there is any evidence to support the 48 week treatment?
Exposed to Hep C in 1981. Diagnosed 1992.
Genotype 1 subgroup not identified
Il28B CC
Previous tx:
1996 Intron-A 3xweek x 5 months non responder
1998 Interferon & ribavirin daily for 28 days non responder
2008 Pegasys & Copegus x 11 months und @ 12 wks & till end of tx but virus came back 6mth after tx completed. So the doctor is considering him a relasper.
Other:
2007 Jaundice - resolved on own. No reason identified
2007 Biopsy grade 1 stage 2
2011 CT - Spleen normal size. Esophageal varices identified (EGD done in response to this found no varicies). Mildly enlarged peripancratic & periportal lymphnodes.
2011 MRI Abd & Elastography - Borderline spleen. Liver normal sized and with smooth surface contour. Mild fatty infiltration. Calculated mean hepatic shear stiffness is elevated at 5.50 kPascals.
2011 Labs (Before triple tx)
Protime 14.6
INR 1.16
Platelets 195
Alk Phos131
ALT 76
AST 49
AFP 1.9
Many thanks if you have made it this far in my ramblings. I realize that not even my husband's doctor can definitely say whether he has cirrhosis. I do appreciate all the expertise based on everyone's own experiences and would like to get your input on if you think he could have cirrhosis and therefore should continued the extra months of treatment of pegasys & ribavirin following the completion of the incivek.
Mckinzie
Thanks everyone for taking the time to read & respond. I tried to respond individually then kept getting confused with the Best answer & report a person buttons. So I hope I have not reported anyone, and I like all the answers!
Eureka - Thanks for you response! Though he is not needing rescue meds, I think the anemia is harder on him this time around - he gets short of breath just to get up to go to the bathroom. Over the years his platelets have always been in the normal range unless he has been on interferon. It is nice to have the support & experience of spouses & I appreciate your knowledge too!
Hector - The doctor had said depending on the MRI & Elastography results, the tx would be 24 vs 48 weeks. The nurse called with the test results & said no definite cirrhosis so we assumed 24 weeks. When we saw the doctor 4 weeks after the start of treatment, the doctor said he thought my husband might have the beginning stages of cirrhosis & had still not made up his mind to recommend 24 to 48 weeks to him.
Jules - Thanks! We spent some time talking about the biospy & we will discuss it with the physician again.
Desrt - The dr who did the EGD said that his esophagus had large folds of skin but when he "blew the air into the esophagus" it was all clear & the folds went away. The doctor did say he could not find any definited varices. He has been tested a few times for the HAV & HBV and has the antibodies for HAV but remains neg for the HBV. They never could give us a reason for the jaundice episode in 2007 - the doctor had thought it might be a common bile duct stone but the ct scan was negative. negative for alcohol use and chemical exposure.
NYgirl - I agree & appreciate that!
Eureka - Thanks for you response! Though he is not needing rescue meds, I think the anemia is harder on him this time around - he gets short of breath just to get up to go to the bathroom. Over the years his platelets have always been in the normal range unless he has been on interferon. It is nice to have the support & experience of spouses & I appreciate your knowledge too!
Hector - The doctor had said depending on the MRI & Elastography results, the tx would be 24 vs 48 weeks. The nurse called with the test results & said no definite cirrhosis so we assumed 24 weeks. When we saw the doctor 4 weeks after the start of treatment, the doctor said he thought my husband might have the beginning stages of cirrhosis & had still not made up his mind to recommend 24 to 48 weeks to him.
Jules - Thanks! We spent some time talking about the biospy & we will discuss it with the physician again.
Desrt - The dr who did the EGD said that his esophagus had large folds of skin but when he "blew the air into the esophagus" it was all clear & the folds went away. The doctor did say he could not find any definited varices. He has been tested a few times for the HAV & HBV and has the antibodies for HAV but remains neg for the HBV. They never could give us a reason for the jaundice episode in 2007 - the doctor had thought it might be a common bile duct stone but the ct scan was negative. negative for alcohol use and chemical exposure.
NYgirl - I agree & appreciate that!
Thanks Hector!
You always seem to be able to take something complex, and break it down in to something that is more understandable.
What I meant by "borderline spleen" - the MRI results are referring to his spleen as borderline enlarged. He had a CT scan earlier in the year which said it was a normal size spleen.
Again thank you for taking the time to help me understand this better.
Best wishes,
Mckinzie
You always seem to be able to take something complex, and break it down in to something that is more understandable.
What I meant by "borderline spleen" - the MRI results are referring to his spleen as borderline enlarged. He had a CT scan earlier in the year which said it was a normal size spleen.
Again thank you for taking the time to help me understand this better.
