Adult I Lower GI Problems and Hepatic Cancer Notes

Adult I Lower GI Problems and Hepatic Cancer Notes  Diarrhea is characterized by 3 or more loose or liquid stools per day o Can be acute or chronic o Causes:  Ingesting infectious organisms  usually the primary c ...

Adult I Lower GI Problems and Hepatic Cancer Notes  Diarrhea is characterized by 3 or more loose or liquid stools per day o Can be acute or chronic o Causes:  Ingesting infectious organisms  usually the primary cause, can be viral, bacterial, or parasitic  Drugs  Food intolerance  Osmotic diarrhea (laxatives cause this – GI rapid transit, fluid does not have time to be absorbed)  Celiac disease  Short bowel syndrome o Clinical manifestations  Large-volume, watery stools  Cramping  Low-grade fever or no fever  N/V before diarrhea begins  Infection with some organisms cause ever, frequent bloody stools, smaller volume  Leukocytes, blood, and mucus may be present in the stool depending on the causative agent  Severe diarrhea produces life threatening dehydration, electrolyte disturbances, and acid-base imbalance  If someone is severely dehydrated, they will present with a low blood pressure and could faint  If they have electrolyte disturbances, we are worrying about heart issues o Diagnostics  History  can’t treat best if we don’t know what is causing it  Stool examination and culture  Culture – only if patient is very ill, has a high fever, or has been having diarrhea for longer than 3 days  We can see blood, mucus, WBCs and parasites  Laboratory studies  CBC, BUN, creatinine, electrolytes o Interprofessional care  Depends on cause  Acute infectious diarrhea is usually self-limiting  Major concerns:  Prevent transmission if it is caused by C. diff  F&E replacement o If the depletion is mild, we can give oral solutions o If the depletion is severe, we give parenteral fluids  Protecting the skin Antidiarrheal agents used carefully o Sometimes can be contraindicated because some infectious diarrheas need for the organism to be expelled o Contact precautions: C. diff  To prevent the spread of infection, anyone entering that room must wear gloves and gown  Applies whether or not contact with the patient or the patient’s environment is anticipated (Wear even if just going in room)  Most important to wash hands and wear gloves o Those at risk for C. diff:  Patients on antibiotics, chemotherapy, immunosuppressed, ICU patients, prolonged hospital stay, surgery, and drugs that suppress gastric acid  Spores can survive up to 70 days on objects  Can be transmitted from patient to patient by health care workers  In order to prevent, this they should frequently wash their hands and frequently change gloves  Treatment for C. diff includes:  Metronidazole (mild to moderate) or vancomycin (severe) o All non-essential antibiotics, stool softeners, laxatives, and antidiarrheal agents should be stopped o We want to stop everything that is nonessential in order to treat the C. diff infection  Fecal microbiota transplantation is emerging as the most effective treatment for recurrence of the condition  Constipation = Syndrome defined by difficult or infrequent stools; hard, dry stools that are difficult to pass; or a feeling of incomplete evacuation o Compared to what is “normal” to an individual  knowing a patient's normal is very important o Etiology (causes)  The diet is usually decreased fiber and decreased fluid with decreased physical activity, But increasing fiber and fluids can sometimes help constipation  The patient ignores the defecation urge  Can be common in diseases like diabetes, Parkinson's disease, and multiple sclerosis  Emotions can cause constipation like anxiety, depression, and stress  Medications can also cause constipation especially opioids  Patients on routine opioids are almost always on a stool softener as well  This can lead to something called cathartic colon syndrome = the colon is not able to squeeze out poop o This is from chronic use of laxatives - the colon becomes dilated and atonic o Clinical manifestations  Absent, or hard/dry stool difficult to pass  bloating  abdominal distention  increased flatulence  rectal pressure  abdominal pain o Complications  hemorrhoids (venous engorgement from straining)  vagal response  common in older patients  Colon perforation  rectal mucosa ulcers  Fissures  oblong tear in skin  Diverticulosis o Diagnostics  History  we can't treat it best if we don't know