Liver disease severe enough to require a liver transplant can come from many causes. Doctors have developed various systems to determine the need for the surgery. Two commonly used methods are by specific disease process or a combination of laboratory abnormalities and clinical conditions that arise from the liver disease. Ultimately, the transplantation team takes into account the type of liver disease, the person’s blood test results, and the person’s health problems in order to determine who is a suitable candidate for transplantation.

In adults, cirrhosis from alcoholism, hepatitis C, biliary disease, or other causes are the most common diseases requiring transplantation. In children, and in adolescents younger than 18 years, the most common reason for liver transplantation is biliary atresia, which is an incomplete development of the bile ducts.

Laboratory test values and clinical or health problems are used to determine a person’s eligibility for a liver transplant.

• For certain clinical reasons, doctors may decide that a person needs a liver transplant. These reasons may be health problems that the person reports, or they may be signs that the doctor notices while examining the potential recipient. These signs usually occur when the liver becomes severely damaged and forms scar tissue, a condition known as cirrhosis.
  • Common clinical and quality-of-life indications for a liver transplant include ascites, or fluid in the belly due to liver failure.
  • In the early stage of this problem, ascites may be controlled with medicines (diuretics) to increase urine output and with dietary modifications (limiting salt intake).
  • Another serious consequence of liver disease is hepatic encephalopathy. This is mental confusion, drowsiness, and inappropriate behavior due to liver damage.
• Several other clinical problems may arise from liver disease.
  • Infection in the abdomen, known as bacterial peritonitis, is a life-threatening problem. It occurs when bacteria or other organisms grow in the ascites fluid.
  • Liver disease causes scarring, which makes blood flow through the liver difficult and may increase the blood pressure in one of the major blood vessels that supply it. This process may result in serious bleeding.
  • Blood may also back up into the spleen and cause it to increase in size and to destroy blood cells.
  • Blood may also go to the stomach and esophagus(swallowing tube). The veins in those areas may grow and are known as varices. Sometimes, the veins bleed and may require a gastroenterologist to pass a scope down a person’s throat to evaluate them and to stop them from bleeding.
• These problems may become very difficult to control with medicines and can be a serious threat to life. A liver transplant may be the next step recommended by the doctor. 

People who have liver disease may have many of the following problems:

• Jaundice – Yellowing of the skin or eyes
• Itching
• Dark, tea-colored urine
• Gray- or clay-colored bowel movements
• Ascites – An abnormal buildup of fluid in the abdomen
• Vomiting of blood
• Blood in the stool
• Tendency to bleed
• Mental confusion, forgetfulness

When Should I Call the Doctor About Liver Transplant Complications?

Call the transplant team whenever a patient with a newly transplanted liver feels unwell or has concerns about his or her medications. The patient should also call the transplant doctor if new symptoms arise. These problems may commonly occur before liver transplantation and indicate that a patient’s liver disease is worsening. They may also occur after transplantation and be a possible sign that the liver is being rejected. The doctor may recommend that the patient be taken to a hospital emergency department for further evaluation.

Acute rejection usually occurs in the first 1-2 months after the transplantation. It is common for the patient to require 1 admission to the hospital for either rejection or infection. The following are just a few examples of when to call the doctor:

• A patient may bleed after surgery, which may be detected by an increase in the amount of blood put out in what are called Jackson-Pratt (JP) drains, rather than by a decrease of blood over time. This may indicate that one of the blood vessels going to the liver is bleeding.
• The patient’s belly is more tender than usual, and he or she has a fever. Infection of the fluid in the belly can be a serious complication. Infection is diagnosed by removing a small amount of fluid from the abdomen and sending it to the laboratory for testing. If infection is present, antibiotics are usually prescribed, and the patient is admitted to the hospital. Infection in liver transplant recipients is usually seen 1-2 months after transplantation.
• After surgery, the patient’s belly is more tender and the skin is turning yellow. This may indicate that bile is backing up and not draining from the liver properly. The doctor may need to evaluate this problem by doing tests, such as a CT scan, ultrasound, or cholangiography. If a major problem exists, the doctor may reoperate (exploratory surgery), use nonoperative treatment, or list for urgent retransplantation.

