Dr Schiano

[PaulaAnn]

64 yr F R/A('83) SS, rayn'ds,divert Hubby died AML ('09).
ABD US 9-2012:Liver norm size,mild heterogen echogencity,non spec may rep. heptocellular dis. Cyst infer R lobe liver w/couple sm areas internal septa.No solid mass/ductal dilation.Gallbladder w/o stones wall thickening/paracholecystic edema.Common duct norm caliber 5.8. Portions pancreas, which can b visualized, norm size echogencity w/o focal mass/ductal dilation.R kidney norm size echogencity w/o focal mass/hydronephrosis.No mass/calculus.Visualized portions L kidney unremarkable no mass/calculus/hydronephrosis.Spleen norm-portions abdominal aorta/inferior vena cava unremarkable No ascites.
IMPRESSION: Cyst R lobe liver.
Mildy hetergeneous appearance liver, nonspec may represent heptocellular disease. No focal hepatic mass.
EGD 2 weeks B4- gr 2 nonbleeding varices. US, Esoph varices/cirrhosis?.wont do anything unless they look like a bleed BP runs low 100-120. NEW gastro this mo!
ABNORMALS - 1/22/2013
WBC 4.1 L
Plts 102 L biologics, rheumy told me why my plats run 100-115 for yrs..
Bun/Creat 14 L
BUN NORM at 11
BILI 1.1 H
AST 39 H
ALT 43
NORMS:
INR 1.0
PT 10.7
Albumin 4.1
Glob 3.7
A/G ratio 1.1
Alk phos norm at 99, once went 164

1) Explain US/labs? cirrhosis...would show? early cirrhosis...not?
2) dr reading US see port hyper? not noted w/report
3) cyst R infer.lobe liver w/interseptation? Concerning/factor in liver, portal hyper?
4) ativan 1mg night to sleep,hurt liver? Or can I use Remeron 15 mg at nighttime instead/better sleep for me
5) Livatone Plus hurt liver? 4 x daily.
Havent drank for 8-9 yrs.
Any other comments?

[PaulaAnn]

Thanks....I am a cancer survivor..stage 1...1998 and had r/a since 1983 so I never figured I wasnt the healthiest person walking.  When I heard the word cancer..well, that was shocking.  I was 49 and that made me think of my mortality...also, the r/a has been a battle.  I do know there are so many others going thru ALOT more than I am.  I'm in a group called ChemoAngels who support cancer patients so I see it.

I just want to make sure that whatever I have, I can get the correct dx /treatment and that something different is not going on. I want to maximize my chances of living as long as I can.   I want to find the proper diagnosis and go from there..especially with a history of cancer and the r/a.  

Thank you so much for your help......Hope you are doing well.

I appreciate your replies to me.  

P

[jonkob]

Yes if its early cirrhosis I wouldn't worry either. The reality is, you are 64 years old. Even with early cirrhosis , provided you take care of yourself, you will probably die of something else first. In other words, you should live a normal life span. The life expectancy of an American woman is 80 years. No reason you cant live another 15 years, even with cirrhosis. Sorry to be blunt, but we all like to think we will live forever, but we wont.
If you were 40 with early cirrhosis then it may be a different story. This is why the doctors aren't so concerned.

[PaulaAnn]

Thank you....trying to watch the Super Bowl but Ravens are running away with it.  Wish it was a closer game.  OOPS...lights out! Now..back to my liver:

I have had rheum arth for almost 30 yrs and I do know lots of my veins are torturous..matches my hands/feet.  Not sure if that has anything to do with this.  Just threw it out.

I have had baseline platelets at 110-120 for a few years now.  I think they went down to 85 when I was laying around in the hospital once. My rheumy has told me its from the biologics I have taken..first Humira for a short time, then Enbrel and now Orencia.  This has been ongoing for about 3 yrs.  Said..we have plenty of platelts...if they go to 100, he wll send me to a specialist.