what's causing it  radiology  abdominal x-ray, barium enema  colonoscopy/sigmoidoscopy  Anorectal manometry which measures pressure of the anal sphincter muscles, the sensation in the rectum, and the neural reflexes that are needed for normal bowel movements o Treatment  Increase dietary fiber (fruits, vegetables, grains), fluids, exercise (preventative)  Daily bulk-forming laxatives can prevent constipation  Other laxatives and enemas  Use with caution, don't overuse  Surgery if constipation is unrelenting and severe  We have to get a lot of information from the patients so that we can give them the best treatment o Patient and caregiver teaching  Eat dietary fiber  drink fluids  exercise regularly  establish a regular time to defecate which can be helpful  do not delay defecation  record your bowel elimination pattern - this can be helpful for health care providers because it can determine what is causing the constipation  avoid laxatives and enemas  Irritable Bowel Syndrome (IBS) o This is characterized by a chronic abdominal pain or discomfort an alteration of bowel pattern o This condition has a mood or mental health aspect unlike IBD which has much less of that (related to stress and anxiety)o diarrhea or constipation may pre-dominate or they may alternate o there is no known organic cause o symptoms may occur for years - there could be a history of GI infections and food intolerances o psychological stressors could be the reason as well, like depression, anxiety, sexual abuse, and PTSD  we cannot care for someone with this condition and ignore the mental health aspect o Criteria for diagnosis  Symptom based criteria for IBS have been standardized  Rome III criteria for diagnosis  Presence of abdominal pain or discomfort at least three months that is associated with two or more of the following:  1. improvement with defecation  2. change in stool frequency at onset  3. change in the stool appearance at onset  Categorized as:  IBS with diarrhea  IBS with Constipation  IBS mixed  IBS unsubtyped o GI symptoms  We will normally see these symptoms in IBS  abdominal distention  nausea  flatulence  bloating  urgency  mucus in the stool  sensation of incomplete evacuation o There can also be non-GI symptoms including fatigue, headache, and sleep disturbances o The way to diagnose IBS is to rule out other disorders  since there is no known cause, we test in order to rule out other diagnoses  there is no single therapy effective for all patients with IBS  we are dealing with psychological factors, dietary changes, drugs to regulate stool output, and reduce discomfort  regular exercise prevents bloating and constipation o Research shows that some carbs can cause irritation to the bowels and contribute to these symptoms  The carbs are called: fermentable, oligo-, di-, mono- saccharides and polyols  known as FODMAPs  These can improve the signs and symptoms of several GI disorders o Treatment mainly consists of diet moderation  the diet needs to increase fiber gradually with greater than 20 grams per day  the diet needs to eliminate gas producing foods the diet needs to eliminate milk if the person is lactose intolerant  the diet needs to eliminate fructose and sorbitol  probiotics are also helpful in some people o Medications  antispasmodics and antidiarrheals o No single therapy has been found to be effective for all patients with IBS o They do need to address psychological factors - this cannot be ignored in their holistic treatment of the condition  Inflammatory Bowel Disease (IBD) o Includes Crohn’s disease and ulcerative colitis o Identified as chronic inflammation of the GI tract with periods of remission and exacerbating which are unpredictable o The exact cause is unknown and there is no cure, so the symptoms are for life o It is an autoimmune disease o It can be classified as either Crohn's disease, which is the inflammation of any segment of the GI tract from the mouth to the anus, or it can be ulcerative colitis, which is the inflammation and ulceration of the colon and rectum o Pattern of inflammation:  Crohn's disease skips around  Ulcerative colitis is continuous o Crohn's disease is the inflammation from the mouth to the anus, it affects all layers of the bowel wall, it skips lesions, and common symptoms include diarrhea and crampy abdominal pain o Ulcerative colitis is the inflammation from the rectum to the colon; it affects the mucosal layer of the bowel