Best wishes,
Mckinzie
McKinzie some of the smartest people on this forum just posted to you...you can take their words to the bank. These are not new folks who are guessing at an answer but instead the exact folks you would want to answer your questions as they have more knowledge in this area than most doctors.
Seriously.
Seriously.
Welcome. I don't have Hector and eureka's knowledge of liver architecture, elastography, and varices, but maybe you could clarify a couple things. You say, " Esophageal varices identified (EGD done in response to this found no varicies)." How were varices "identified" and what was the explanation for the conflicting dxs?
I'm assuming your husband's HAV/HBV antibody/antigen status have been tested at least a couple times in the last 20 years. You state, "2007 Jaundice- resolved on own. No reason identified" If there was nothing identified, what - if anything - was ruled out? Viral hep, alcohol, carbon tetrachloride exposure?
I agree with Hector - "is there is any evidence to support the 48 week treatment? "
Not from what you posted." - but your husband has done more IFN than most people on this board. Only he knows how well he tolerates tx, what - if any - sx he's been left with in the past, and how well the current tx fits in with what's going on currently in his life.
Good Luck to both of you with his decision.
I'm assuming your husband's HAV/HBV antibody/antigen status have been tested at least a couple times in the last 20 years. You state, "2007 Jaundice- resolved on own. No reason identified" If there was nothing identified, what - if anything - was ruled out? Viral hep, alcohol, carbon tetrachloride exposure?
I agree with Hector - "is there is any evidence to support the 48 week treatment? "
Not from what you posted." - but your husband has done more IFN than most people on this board. Only he knows how well he tolerates tx, what - if any - sx he's been left with in the past, and how well the current tx fits in with what's going on currently in his life.
Good Luck to both of you with his decision.
Hi Mckinzie...welcome to the forum! I have to agree with Eureka and Hector that you should insist on a liver biopsy. Yes they are invasive and can be dangerous but they are painless and will give you a definitive answer. For me going through the Hep C journey has been the "not knowing" or "what ifs". So to give yourself a peace of mind, whether it be good or bad, at least you will know if he is cirrhotic or not.
Come back to the forum often because there are a lot of pros on here who know more than most doctors. Everyone is here to help you so please don't feel intimidated.
Best of luck to you and your husband!
Jules
Come back to the forum often because there are a lot of pros on here who know more than most doctors. Everyone is here to help you so please don't feel intimidated.
Best of luck to you and your husband!
Jules
I agree with what eureka has to say. There is a short time period when a patient has stage 4 liver disease as diagnosed by biopsy (the gold standard for staging liver disease) that the other complications of cirrhosis have not manifested themselves. If your husband should fall into that narrow window it is "technically" possible. But then again if there is any question of the stage of liver disease a biopsy is always performed use contraindicated due to other health issues.
His doctor, a hepatologist, should have already decided how long he plans on treating your husband based on his diagnosis before even starting treatment. He said nothing about duration of treatment? I would think that anyone would want to know if they were making a 6 month or yearly commitment?
Hector
His doctor, a hepatologist, should have already decided how long he plans on treating your husband based on his diagnosis before even starting treatment. He said nothing about duration of treatment? I would think that anyone would want to know if they were making a 6 month or yearly commitment?
Hector
Novels, rambling, and even rants are welcome. Actually your post was very good, lots of information. Someone else would have to comment on using Elastography vs Biopsy but if the doctor can't tell if he has cirrhosis by that method and from my poor understanding a biopsy will tell to a high degree ..
How is he tolerating this round of tx? In a similar situation after having treated three times previously I'd have to have serious reasons not to continue for 48 weeks with or without cirrhosis. This, of course, is a personal decision with a slew of factors only you and your husband can weigh properly.
Others will come and comment on the numbers all I know is drop the 1 and 95 is the highest I've ever seen my platelets. It's a good number to start with.
All the very best. Here's to this being his last treatment!
How is he tolerating this round of tx? In a similar situation after having treated three times previously I'd have to have serious reasons not to continue for 48 weeks with or without cirrhosis. This, of course, is a personal decision with a slew of factors only you and your husband can weigh properly.
Others will come and comment on the numbers all I know is drop the 1 and 95 is the highest I've ever seen my platelets. It's a good number to start with.
All the very best. Here's to this being his last treatment!
"is there is any evidence to support the 48 week treatment? "
Not from what you posted.
"Can you have cirrhosis if your liver is normal sized and has smooth surface contour?"
No. The definition of cirrhosis is a change in the liver's architecture which includes nodular growth. Which is what cirrhosis can be seen on an ultrasound, CT scan or MRI. The liver hardens as it becomes more scarred and usually shrinks in size.
So to cut to the chase....Your husband does NOT have cirrhosis.
Why?
