Digestive disorders

I./4.2.: Symptomatology

In its initial stage primary liver cancer (HCC) is a disease poor in symptoms and it develops on the base of hepatic cirrhosis in 80% of cases. The development of a hepatic carcinoma may be suggested by a rapid deterioration in the general state of patients with hepatic cirrhosis, accompanied by dull abdominal pain below the right costal arch, lack of appetite, weight loss, fatigue and weakness. Thrombosis of the hepatic and portal veins, rapidly developing ascites which can occasionally be inflamed or hemorrhagic may suggest a malignant tumor. In approx. 5% primary hepatic carcinoma may be associated with hypoglycemia, polycythemia, hypercalcemia and porphyria. Spontaneous rupture of the liver that causes an abdominal hematoma (hemoperitoneum) manifesting as an acute abdomen occurs in 1–2% of patients. Primary hepatic carcinoma may also be the underlying cause of fever with unknown origin.

During physical examination one may palpate a hard, nodular, tender liver with an uneven surface; sounds of friction heard over it and related to breathing suggest the involvement of the hepatic capsule.

Laboratory findings include – usually in advanced cases – accelerated ESR, anemia, increased activity of cholestatic enzymes (alkaline phosphatase, gamma glutamyl transferase) and lactate dehydrogenase, as well as pathologic levels of conjugated bilirubin in the serum. Of the tumor markers, the most frequently used alpha-fetoprotein (AFP) alone has low sensitivity and specificity. At a threshold of 20 ng/mL its sensitivity and specificity are 62% and 78% respectively. Its significance is primarily in the differentiation of focal hepatic lesions recognized by imaging examinations. Over a level of 200 ng/mL its predictive value exceeds 90%. In patients with hepatic cirrhosis, prolonged significantly abnormal AFP values may suggest HCC. Spurious negative results are common in patients with small-sized tumors. AFP test is a sensitive, important examination for the follow-up of positive tumors after therapy; it shows the results attained by the treatment, or the recurrence of the tumor.

Des-gamma carboxyprothrombin (DCP), the presence of which is also induced by the absence of Vitamin K, is another tumor marker used in the diagnosis of HCC. It may be positive in more than 90% of patients with liver cancer; however its low specificity is a disadvantage. It is not used in the everyday practice in Hungary.