wall, it is continuous, and common symptoms include bloody diarrhea, abdominal pain, and it ranges from mild, moderate, and severe o The signs and symptoms of Crohn's disease and ulcerative colitis are typically the same o Symptoms can get worse - up to 10 stools per day, bleeding, and systemic symptoms which includes fever and malaise  It could even be more stools per day because that's how the condition is o Complications  Local complications include:  Hemorrhage  Strictures  Perforation with possible peritonitis - this can lead to sepsis  Fistulas – depends on what the fistula is connecting what the s/s will be  CDI = Clostridium difficile infection  Abscess  Colonic dilation - toxic megacolon, colon turns purple and gets large  Nutrition problems  A high risk for colorectal cancer which means that regular screening is very important There can also be systemic complications which include the joints, eyes, mouth, kidneys, bones, vascular system, and skin problems  Circulating cytokines can trigger inflammations  Can also be associated with liver failure o Diagnostic studies  History and physical examination are important  Blood studies: CBC, electrolyte levels, protein levels  Stool cultures: pus, blood, mucus  Imaging studies: double-contrast barium enema, small bowel series, abdominal ultrasound, CT scan, MRI, and colonoscopy o Goals of treatment for IBD  Rest the bowel by making the patient NPO  we give them IV fluids, because we would probably have to do that anyway if they're in the hospital and have fluid and electrolyte imbalances  Control inflammation  Combat infection  Correct malnutrition  Alleviate stress  Provide symptomatic relief  Improve quality of life o Nutrition goals  Provide adequate nutrition without exacerbating symptoms  High-calorie, high-vitamin, high protein, low-residue (low in fiber) diet,  Correct and prevent malnutrition  Consider TPN if the patient is on complete bowel rest  Replace F&E losses  At risk for low sodium and potassium levels due to diarrhea  Physical and emotional rest  Referral for counseling or support group  Surgical therapy o Nutritional therapy  Foods that trigger exacerbations may vary  Food diary helps identify problems for individuals  Avoid:  Lactose intolerance  High-fat foods  Cold foods  High-fiber foods  Smoking should be avoided o Medications  Amincosalicylates = decreases inflammation  Antimicrobials  Corticosteroids = decreases inflammation  Immunosuppressants = suppresses the immune response  Goals of drug treatment are to induce and maintain remission If there is no response to traditional therapy, like targeting the offending section of the bowels, then surgery is the answer o Interprofessional care  Indications for surgical therapy for IBD  Failure to respond to traditional therapy  Massive bleeding  Drainage of abdominal abscess  Perforation  Obstruction  Fistulas  Inability to decrease steroids - surgery can prevent effects of chronic steroid use  Severe anorectal disease  Tissues changes indicating dysplasia or carcinoma o Chronic ulcerative colitis surgical therapy  Since ulcerative colitis only effects the colon, a total proctocolectomy is curative  Procedures for chronic ulcerative colitis:  Total proctocolectomy with ileal pouch/anal anastomosis  Total proctocolectomy with permanent ileostomy  These are surgical procedures that can be performed laparoscopically  A total proctocolectomy means that the patient is cured  we take out the colon and the rectum  IPAA (ileal pouch/anal anastomosis)  Combination of 2 procedures o Performed 8 to 12 weeks apart o First procedure the colon is removed, and the pouch is constructed, which is a temporary ileostomy to allow all suture lines to heal before pressure and stool go through o In the second procedure, the ileostomy is closed, and stool is diverted back through the newly formed pouch o Initially: 4-6 stools per day, which will decrease over 3-6 months  Patient is able to resume control of defecation at the anal sphincter  Major complication: acute or chronic pouchitis  A total proctocolectomy with ileal pouch and anal anastomosis is the most commonly used surgical procedure for ulcerative colitis o A diverting ileostomy is performed which is temporary in an ileal pouch is created an anastomosed directly to the anus o We divert the small intestine to the abdominal wall, then outside the patients so the poop can go there; a colostomy is not used here - only