If a patient comes to the hospital or an emergency department, the doctor will obtain blood tests, liver function tests, blood clotting tests, electrolytes, and kidney function tests. The doctor may also draw blood levels of certain immunosuppressive medications to make sure they are in the right range. If an infection is considered possible, cultures for viruses, bacteria, fungi, and other organisms may be grown. These may be checked for in the urine, sputum, bile, and blood.

Pretransplant tests are done to evaluate the severity of the liver disease and to determine when the patient should be placed on the waiting list. Once this initial evaluation is complete, the case is presented to a review committee of physicians and other staff members of the hospital. If the person is accepted as a candidate, he or she is placed on the waiting list for a liver transplant. A recipient may undergo some of the following tests before the transplantation:

• CT scan of the abdomen: This is a computerized picture of the liver that allows the doctor to determine the liver size and to identify any abnormalities, including liver tumors, that may interfere with the success of a liver transplantation.
• Ultrasound of the liver: This is a study that uses sound waves to create a picture of the liver and the surrounding organs. It also determines how well the blood vessels that carry blood to and from the liver are working.
• ECG: Short for electrocardiogram, this is a study that shows the electrical activity of the heart.
• Blood tests: These include blood type, blood cell count, blood chemistries, and viral studies.
• Dental clearance: A person’s regular dentist may fill out the form. Immunosuppressive medications may increase the chance of infection and if the teeth have cavities or periodontal disease, this can lead to infection. Therefore, a dental evaluation is important before beginning these medicines.
• Gynecological clearance: The patient’s gynecologist may provide clearance.
• Purified protein derivative (PPD) skin test: The PPD test is performed on the arm to check for any exposure to tuberculosis.

What Is Self-Care at Home When Healing from a Liver Transplant?

Home care involves building up endurance to carry out daily life activities and recovering to the level of health that the patient had before surgery. This can be a long, slow process that includes simple activities. Walking may require assistance at first. Coughing and deep breathing are very important to help the lungs stay healthy and to prevent pneumonia. Diet in the hospital may at first consist of ice chips, then clear liquids, and, finally, solids. It is important to eat well-balanced meals with all food groups. After about 3-6 months, a person may return to work if he or she feels ready and it is approved by the primary transplant doctor.

Preventing rejection: Home care also involves taking several medications to help the liver survive and to prevent the patient’s own body from rejecting the new liver. A person with a new liver must take medications for the rest of his or her life. The immune system works to protect the body from invading bacteria, viruses, and foreign organisms.

Unfortunately, the body cannot determine that the newly transplanted liver serves a helpful purpose. It simply recognizes it as something foreign and tries to destroy it. In rejection, the body’s immune system attempts to destroy the newly transplanted liver. Without the intervention of immunosuppressive drugs, the patient’s body would reject the newly transplanted liver. Although the medications used to prevent rejection act specifically to prevent the new liver from being destroyed, they also have a general weakening effect on the immune system. This is why transplant patients are more likely to get certain infections. To prevent infections, the patient must also take preventive medications. There are 2 general types of rejection, as follows:

• Immediate, or hyperacute, rejection occurs just after surgery, when the body immediately recognizes the liver as foreign and attempts to destroy it. Hyperacute rejection occurs in about 2% of patients.
• Acute rejection usually occurs in the first two months after transplant and is usually treatable with medication adjustments. About 25% of patients have at least one acute rejection episode.
• Delayed, or chronic, rejection can occur years after surgery, when the body attacks the new liver over time and gradually reduces its function. This occurs in 2-5% of patients.

The incision on the belly is in the shape of an upside-down Y. Small, plastic, bulb-shaped drains are placed near the incision to drain blood and fluid from around the liver. These are called Jackson-Pratt (JP) drains and may remain in place for several days until the drainage significantly decreases. A tube called a T-tube may be placed in the patient’s bile duct to allow it to drain outside the body into a small pouch called a bile bag. The bile may vary from deep gold to dark green, and the amount produced is measured frequently. The tube remains in place for about 3 months after surgery. Bile production early after the surgery is a good sign and is one of the indicators surgeons look for to determine if the liver transplant is being “accepted” by the patient’s body.

