Jaundice in combination with hepatocellular carcinoma can be caused by hepatocellular carcinoma itself or often combined with cirrhosis, or by means of anti-tumor therapy, often appearing in the middle and late stages of hepatocellular carcinoma, and is one of the main causes of death in hepatocellular carcinoma patients.
I. Mechanism of occurrence
Jaundice is one of the common complications of middle and late stage hepatocellular carcinoma patients, with a complication rate of about 29.6 to 37.5%. According to the etiology of jaundice, it can be divided into hemolytic jaundice (prehepatic jaundice), hepatocellular jaundice (hepatogenic jaundice) and obstructive jaundice (post-hepatic jaundice), and the jaundice complicated by hepatocellular carcinoma belongs to the latter two types, with obstructive jaundice being the most common, with the following mechanisms.
1, Intrahepatic and hilar tumor nodules or enlarged hilar lymph nodes compress bile ducts at all levels, resulting in poor bile drainage, combined bilirubin and non-conjugated bilirubin reflux into human blood, and increased bilirubin concentration in blood, mainly combined bilirubin, causing obstructive jaundice.
2, intrahepatic tumor invasion of the bile ducts, resulting in incomplete or complete obstruction of the bile ducts, and can be partially necrosis off, descending to the extrahepatic bile ducts, suddenly blocking the bile ducts, causing obstructive jaundice, according to reports, the incidence of this mechanism is about 1.5%-8%.
3.Cancer embolism formation in the bile duct, including necrotic tumor shedding, growing in the bile duct, primary tumor in the liver breaking into the bile duct, or tumor bleeding, blood clots containing cancer cells forming emboli, obstructing the bile duct, etc., can lead to complications of obstructive jaundice.
4.Diffuse hepatocellular carcinoma or combined with severe cirrhosis, due to extensive hepatocellular damage, the production of bilirubin in the liver. The metabolism and excretion are impaired, resulting in elevated levels of both conjugated and unconjugated bilirubin in the blood, causing hepatocellular jaundice, and also obstructive jaundice due to the compression of the biliary system by intrahepatic tumors, resulting in mixed jaundice.
5. Some anti-hepatocellular carcinoma treatments may also cause jaundice, such as hepatic artery chemoembolization, percutaneous anhydrous ethanol injection. External radiation therapy, etc. Qian Jianmin et al. reported that 102 cases of mid- to late-stage primary hepatocellular carcinoma treated with hepatic artery embolization were complicated by jaundice in about 10 cases, accounting for 9.8%, the mechanism of which is not completely clear.
II. Clinical manifestations
The main clinical manifestations of jaundice in patients with hepatocellular carcinoma complicated by jaundice are in hepatomegaly. Pain in liver area. Loss of appetite. On the basis of common symptoms of hepatocellular carcinoma such as emaciation, splenomegaly and ascites, skin and sclera appear. The urine is dull yellow or yellow-green, the stool becomes light gray or white-taupe colored, the skin itches, biliary colic, or is accompanied by chills. High fever, etc. The main clinical manifestations can be divided into three types: cholangitis with abdominal pain, fever and jaundice as the main manifestations; progressive painless jaundice; and fluctuating jaundice.
Three, diagnosis and differential diagnosis
(I) Diagnostic points
The diagnosis of this disease is not difficult for patients whose diagnosis of hepatocellular carcinoma has been clearly established. The diagnosis can be made when patients with hepatocellular carcinoma present with yellow staining of skin, sclera and urine and elevated bilirubin concentration in blood, or without yellow staining of skin, sclera and urine, but only with elevated bilirubin concentration in blood. Significantly elevated conjugated bilirubin in blood, positive urinary bilirubin, itchy skin cancer seen, and white-taupe colored stools are obstructive jaundice; elevated serum conjugated bilirubin and unconjugated bilirubin, with conjugated bilirubin predominating, positive urinary bilirubin, and increased urinary bilirubinogen are hepatocellular jaundice.
(II) Differential diagnosis
For patients whose diagnosis of hepatocellular carcinoma is not yet clear and who have jaundice as the first symptom, the diagnosis of this disease has some difficulties. It must be compared with bile duct cancer. Jaundice in hepatocellular carcinoma often has a history of hepatitis and cirrhosis, and appears in the late stage of hepatocellular carcinoma, accompanied by right upper abdominal distension and pain, and mostly has elevated blood AFP concentration; while cholangiocarcinoma, pancreatic head carcinoma and duodenal jugular tumor mostly have no history of hepatitis and cirrhosis, and only has painless progressive jaundice as the first symptom, and the blood AFP concentration is mostly normal, and abdominal ultrasound, CT, MRI, PTC (percutaneous cholangiopancreatography) is the first symptom. puncture hepatic cholangiography), ERCP (endoscopic retrograde cholangiopancreatography). Nuclear cholangiography, angiography and other tests can help to identify the above diseases.