an ileostomyo The entire colon is removed for ulcerative colitis o This is a better procedure because the patient is able to resume control of defecation at the anal sphincter  There are different kinds of pouches, like the S pouch, the J pouch, and the W pouch o It doesn't matter what kind of pouch we use but the intestines are sewn back together to make a new rectum temporarily  Total proctocolectomy with permanent ileostomy  This is a one-stage operation  It includes the removal of the colon and the rectum, and closes anus  The end of the terminal ileum is brought out through the abdominal wall to form an ostomy or a stoma  Continence is not possible here with this procedure o Crohn’s disease surgical therapy  Conservative surgery is advocated  Most patients with Crohn's disease usually require surgery  Avoided as longs as possible  Most common surgery is a resection of diseased segments with reanastomosis of the remaining intestine  Disease often recurs at anastomosis site  Short bowel syndrome comes from the repeated removal of sections of the small intestine and includes lifetime IV fluid boluses and parenteral nutrition  Strictureplasty is also a common procedure  This includes widening of strictures obstructing the bowel  keeps the bowel intact, so reduces the risk of short bowel syndrome o Interprofessional care  surgical therapy  Postoperative care: general post op care, in addition to:  If an ileostomy is formed: monitoring of stoma viability and skin integrity around the stoma o Should have a clear pouch right after surgery o Output may be as high as 1500 to 1800 milliliters per 24 hours - this decreases over days to weeks with more fluid being absorbed, then ostomy output will thicken to a paste-like consistency with less volume o Measurement of output is important to monitor for issues related to excessive output o Observe for fluid and electrolyte imbalance, hemorrhage, abdominal abscess, small bowel obstruction, and dehydration  Remove the NG tube once bowel function has returned  Postoperative care with an ileoanal anastomosis  Transient incontinence of mucus from manipulation of anal canal Kegel exercises  Perianal skin care o Nutrition therapy  Balanced, healthy diet with goals of:  1. Adequate nutrition without exacerbating symptoms  2. Correct and prevent malnutrition  3. Replace fluid and electrolyte losses  4. Prevent weight loss  Problems result from decreased oral intake, blood loss, and possible malabsorption of nutrients o Nursing management  Planning: overall goals  Decreased number and severity of acute exacerbations  Normal fluid and electrolyte balance  Freedom from pain or discomfort  Compliance with medical regimen  Nutritional balance  Improved quality of life  Nursing interventions should be directed at achieving those goals  We need to ask, “what can I do as a nurse to help the patient be free from pain or discomfort?”  It depends on the patient  Surgical patients will need pain meds, bowel distention patients with gas will need interventions to relieve the gas  During acute phases, we need to implement strategies that would focus on resting the bowel, hemodynamic stability, and pain control  This means administering analgesics and anti-inflammatory medications  With fluid and electrolyte imbalances, we need to:  Measure accurate I&O  Monitor electrolytes and vital signs  Monitor stool output for amount, blood (monitor CBC)  Monitor emesis for blood  Administer IV fluids and electrolytes  Watch for orthostatic hypotension  Skin care needs to be completed with meticulous perianal skin care using plain water and skin barrier cream  Nutritional support needs to include a daily weight  If losing weight not absorbing nutrients o Patient teaching  Importance of rest and diet management  Perianal care  Drug action and side effects  Symptoms of recurrence of disease  When to seek medical care Ways to reduce stress  there is a relationship between emotions and the GI tract  Smoking cessation: associated with more severe diseases in Crohn's o Nursing management: evaluation  Expected outcomes:  Decrease number of diarrhea stools  Body weight maintained within normal range  Freedom from pain and discomfort  Use of effective coping strategies  We need to think, “how am I going to get my patient there?” o Gerontologic considerations  In older patients, distal colon (proctitis) and left-sided ulcerative colitis is usually involved in ulcerative