After surgery, the patient is taken to the intensive care unit, is monitored very closely with several machines. The patient will be on a respirator, a machine that breathes for the patient, and will have a tube in the trachea (the body’s natural breathing tube) bringing oxygen to the lungs. Once the patient wakes up enough and can breathe alone, the tube and respirator are removed. The patient will have several blood tests, X-ray films, and ECGs during the hospital stay. Blood transfusions may be necessary. The patient leaves the intensive care unit once he or she is fully awake, able to breathe effectively, and has a normal temperature, blood pressure, and pulse, usually after about 1-2 days. The patient is then moved to a room with fewer monitoring devices for a few days longer before going home. The average hospital stay after surgery is about 2 weeks.

After liver transplantation, the patient must visit the transplant surgeon or hepatologist frequently, about 1-2 times a week over about 3 months. After this time, the primary doctor may also see the patient, but the transplant doctor the patient about once a month for the remainder of the first year after transplantation.

Ideally, the transplant surgeon and hepatologist monitor the patient’s progress through blood tests and contact with the primary doctor. One year after transplantation, follow-up care is individualized. If a patient ever requires a visit to an emergency department, and is discharged from there, he or she should generally follow up with his or her primary transplant doctor in 1-2 days.

Before undergoing liver transplantation, people who have liver disease should avoid medications that may further damage the liver.

• Large amounts of acetaminophen (Tylenol) may be harmful and can damage the liver. (Acetaminophen is contained in many over-the-counter drugs; therefore, patients with liver disease must be particularly watchful.) Sleeping pills and benzodiazepines (Valium and similar medicines) can build up faster in the blood when the liver doesn’t work well. They can make a person confused, worsen existing confusion, and, in some cases, cause coma. If possible, try to avoid taking these medicines.
• Alcohol is an ingredient in some cough syrups and other medications. Alcohol can severely damage the liver, so it is best to avoid alcohol-containing medications.
• The female transplantation patient should not take oral contraceptives because of the increased risk of blood clot formation.
• No transplant recipient should receive live virus vaccines (especially polio), and no household contacts should receive these either.
• Pregnancy should be avoided by transplant recipients until at least 1 year after transplantation. If a woman wants to become pregnant, she should speak with her transplantation team regarding any special risks, as the immunosuppressive medications may need to be changed. In many cases, women successfully become pregnant and give birth normally after transplantation, but they should be carefully monitored because of the higher incidence of premature births. Mothers should avoid breastfeeding because of the risk of the baby’s exposure to the immunosuppressive medicines through the milk.

The 1-year survival rate after liver transplantation is about 88% for all patients, but will vary depending on whether the patient was at home when transplated or critically in the intensive care unit. At 5 years, the survival rate is about 75%. Survival rates are improving with the use of better immunosuppressive medications and more experience with the procedure. The patient’s willingness to stick to the recommended posttransplantation plan is essential to a good outcome.

Generally, anyone who develops a fever within a year of receiving a liver transplant is admitted to the hospital. Patients who cannot take their immunosuppressive medicines because they are vomiting should also be admitted. Patients who develop a fever more than a year after receiving a liver transplant and who are no longer on high levels of immunosuppression may be considered for management as an outpatient on an individual basis.

Complications are problems that may arise after liver transplantation. Many should be recognizable by the patient, who should call the transplantation team to inform them of the changes.

Possible complications after liver transplantation:

• Infection of the T-tube site: This tube drains bile to the outside of the body into a bile bag. Not all patients require such a tube. The site may become infected. This can be recognized if the patient notices warmth around the T-tube site, redness of the skin around the site, or discharge from the site.
• Dislodgement of the T-tube: The tube may come out of place, which may be recognized by breakage of the stitch on the outside of the skin that holds the tube in place or by an increase in the length of the tube outside the body.
• Bile leak: This may occur when bile leaks outside of the ducts. The patient may experience nausea, pain over the liver (the right upper side of the abdomen), or fever.
• Biliary stenosis: This is narrowing of the duct, which may result in blockage. The bile may back up in the body and result in yellowing of the skin.

