Managing Symptoms

Tuesday 1 May, 2018

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On this page: Jaundice | Poor appetite and weight loss | Pain | Fluid build-up | Confusion |


Both primary and secondary cancer in the liver can cause various symptoms, but there are ways to manage them. With advanced cancer, the palliative care team may be involved in managing symptoms.

Jaundice

One of the jobs of the liver is to process bilirubin, a yellow pigment that is formed when red blood cells in the body break down. Normally, the bilirubin passes through the bile duct to the bowel and then passes out of the body in stools (faeces).

With liver cancer, bilirubin sometimes builds up in the blood. This can be because the cancer has blocked a bile duct, the liver is not working properly (progressive liver function failure), or the liver has been replaced by widespread tumour.

The build-up of bilirubin in the blood is known as jaundice. It can cause yellowish skin and whites of the eyes, itchiness, pale stools or dark urine.

Jaundice can sometimes be relieved by unblocking the bile duct with a tiny tube called a stent (see below for how stents are inserted). Stenting is not always recommended in advanced cancer.

The itching caused by jaundice is often worse at night. It can be relieved to some degree by keeping your skin moisturised. Try to avoid alcohol, spicy food, hot baths and direct sunlight, which can make the itching worse. Medicine can be prescribed if the itching continues and is uncomfortable.

How stents are inserted

A stent can be placed in your liver to clear a blocked bile duct and relieve symptoms of jaundice. The earlier the stent is inserted, the less severe the symptoms. Stenting can be done in two ways.

Endoscopic stent placement

This is done as a day procedure. You will have a local anaesthetic and possibly a sedative to help you relax.

A gastroenterologist or surgeon will insert a long, flexible tube with a camera and light on the end (endoscope) through your mouth, stomach and small bowel into the bile duct. Pictures show up on a screen so the doctor can see where to put the stent. The stent is put in using the endoscope, which is then removed.

Recovery from an endoscopic stent placement is fairly fast. Your throat may feel sore for a short time and you may need to stay in hospital overnight.

After the procedure, the bile duct may become infected and the pancreas may become inflamed – your doctor will talk to you about what can be done if this occurs.

Percutaneous stent placement

Sometimes a stent cannot be inserted using an endoscope so it is placed through the skin, using ultrasound and x-rays for guidance. This requires a small operation.

The operation may be done under general anaesthetic or heavy sedation, and you will usually stay in hospital overnight. You may have a small plastic tube (drain) coming out through the skin for some days. This lets fluid drain from the area.

Stent

Poor appetite and weight loss

Because the liver plays a key role in the digestive system, cirrhosis and cancer in the liver can both cause you to lose your appetite and you may lose weight. Chemotherapy, radiation therapy and other cancer treatments can also have an impact, especially if you experience side effects such as nausea and vomiting, mouth ulcers, and taste and smell changes.

The tips below can help you prevent or manage appetite changes and weight loss after a diagnosis of liver cancer.

How to stay well nourished

  • Snack during the day – eat 5–6 small meals rather than three large ones each day.
  • Ask your family and friends to cook for you and offer you food throughout the day.
  • Keep a selection of snacks handy, e.g. in your bag or car.
  • Try eating different foods. Your taste and tolerance for some foods may have changed and may continue to change.
  • Ask your dietitian how you can increase your energy and protein intake.
  • Eat when you feel hungry or crave certain foods, but be careful not to become too full by eating too quickly.
  • Ensure you have room for nourishing food – avoid filling up on liquids at mealtimes, unless it's a hearty soup.
  • Prevent dehydration by drinking liquids between meals (e.g. 30–60 minutes before or after meals).
  • See Nutrition and Cancer for more information and recipes.

Pain

In some people, liver cancer can cause pain, particularly in the upper right area of the abdomen. This usually only happens in more advanced cases.

Pain associated with liver cancer can be managed with pain medicines. These may be mild, like paracetamol; moderate, like codeine; or strong and opioid-based, like morphine. Radiation therapy, chemotherapy or surgery may also provide relief by reducing the size of a liver tumour that is causing pain.

How to cope with pain

  • Keep track of your pain in a symptom diary and try to describe it – what the pain feels like, how intense it is, exactly where it is, where it comes from and travels to, how long it lasts, and if it goes away with a specific pain medicine or with any other therapy, such as a heat pack.
  • Allow a few days for your body to adjust to the dose of pain medicine and for any drowsiness to improve.
  • Let your doctor know if you have vivid dreams, nausea or other side effects after taking a strong pain medicine such as morphine. Adjusting the dose may help, or you can try other methods of pain relief.
  • Use a laxative regularly to prevent or relieve constipation from codeine or morphine.
  • Take pain medicine regularly as prescribed, even when you're not in pain. It's better to stay on top of the pain.
  • See Overcoming Cancer Pain for more information on managing pain.

Fluid build-up

Ascites is when fluid builds up in the abdomen. Chronic cirrhosis can increase pressure in the blood vessels inside the liver, forcing fluid to leak into the abdomen. Ascites can also be caused by the cancer itself blocking lymph vessels or producing extra fluid. The build-up of fluid causes swelling and pressure in the abdomen. This can be uncomfortable and may make you feel breathless.

A procedure called paracentesis or ascitic tap can provide relief. The skin on the abdomen is numbed with a local anaesthetic. Using ultrasound images as a guide, a radiologist inserts a thin needle and plastic tube into the abdomen. The tube is connected to a drainage bag outside your body. It will take a few hours for all the fluid to drain into the bag, and then the tube will be removed from your abdomen.

Water tablets (diuretics) are sometimes prescribed before and/or after paracentesis to slow down the build-up of fluid.

Confusion

Chronic liver disease may cause toxic substances to build up in the blood, which can affect brain function. This is known as hepatic encephalopathy and it can lead to confusion or disorientation and, in severe cases, coma. It is important not to drive if you have any symptoms of this condition, and for carers to be aware that these symptoms can develop. Hepatic encephalopathy can be frightening for carers and family members, but it can be controlled with medicines. Talk to the health care team if you are concerned.


Reviewed by: A/Prof Nicholas O'Rourke, University of Queensland, and Head of Hepatobiliary Surgery, Royal Brisbane and Women's Hospital, QLD; Dr Lorraine Chantrill, Senior Staff Specialist Medical Oncology, The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, and Honorary Research Fellow, Garvan Institute of Medical Research, NSW; A/Prof Mark Danta, Hepatologist, St Vincent's Hospital, Sydney, and St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, NSW; Dr Samuel Davis, Diagnostic and Interventional Radiologist, Qscan Radiology Clinics and Royal Brisbane and Women's Hospital, QLD; David Fry, Consumer; Dr Nigel Mott, Diagnostic and Interventional Radiologist, Wesley Hospital and Royal Brisbane and Women's Hospital, QLD; Chris Rivett, 13 11 20 Consultant, Cancer Council SA; Meg Rogers, Nurse Coordinator, Upper Gastrointestinal Service, Peter MacCallum Cancer Centre, VIC; A/Prof Simone Strasser, Senior Staff Specialist, AW Morrow Gastroenterology and Liver Centre and Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, and Central Clinical School, Sydney Medical School, University of Sydney, NSW.

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