colitis patients  Diagnosis can be difficult  It can be confused with C. diff infection or confused with colitis associated with diverticulitis or NSAID ingestion  Usually, older people know they have IBD and they have to convince everyone else to believe them  They have periods of remissions and exacerbations like everyone else  The older the adult, the greater risk of adverse effects, hospitalization, or mortality  Complications can result from corticosteroids, immunosuppressants therapy, and biologic therapy  They are more vulnerable to volume depletion from diarrhea  It’s more difficult to deal with fecal urgency if it's physically limited  They are more vulnerable to inflammation of the colon from drug use in systemic vascular disease like NSAIDs and others  Diverticulosis and diverticulitis o Most common in sigmoid colon o Diverticula  saccular dilations or outpouchings of the mucosa in the colon  These are common, most people do not develop diverticulitis o Diverticulosis  the presence of multiple noninflamed diverticula o Diverticulitis  inflammation of the diverticula o Diverticulosis manifestations  Usually asymptomatic, but can include:  Abdominal pain  Bloating  Flatulence  Changes in bowel habits  Can bleed more if serious or diverticulitis develops o Diverticulitis manifestations  Acute pain in LLQ (most common symptom)  N/V  Palpable mass in abdomen  Fever  systemic symptom o Diagnostic studies Usually found on routine colonoscopy  CT scan o Complications of diverticulitis  Perforation  Abscess  Peritonitis  Bleeding o Rupture needs surgery to have it taken care of o Prevention of both conditions  Increase fiber, fluid intake, and physical activity  Decrease fat intake and red meat  Weight reduction if needed  Avoid increased intraabdominal pressure (don’t lift, don’t strain, don’t bend, don’t cough)  There is no current evidence supporting that diverticulitis can be prevented by avoiding nuts and seeds o Treatment of both conditions  Increase fluid to 2500 to 3000 mL a day  Take bran and bulk forming laxatives  If you already have it, low fiber diet  Usually outpatient  bowel rest to let inflammation subside, antibiotics, and clear liquids  Inpatient is only if the person has severe s/s, unable to tolerate fluids, comorbid disease, and systemic manifestations of infection like significant fever and leukocytosis  If the patient is hospitalized, they need to be NPO, have IV fluids and antibiotics  Observe for signs of abscess, bleeding, and peritonitis  Monitor WBC  Analgesics if needed  Once acute attack is over, progress diet as tolerated, ambulate  Surgery only for complications not manageable otherwise o Typically, resection of involved colon and reanastomosis, possibly temporary colostomy  Colorectal cancer o Many colon cancers begin in polyps which are abnormal growths that can look flat or like tiny mushroom stalks o Risks  Personal history of IBD, colorectal cancer, or diabetes  Personal or family history of familial adenomatous polyposis or nonpolyposis colorectal cancer  Obesity  More than 7 servings of red meat each week  Cigarette smoking  More than 4 drinks of alcohol per week o Pain is a common signo S/S can be ever so slightly different depending on where it is in the colon o Manifestations  S/s do not appear until the disease is advanced  important to screen  Iron-deficiency anemia, rectal bleeding, intestinal obstruction, or perforation  Early: fatigue, weight loss, or none at all  More advanced: abdominal tenderness, palpable mass, hepatomegaly, ascites, bleeding o Complications  obstruction, bleeding, perforation, peritonitis, and fistula o Diagnostics  Persons of average risk  Thorough history including family  Regular screening for polyps and cancer starting at age 50  do 1 of these: o Flexible sigmoidoscopy every 5 years, but it only detects about 50% of cancers o Colonoscopy every 10 years (gold standard) o Double-contrast barium enema every 5 years o CT colonography every 5 years  Other tests o Fecal occult blood test every year  can provide false positives o Fecal immunochemical test every year  Persons at risk begin screening earlier and more often  Stool testing for fecal blood is less favorable but acceptable  new tests can detect DNA mutations that may indicate presence of CRC  Once diagnosis is mad from biopsy, CBC is done to check for anemia, liver function checked (mets, but can be normal even if mets are present), CT or MRI