• Infections: Infections may result from being on the immunosuppressive medications. Although these medications are meant to prevent rejection of the liver, they also decrease the ability of the body to fight off certain viruses, bacteria, and fungi. The organisms that most commonly affect patients are covered with preventive medications. Notify the transplantation team if any of the following infections arise:

• Viruses
  • Herpes simplex viruses (types I and II): These viruses most commonly infect the skin but may occur in the eyes and lungs. Type I causes painful, fluid-filled blisters around the mouth, and type II causes blisters in the genital area. Women may have an unusual vaginal discharge.
  • Herpes zoster virus (shingles): This is a herpesvirus that is a reactivated form of chickenpox. The virus appears as a wide pattern of blisters almost anywhere on the body. The rash is often painful and causes a burning sensation.
  • Cytomegalovirus: This is one of the most common infections affecting transplant recipients and most often develops in the first months after transplantation. Symptoms include excessive tiredness, high temperature, aching joints, headaches, abdominal problems, visual changes, and pneumonia.
• Fungal infections: Candida (yeast) is an infection that may affect the mouth, esophagus (swallowing tube), vaginal areas, or bloodstream. In the mouth, the yeast appears white, often on the tongue as a patchy area. It may spread to the esophagus and interfere with swallowing. In the vagina, a white discharge that looks like cottage cheese may be present. To identify yeast in the blood, the doctor will obtain blood cultures if the person has a fever.
• Bacterial infections: If a wound (including the incision site) has drainage and is tender, red, and swollen, it may be infected by bacteria. The patient may or may not have a fever. A wound culture (test for the organism) will be obtained and appropriate antibiotics given.
• Other infections: Pneumocystis carinii is similar to a fungus and may cause pneumonia. The patient may have a mild, dry cough and a fever. This infection is prevented with sulfamethoxazole-trimethoprim (Bactrim, Septra). If the patient develops this infection, it may be necessary to give higher doses or intravenous antibiotics.
• Diabetes: Diabetes is a condition in which blood sugar levels are too high. This may be caused by the medications the person takes. Patients may experience increased thirst, increased appetite, blurred vision, confusion, and frequent, large volumes of urination. The transplantation team should be notified if these problems occur. They can perform a quick blood test (a fingerstick glucose test) to see if the blood sugar level is elevated. If it is, they may start the patient on medications to prevent it and recommend diet and exercise.
• High blood pressure: This may be a side effect of the medications. The patient’s doctor will monitor the blood pressure with each clinic visit and, if it is elevated, may start medications to lower blood pressure.
• High Cholesterol: This may be a side effect of the medications, the patient’s doctor will monitor the cholesterol levels periodically with blood tests and may recommend diet changes or start medications if necessary.

A kidney transplant  is surgery to put a healthy (donor) kidney into your body. There are two types of donors:

• Living donors. A living donor may be a family member, a friend, a coworker, or any person who is willing to give a kidney to someone in need. A person only needs one healthy kidney to live.
• Deceased donors. A deceased donor is someone who has recently died.

You may need to have tests to see how well the donor kidney matches your tissue type and blood type. A close tissue match reduces the chances that your body will reject the new kidney. You will also be evaluated to make sure that you do not have significant heart or lung disease or other diseases, such as cancer, which might decrease your life span.

Kidney transplant surgery takes about 3 hours. During surgery, the donor kidney will be placed in your lower abdomen, blood vessels from the donor kidney will be connected to arteries and veins in your body, and the ureter from the donor kidney will be connected to your bladder. Blood is then able to flow through the new kidney, and the kidney will begin to filter and remove wastes and to produce urine.

The new kidney usually begins to function right away. In most cases, diseased or damaged kidneys are not removed unless you have a severe infection of the kidney (pyelonephritis), kidney cancer, nephrotic syndrome, or extremely large polycystic kidneys.

What To Expect After Surgery

You will have to stay in the hospital for several days after you receive your new kidney. In some cases, it may take time for your new kidney to produce urine. So you may have to receive dialysis and take medicines, such as diuretics, that help your new kidney get rid of excess water and salt from your body.

After the surgery you will have to take medicines to suppress your immune system. These medicines are used to help keep your body from rejecting your new kidney. You will need to take these medicines for the rest of your life.