My pcp doesn't seem too concerned, the colorectal surgeon looked at my labs and US and wasnt either.  My rheumy said if its cirrhosis, it is early...we will just watch the labs I get done every 4 months or so.  My gastro..who I have kicked off my team...didnt even call me back after receiving the US results.  I went to Medical Records to get the report myself.  I decided to go with a NEW gastro who I fought for and will see this week.  I need someone who cares about the patient.  The old gastro is in a large clinic, takes 3 weeks to get egd results back and never calls you...but sends a recorded message that its time for your scope..press 1 for an appt, 2 to cancel.  So.....I was not pleased.  He also missed a polyp that my colorectal surgeon caught a day later. No confidence in him.. Their office is part of a clinic of gastro/heps.

I knew the whoosing sound was the flow thru the vein.  So I knew the dr that read my report heard it.  

I always get my records but sometimes get scared to see them.  Knowledge is power though.  But I wouildnt mind being blissfully ignorant at times.

We'll see what the new gastro says...bringing all my records though I know he has them..sometimes they get lost.  

My labs haven't been too bad ...some abnormals slightly....so I'm hoping things willl stabilize.  

Thank you for your help..  I am starting on the Livatone Plus since Dr Schiano had no problem with that.

How are you doing?  Thank you for helping me with some of my questions....I have lots of them.  

P

[jonkob]

Heptocellular disease is a broad term that can include anything from fatty liver to cirrhosis. Ultrasounds are very "user dependent". One center can show a heterogenous liver and another show normal, in the same day. The tell tale signs are often visible on the US when its advanced (regenerative nodules, nodular liver, shrunken liver, enlarged spleen etc). But in early stages probably not.

Your varices MAY or MAY NOT be related to the liver. I would think, and I could be wring, but usually with the PH that would cause the varices the spleen would be enlarged. Although you do have low platelets.

Probably a biopsy is the best route, if you really need a conclusive answer.

Th wooshing sound is the blood flow through the portal vein, you are supposed to hear that.

My US was completely normal except for the "mild hetereogenicity. My doctor said he wouldn't even had mentioned it to me if I hadn't insisted on reading the report. Its meaningless on its own.

What does your doctor think?

[PaulaAnn]

1) Would the US show cirrhosis if it was a higher stage? and would it be marked as such or other wording? would the dr reading the report state that it leans towards cirrhosis instead of writing "may represent heptocellular disease"?  

2)Would the portal hypertension show on the US?  The dr who read the US didnt mention PH and the reason for the US was  DX: ESOPH VARICES r/o cirrhosis.   I did hear the whooshing sound during the US.  

3)Is mildly hetergeneous appearance suggestive of cirrhosis?  

4)he remeron 15mg would be out then for nighttime?  

5) Could it be PBC or PSC?

Thank you for your help.  I'm alone and want to get as much knowledge as I can before my appts.

[PaulaAnn]

Is echotexture the same as echogencity?  Are they interchangeable?  My report said may represent heptocellular disease...didnt mention anything about poss patches of fat.  I wish it would have.  I have gr 2 non bldg varices according to my old gastro..new one this week.  I want him to redo the egd and look.

Was the rest of your report good?  

Thank you for your post....  

[jonkob]

I also have a "mildly hetergeneous" echotexture. I had a moderate to severe fatty liver that I corrected with diet. The ultrasound read: "mildly hetergeneous echotexture possibly representing mild patches of fat"
I asked a radiologist recently as a hospital and she told me that a heterogenous echotexture is a very common finding. Its not as concerning as a coarsened echotexture. Just my two cents until the good doctor answers.

[PaulaAnn]

1) Would the US show cirrhosis if it was a higher stage and would the report state that it leans towards cirrhosis instead of heptocellular disease?  

2) Would the portal hypertension show on the US..the dr who read it, didnt mention and the reason for the US was  DX: ESOPH VARICES r/o cirrhosis.   I did hear the whooshing sound during the US.  

3) Is mildly hetergeneous appearance usually cirrhosis?  

4) The remeron 15mg would be out?  

5) Could it be PBC or PSC?

Thank you for your help.  I'm alone and its so difficult.  

[Thomas D Schiano, MD]

ativan and livatone are OK to take.  I do not think the cyst is of consequence.  You could have early cirrhosis or even non-cirrhotic portal hypertension.  You may need a liver biopsy to definitely differentiate.