of abdomen (mets and extensiveness of tumor)  CEA (carcinoembryonic antigen): blood test, not good for diagnosing but can be used to monitor treatment (chemo) or recurrence (if surgically removed) – can be increased for a lot of other reasons (other cancers, IBD, COPD, and others) o Staging helps determine how the treatment is going to go  Stages are 0-4 o Treatment  Surgical goals  Complete resection of tumor (best case)  Thorough exam of abdomen  Removal of all lymph nodes that drain area of cancer  Restoration of bowel continuity and function  Prevention of surgical complications  Colonoscopy is usually able to remove all polyps if there are some  Polypectomy: some can be removed during colonoscopy  if margins free of cancer cells this may be all that is needed Colon resection, based on stage determines how much is taken and if anastomosis occurs (or not, but usually temporary if needed - due to perforation, peritonitis, hemodynamically unstable)  Stage IV: surgery usually palliative, chemo/radiation used control the spread and help with pain  Chemotherapy  Shrink tumor before surgery, high risk - stage 2, 3, and 4  Radiation  Shrink tumor, with chemo, palliative  Rectal cancer: 3 surgical options  Local excision this is usually not an option because the cancer is more extensive at the time it is found, so locally it will not work as well  Abdominal-perineal resection with colostomy o Removal of the tumor and rectum when the tumor is distal o Colostomy is permanent  Lower anterior resection which this is used most frequently o preserves sphincter function when the tumor is more proximal o May have temporary colostomy o Have more proximal patient has more independence because of temporary colostomy  The decision is based on location and staging of cancer o Acute care  Likely, preoperative bowel cleansing prior to elective bowel surgeries  There is no evidence to support different outcomes when the bowel is clean and when it is not  Routine post-op care  May have surgical drains  May have temporary or permanent colostomy  this requires a lot of education around this for the patient and the family  If a colostomy is present it will probably be there for 6 to 12 weeks  Wound care  Ostomy ABCs o An ostomy is defined as a surgical procedure that allows intestinal contents to pass from the bowel through an opening in the skin on the abdomen o A stoma is defined as an opening created when intestine is brought through the abdominal wall and sutured to the skin o An anastomosis is the re connection of two ends of the bowel  Ostomy surgery – types o The surgeries are named according to their location and type o The more distal the ostomy, the content will resemble “normal” feces, and control might be possible with irrigationo Ileostomy: liquid or thin paste since the colon is bypassed completely, the patient has no control o Ascending is liquid feces o Transverse is semi-solid feces o Descending is firmer feces o The more distal the ostomy, the more likely the patient may have control over it o End stoma  The proximal end is brought out as a single stoma, making the colostomy or ileostomy  The distal portion surgically is removed or sewn and left and abdominal cavity  this is called Hartmann’s pouch  There is a potential for re-anastomosis with Hartmann’s pouch  Hartmann’s pouch preserves the ability to sew them back together, as opposed to removing it completely o Loop stoma  Intact posterior wall that separates the two openings  Usually temporary  Plastic rod holds loop in places for 2-7 days  Pouched with 1 appliance o Double barrel stoma  Bowel is divided, both ends are brought out  2 separate stomas: if they close together, they can be pouched together  If not, they are in separate pouches  Usually temporary o Pre-op care  Emotional support - radical change in body image, loss of control over illumination, fear of odors  Patient and caregiver teaching about ostomy care  Selection of site - within rectus muscle, flat surface, visible to the patient o Post-op care  We need to assess the stoma every 4 hours  We look for the color to be rosy pink to red  Make sure it is not dusky blue (cyanotic) or brown-black (necrotic)  We also need to look for edema  There will be mild to moderate edema, but it will resolve over about 6 weeks  We also need to assess for bleeding to make sure that there is no excessive bleeding  When peristalsis returns, colostomy starts functioning  Record