IV. Treatment
Patients with hepatocellular carcinoma complicated by jaundice should be treated actively for the primary tumor in the liver if conditions allow. It is the fundamental measure to control and eliminate jaundice. In the case of jaundice, we should also actively promote cholestasis to reduce jaundice or control its progress, improve the patient’s general condition as much as possible, reduce the patient’s pain, and seek the opportunity for follow-up treatment.
(A) Internal treatment
1, general treatment Bed rest, give a low-fat, high-protein, high-calorie, vitamin-rich, easy-to-digest diet, quit smoking and alcohol. In case of combined hepatic encephalopathy, protein diet should be restricted or prohibited.
2.Hepatoprotective and biliary drug therapy Inosine can promote the recovery of damaged liver cells, hepatocyte regeneration, hepatocyte protection from toxic damage, potassium magnesium menthylate can accelerate the trinucleic acid cycle in liver cells, coenzyme A, adenosine triphosphate can promote the body’s energy metabolism, are conducive to the improvement of liver function, so that the level of bilirubin in the blood decreased, can be used as appropriate.
3, hormone hormone can reduce the damage to the body when the toxin should be yellow, and inhibit the mononuclear phagocyte system, reduce bilirubin production, inhibit the progress of xanthogranuloma. Prednisolone is commonly used clinically, 20-30mg per day.
4.Supplementation of plasma albumin Albumin can combine with non-conjugated bilirubin in blood to form conjugated bilirubin and reduce the damage of non-conjugated bilirubin to the body.
5.Liver enzyme inducer can strengthen the activity of enzymes related to bilirubin metabolism in hepatocytes to promote the metabolism and excretion of bilirubin, commonly used phenobarbital, etc.
6.Percutaneous transhepatic bile duct drainage (PTCD) refers to percutaneous hepatic puncture bile duct drainage to drain bile out of the body, which is one of the common palliative treatment methods for malignant biliary obstruction. It is suitable for biliary obstruction caused by primary and metastatic hepatocellular carcinoma that cannot be surgically resected, or when the jaundice index is too high before tumor resection and jaundice must be reduced and liver function improved.
(II) Surgical treatment
1.Tumor resection Patients with obstructive jaundice caused by bile duct compression by hepatocellular carcinoma, whose bile ducts are not invaded, and whose general condition is good, and whose heart, lung and kidney functions are normal, and whose tumors are indicated for surgical resection, should undergo tumor resection in time, and the surgical methods include regular resection and irregular resection of liver. After the operation, the bile duct compression can be released and jaundice can be completely eliminated.
2.Placement of drainage tube During the surgery of cholecystectomy, common bile duct exploration and lobectomy, T-type, U-type and Y-type drainage tubes are placed to pass through the lumen occupied or compressed by the tumor, and a high jejunostomy is performed at the same time, and the hepatobiliary drainage tube and jejunostomy are led out of the body separately. For some very advanced cases that have lost the opportunity of dissection, percutaneous hepatic puncture for hepatobiliary drainage (PTCD) can be used.
3.Hepatic artery ligation can block 90% of the blood supply of the tumor and reduce only 25% of the blood supply of normal liver tissue, which can shrink the tumor or even cause ischemic necrosis, reduce the pressure on the biliary system, relieve jaundice, and have certain anti-tumor effects.
4.hepatic artery cannulation chemotherapy After entering the abdomen, the right artery of the gastric omentum is found at the greater curvature of the stomach, a section of artery about 1cm long is isolated, traction is made with a sleeve wire, the anterior wall is cut and the catheter is inserted up to the hepatic artery, according to the location of the tumor, the intrinsic hepatic artery, the right hepatic artery or the left hepatic artery is inserted, the catheter is fixed and led out of the abdominal wall, and cannulation chemotherapy is performed, or chemotherapy is performed with a micro-chemotherapy pump, which is buried under the skin.
5.Bile duct-jejunostomy When liver cancer compresses the bile duct and cannot be removed surgically, bile duct-jejunostomy can be performed to draw bile into the intestine to reduce gangrene. There are many procedures of this method, including left and right hepatic duct-jejunostomy, left intrahepatic bile duct-jejunostomy, etc. The appropriate anastomosis point can be selected according to the tumor compression site, and U-tube can also be placed to drain during the operation.