First, according to the MRI which is the highest imaging technology available "Liver normal sized and with smooth surface contour." This means no cirrhosis by definition.
Secondly, According to Elastography report if your husband has relatively little liver damage. Advanced liver fibrosis (severe fibrosis or cirrhosis, corresponding to Metavir scores F3 and F4, respectively) was defined for liver stiffness values at least 9.5 kPa, based on results from studies conducted in both HCV-monoinfected and HIV/HCV-coinfected patients.
F3 = >9.5
F4 (cirrhosis) > 12.3
Thirdly, your husband does not have portal hypertension which is one of the first complications of cirrhosis. Otherwise his spleen would be enlarged, he would have varices and his platelet count would be much lower.
What do you mean "Borderline spleen"? There is no such medical term.
" I realize that not even my husband's doctor can definitely say whether he has cirrhosis." Yes, he can. And it is all there in the data you posted.
Why speculate and worry about something there is no reason to worry about? We are not doctors here. To answer all your questions you just have to ask the expert, his doctor, he can interrupt all the data for you just like I have done.
If you don't understand something your job is to ask and their job is to explain it to you.
Good luck.
Hector
Not from what you posted.
"Can you have cirrhosis if your liver is normal sized and has smooth surface contour?"
No. The definition of cirrhosis is a change in the liver's architecture which includes nodular growth. Which is what cirrhosis can be seen on an ultrasound, CT scan or MRI. The liver hardens as it becomes more scarred and usually shrinks in size.
So to cut to the chase....Your husband does NOT have cirrhosis.
Why?
First, according to the MRI which is the highest imaging technology available "Liver normal sized and with smooth surface contour." This means no cirrhosis by definition.
Secondly, According to Elastography report if your husband has relatively little liver damage. Advanced liver fibrosis (severe fibrosis or cirrhosis, corresponding to Metavir scores F3 and F4, respectively) was defined for liver stiffness values at least 9.5 kPa, based on results from studies conducted in both HCV-monoinfected and HIV/HCV-coinfected patients.
F3 = >9.5
F4 (cirrhosis) > 12.3
Thirdly, your husband does not have portal hypertension which is one of the first complications of cirrhosis. Otherwise his spleen would be enlarged, he would have varices and his platelet count would be much lower.
What do you mean "Borderline spleen"? There is no such medical term.
" I realize that not even my husband's doctor can definitely say whether he has cirrhosis." Yes, he can. And it is all there in the data you posted.
Why speculate and worry about something there is no reason to worry about? We are not doctors here. To answer all your questions you just have to ask the expert, his doctor, he can interrupt all the data for you just like I have done.
If you don't understand something your job is to ask and their job is to explain it to you.
Good luck.
Hector
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Exactly what I did and how I felt when I happened on the forum... welcome. The elastography results do not indicate cirrhosis, nor for the most part do his other results, but the 'gold standard' for measuring liver fibrosis is still via liver biopsy, though even biopsies are not without error.
Since your husband's physician is a Transplant doctor, the expectation would be that he is sufficiently experienced to make good estimations based on his knowledge and your husband's history. Though there is no clear absolute signal showing that your husband has cirrhosis, I don't think the doctor's "gut" should be ignored either.
I agree with my friend Hector that the results you posted make it unlikely your husband has frank cirrhosis, but there are some points on which we have differing opinions. Cirrhosis CAN be present even if the liver is 'normal sized and has a smooth surface contour' -- unfortunately, imaging, be it MRI, ultrasound, or CT Scan, does not have a high specificity or sensitivity in detecting early cirrhosis. Because the liver's condition is not homogenous, surface contour can belie existing fibrosis within the interior liver parynchema. Though encouraging, normal imaging does not rule out cirrhosis.
God that your husband's platelets are in the normal range, but again that alone does not exclude cirrhosis. It would be important to track what kind of decline in platelets your husband has had over the years, and it is perhaps longer history review that is leading your husband's doctor to have concerns. Because decompensatory mechanisms differ greatly from person to person, absence of enlarged spleen does not exclude cirrhosis either.
I should emphasize that I am not of the opinion that your husband has cirrhosis, but it's important to remember that decompensating symptoms are a positive test for cirrhosis, but the absence of varices, abnormal liver contour, normal spleen size, etc. is not a negative test; in other words not having those symptoms does not rule out cirrhosis. I say this with certainty because my husband's biopsy revealed early cirrhosis although he had no other indicators of such.
In the end, I think whether or not your husband should extend treatment will be as much a 'evidence' based decision as it is an 'experience' based decision. If your husband has tolerated treatment without debilitating side effects, it may be a good safety measure; if treatment continuation would be a burden, perhaps insisting on a biopsy before pursuing his doctor's recommendation any further would be a helpful decision-maker. Good luck whatever the decision.
~eureka