volume, color, and consistency of drainage  Excessive gas is common during first 2 weeks  Should have BM within 72 hours  The pouching system protects skin, contains odors, and collects drainage We should empty the bag when it is 1/3 full  The pouch should be transparent in the initial postoperative period  Nurses need to see the stoma and assess the output  the patient can move to something else that is not so clear, but at first, we need it to be clear so we can see it  o Colostomy care  Diet  well balanced  Adequate fluid intake  No dietary restrictions, but the patients need to avoid or limit intake of gas or odor producing foods  Irrigations  These may be used to stimulate emptying of the colon  Regularity is possible when the stoma is in the distal colon or rectum  Bowel can be trained with little to no spillage between irrigations o Ileostomy care  Pouch is worn at all times  Drain frequently  Drainage is extremely irritating to the skin, so the nurses need to clean the skin if there is leakage  The skin barrier should protect all exposed skin from drainage  Use open ended, drainable pouch  Change the pouch every 4-7 days Observe for fluid and electrolyte imbalances  patient needs to know the signs and symptoms of these as well, especially ones associated with potassium and sodium  Output needs to be at 24 to 48 hours post-op  this may be negligible  There will be a high volume of liquids expelled when peristalsis returns  around 1000 to 1800 milliliters per day  As the small bowel adapts, it will be come around 500 milliliters per day  Poop will be dark green then progress to yellow  Diet  Fluids need to be consumed at 2 to 3 liters per day, especially when excessive fluid is lost due to heat and sweating  There is a high risk for obstruction of stoma because the lumen is small o In order to combat that, the patient needs to eat a low fiber diet and increase it gradually  The goal is to create a normal, presurgical diet  If terminal ileum is removed, cobalamin replacement may be needed because this is where cobalamin is absorbed o Postop adaptation  Adaptation is a slow process  This includes grief and body image disturbance  Support is needed  Sexual function concerns both men and women  Surgery has potential to impact nerves important in sexual expression  Make sure patient empties the pouch before sex  Hepatic cancer o This is the most common cause of death in patients with cirrhosis o Metastatic hepatic cancer is more common than primary due to the blood flow to the liver because cancer cells from other parts of the body are carried to the liver o Clinical manifestations  The signs and symptoms are very similar to cirrhosis  Hepatic cancer will present with splenomegaly, hepatomegaly, fatigue, peripheral edema, and ascites  Late stages include fever and chills, jaundice, anorexia, weight loss, palpable mass, and RUQ pain o Diagnostics  Radiology: ultrasound, CT, MRI (MRI can diagnose without need for biopsy because hepatic cancer does not look like cirrhosis)  Percutaneous biopsy is occasionally performed if other tests are inconclusive or tissue needed to guide treatment  There is a risk with this because the liver is very vascular, can cause bleeding and the tumor could be spread, so we avoid the biopsy if possible Serum alpha-fetoprotein levels are elevated in 60% of patients with hepatic cancer  If the patient is diagnosed with hepatocellular carcinoma or another form of AFP producing cancer, an AFP test may be ordered periodically to help monitor the person's response to therapy and to monitor for cancer recurrence o Interprofessional care  Prevention focuses on treating chronic hepatitis and chronic alcohol abuse  Screening includes: Alpha-fetoprotein and CT or MRI or ultrasound  Treatment depends on:  Size, number, location of tumors  Blood vessel involvement  Age and overall health  Extent of other liver disease  Surgical resection: best chance for a cure, only 15% of patients have enough healthy liver for this surgery  Transplant: good prognosis  To be a good transplant option, they need to be relatively healthy otherwise which is why they will have a good prognosis with the transplant  Percutaneous ablation is an injection of ethanol or acetic acid  the temperature of the probe can be altered to be cold or hot, but this is usually for early stage liver cancer  Overall prognosis of hepatic cancer is poor  We focus on keeping the patient comfortable