While nine of the 17 most common cancers of men and eight of the 18 most common cancers of women decreased in incidence in the U.S. (2009-2013), liver cancer had the greatest increase in incidence for both men and women (Annual Report to the Nation on the Status of Cancer, 1975 – 2014).
Death rates decreased for 11 of the top 16 cancers in men and for 13 of the top 18 cancers in women. However, liver cancer death rates increased for men and women (Ibid).
A study by the University of Alabama at Birmingham and the Global Burden of Disease Liver Cancer Collaboration found that one-third of liver cancer deaths were attributable to the hepatitis B virus (HBV), 30 percent to alcohol, 21 percent to the hepatitis C virus (HCV), and 16 percent to other causes, including Non-alcoholic steatohepatitis (NASH) (JAMA Oncology, October 5, 2017 online edition).
Primary care practices can have a profound effect on liver cancer incidence and death rates through readily available best practices recommended by the United States Preventive Services Task Force, the American Association for the Study of Liver Diseases, and the Infectious Disease Society of America, and identified in A National Strategy for the Elimination of Hepatitis B and C, National Academies, 2017, and the 2016 – 2020 Colorado Cancer Plan, produced by the Colorado Department of Public Health and Environment (CDPHE).
The Centers for Disease Control and Prevention (CDC) states that there are 350 million people worldwide and approximately 1.2 million people in the U.S. with the hepatitis B virus (HBV). CDPHE estimates there are 15,436 cases of chronic, unresolved hepatitis B and there has been an increase in reported cases over the last four years (2013-2016), primarily along the I-25 corridor. HBV is a vaccine-preventable contagious liver disease that is spread through blood, semen, or other body fluids. Hepatitis B can also be passed from an infected mother to her baby at birth. This course will discuss prevalence, high risk populations, vaccination, treatment, and health consequences of long-term infection.
Instructor: Michael Kriss, MD, Assistant Professor of Medicine, Gastroenterology – Hepatology, University of Colorado Hospital
The hepatitis C virus (HCV) is the most common blood borne infectious disease in the U.S., affecting approximately 3.5 million people. A 2017 prevalence study for Colorado estimated there are 50,153 people in the state with HCV. The disease wasn’t identified until 1989 and an accurate test to detect the virus in the blood supply wasn’t created until 1992. Before then, many baby boomers (born between 1945 and 1965) came into contact with infected blood through medical procedures, blood or blood product donations, air gun innoculations (primarily Vietnam vets), sharing works while injecting or snorting drugs, and tattooing in unsafe facilities. There are now multiple treatments on the market that are highly effective in curing patients of HCV. Pricing has come down so that most people, even those on Medicaid in Colorado, can access treatment. Patients who have had the virus for 20 or 30 years are at greater risk of cirrhosis and liver cancer due to the development of fibrosis. Meanwhile, we are seeing a surge in new HCV infections throughout the nation as a result of the opioid crisis and sharing works (needles, syringes, cotton, rinse water, and more).
Instructor: Sarah E. Rowan, MD, Associate Director, HIV and Viral Hepatitis Prevention, Denver Public Health
Alcoholic hepatitis is inflammation of the liver caused by drinking alcohol. It is most likely to occur in people who drink heavily over many years. However, the relationship between drinking and alcoholic hepatitis is complex. Not all heavy drinkers develop alcoholic hepatitis, and the disease can occur in people who drink only moderately. Just about everyone who has alcoholic hepatitis is malnourished. Drinking large amounts of alcohol suppresses the appetite, and heavy drinkers get most of their calories in the form of alcohol. Signs and symptoms of severe alcoholic hepatitis include: fluid accumulation in the abdomen (ascites); confusion and behavior changes due to a buildup of toxins normally broken down and eliminated by the liver; and kidney and liver failure.
Instructor: Clark Kulig, MD, Transplant Hepatology, Presbyterian/St. Lukes Medical Center
Non-alcoholic Steatohepatitis (NASH)
Nonalcoholic fatty liver disease (NAFLD) is a condition in which excess fat is stored in the liver. Heavy alcohol use does not cause this buildup of fat. Two types of NAFLD are simple fatty liver and nonalcoholic steatohepatitis (NASH). Simple fatty liver and NASH are two separate conditions. People typically develop one type of NAFLD or the other, although sometimes people with one form are later diagnosed with the other form of NAFLD. NASH is a form of NAFLD in which you have hepatitis—inflammation of the liver—and liver cell damage, in addition to fat in your liver. Inflammation and liver cell damage can cause fibrosis, or scarring, of the liver. NASH may lead to cirrhosis or liver cancer. Experts are not sure why some people with NAFLD have NASH while others have simple fatty liver. Only a small number of people with NAFLD have NASH. It’s estimated that about 20 percent of people with NAFLD have NASH. Between 30 and 40 percent of adults in the United States have NAFLD. About 3 to 12 percent of adults in the U.S. have NASH.
Instructor: Mary Ann Y. Huang, MD, MS, FAASLD, Transplant Hepatology, Peak Gastroenterology
Cirrhosis is a complication of liver disease which involves loss of liver cells and irreversible scarring of the liver. Alcohol and viral hepatitis B and C are common causes of cirrhosis, although there are many other causes. Cirrhosis can cause weakness, loss of appetite, easy bruising, yellowing of the skin (jaundice), itching, and fatigue. Diagnosis of cirrhosis can be suggested by history, physical examination and blood tests, and can be confirmed by liver biopsy. Complications of cirrhosis include edema and ascites, spontaneous bacterial peritonitis, bleeding from varices, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, hypersplenism, and liver cancer. Treatment of cirrhosis is designed to prevent further damage to the liver, treat complications of cirrhosis, and preventing or detecting liver cancer early. Transplantation of the liver is an important option for treating patients with advanced cirrhosis.
Instructor: Lisa Forman, MD, MSCE, Associate Professor of Medicine, Program Director, Gastroenterology – Hepatology, University of Colorado Hospital
Liver Cancer (Hepatocellular Carcinoma)
Each year in the United States, about 22,000 men and 9,000 women get liver cancer, and about 16,000 men and 8,000 women die from the disease. The percentage of Americans who get liver cancer has been rising for several decades, principally due to hepatitis C among baby boomers. Men died from liver cancer at more than twice the rate of women, and Hispanic men and women had the highest rates of getting liver cancer over all ethnicities. Many liver cancer cases are related to the hepatitis B virus or hepatitis C virus. Other behaviors and conditions that increase risk for getting liver cancer are: heavy alcohol use; cirrhosis; obesity; NASH; diabetes.
In its early stages, liver cancer may not have symptoms that can be seen or felt. However, as the cancer grows larger, people may notice multiple symptoms. Treatments may include: Surgical options, which are often limited due to underlying cirrhosis; ablative therapy; oral chemotherapeutic agents; or liver transplantation.
Instructor: Bahri Bilir, MD, Medical Director of Liver Transplantation, Presbyterian/St. Lukes Hospital
A liver transplant is a surgical procedure performed to replace a diseased liver with a healthy liver from another person. The liver may come from a deceased donor or from a living donor. Family members or individuals who are unrelated but make a good match may be able to donate a portion of their liver. This type of transplant is called a living transplant. Individuals who donate a portion of their liver can live healthy lives with the remaining liver, which grows back to its full size. An entire liver (from a deceased donor) may be transplanted, or just a section. Because the liver is the only organ in the body able to regenerate, a transplanted portion of a liver can grow to normal capacity within weeks. Liver transplantation is the most curative option for someone with hepatocellular carcinoma. It was contraindicated in patients with HCC until 1996 when Milan criteria were developed related to number of lesions, lesion sizes, no vascular invasion, and no metastasis. The five year survival rate is greater than 70%. Approximately 17,000 patients are on the liver transplant waiting list, and 1,500 will die each year. Colorado has three transplant centers and you will be provided information for referral for liver transplantation.
Instructor: James R. Burton, MD, Associate Professor of Medicine, Medical Director of Liver Transplantation, University of Colorado Hospital
Application for CME credit has been filed with the American Academy of Family Physicians. Determination of credit is pending.
At the end of this course, you will be able to:
* Improve adherence to evidence-based clinical guidelines in practice.
* Synthesize appropriate diagnosis and treatment plans for the following conditions:
o Hepatitis B (HBV)
o Hepatitis C (HCV)
o Alcoholic hepatitis
o Non-alcoholic steatohepatitis (NASH)
* Understand the fundamental principles behind diagnosis and treatment of cirrhosis, liver cancer and understand the fundamental process of liver transplant and post-transplant management and outcomes
o Liver cancer
o Liver transplantation
* Demonstrate ability to communicate effectively with the patient to ensure that diagnosis and treatment recommendations are understood.
* Recognize when to refer to or consult with other specialists to provide optimal patient care.
Liver Diseases Seen in Primary Care – Live Course
Saturday, May 19, 2018
8:00 A.M. to 8:30 A.M. – registration and breakfast (provided)
8:30 A.M. – Opening remarks, John Reilly, Jr., MD, Dean, University of Colorado School of Medicine
8:40 A.M. to 9:40 A.M. – Hepatitis B – Michael Kriss, MD
9:40 A.M. to 10:40 A.M. – Hepatitis C – Sarah Rowan, MD
10:40 A.M. to 11:40 A.M. – Alcoholic Hepatitis – Clark Kulig, MD
11:40 A.M. to 12:40 P.M. – Non-Alcoholic Steatohepatitis (NASH) – MaryAnn Huang, MD, MS, FAASLD
12:40 P.M. to 1:30 P.M. – lunch (provided)
1:30 P.M. to 2:30 P.M. – Cirrhosis – Lisa Forman, MD, MSCE
2:30 P.M. to 3:30 P.M. – Liver Cancer – Bahri Bilir, MD
3:30 P.M. to 4:30 P.M. – Liver Transplantation – Jay Burton, MD
Early Bird $55 (available through May 12)
Payable by check to Liver Health Connection or through our Donate button/PayPal account on our web site, http://www.liverhealthconnection.org. Specify that it is for the Liver Diseases Live Course and include your contact information for registration receipt.
University of Colorado Hospital
Anschutz Medical Campus
Research Building 2, Krugman Conference Hall
(a map and parking information will be sent after registration)
This live course is produced by Liver Health Connection in support of the 2017 Health and Human Services National Strategy for the Elimination of Hepatitis B and C. It is supported by the Colorado Academy of Family Physicians and the University of Colorado School of Medicine.