During the first weeks to months after your surgery, your body may try to reject your new kidney. This is called acute rejection and occurs in less than 20 out of 100 people after transplant. Most of the time, acute rejection can be treated with antirejection (immunosuppressive) medicines.¹

Chronic rejection (also called chronic allograft failure) is a process of gradual, progressive loss of kidney function and can occur many months to several years after your surgery. Experts don’t fully understand what causes chronic rejection. There is no treatment for chronic rejection. Most people go back on dialysis or have another transplant.

Kidney transplant surgery is done so that a healthy kidney (donor kidney) can do what your diseased kidney can no longer do. Kidney transplant is used when you have severe chronic kidney disease (renal failure) that cannot be reversed by another treatment method. You will not be able to have this surgery if you have an active infection, another life-threatening disease such as cancer, or severe heart or lung disease.

If you have severe chronic kidney disease and choose to have a kidney transplant, you may live longer than if you choose only to treat your kidney disease with dialysis alone.

In the past, transplants using a kidney from a first-degree relative, such as your father, mother, brother, or sister, were the most successful. But with modern antirejection drugs, kidneys from people you are not related to work well, too. Transplants from living donors or from deceased donors can succeed.

The risks of having a kidney transplant include:

• Rejection of the new kidney.
• Severe infection.
• Bleeding.
• Reaction to the anesthesia used for surgery.
• Failure of the donor kidney.

Kidney transplant may be a better treatment for you than dialysis, because survival rates are better after transplant. You will also be able to live a more normal life, because you won’t have to have dialysis. Although a kidney transplant is an expensive procedure, it may actually be less costly than long-term dialysis treatments.

There is often a long wait before you receive a donor kidney. And there is no guarantee that the transplant will be successful. Fewer complications occur in people who are good candidates for surgery and who do not have other serious medical conditions, such as unstable coronary artery disease or cancer, that may limit their life expectancy.

Not everyone is able to have a kidney transplant. You will not usually have a kidney transplant if you have an active infection or another life-threatening disease, such as cancer or significant heart or lung disease.

After having a kidney transplant, you will have to take medicines that suppress your immune system (antirejection or immunosuppressive medicines) to help prevent your body from rejecting the new kidney. You will need to take these medicines for the rest of your life. Because these medicines weaken your immune system, you will have an increased risk for serious infections. There is also the chance that your body may still reject your new kidney even if you take these medicines. If this happens, you will have to start dialysis and possibly wait for another kidney transplant.

Immunosuppressive medicines also increase your risk of other diseases, such as skin cancer and lymphoma. You have a greater risk for diabetes, high blood pressure, heart disease, cataracts, and inflammation of the liver (cirrhosis) if you are taking these medicines.

What Is an Inguinal Hernia?

Symptoms of Inguinal Hernia

What Is a Hernia?

A hernia occurs when an organ or fatty tissue squeezes through a weak spot in a surrounding muscle or connective tissue called fascia. The most common types of hernia are inguinal (inner groin), incisional (resulting from an incision), femoral (outer groin), umbilical (belly button), and hiatal (upper stomach).

In an inguinal hernia, the intestine or the bladder protrudes through the abdominal wall or into the inguinal canal in the groin. About 96% of all groin hernias are inguinal, and most occur in men because of a natural weakness in this area.

In an incisional hernia, the intestine pushes through the abdominal wall at the site of previous abdominal surgery. This type is most common in elderly or overweight people who are inactive after abdominal surgery.

A femoral hernia occurs when the intestine enters the canal carrying the femoral artery into the upper thigh. Femoral hernias are most common in women, especially those who are pregnant or obese.

In an umbilical hernia, part of the small intestine passes through the abdominal wall near the navel. Common in newborns, it also commonly afflicts obese women or those who have had many children.

A hiatal herniahappens when the upper stomach squeezes through the hiatus, an opening in the diaphragm through which the esophagus passes.

Ultimately, all hernias are caused by a combination of pressure and an opening or weakness of muscle or fascia; the pressure pushes an organ or tissue through the opening or weak spot. Sometimes the muscle weakness is present at birth; more often, it occurs later in life.

Anything that causes an increase in pressure in the abdomen can cause a hernia, including:

• Lifting heavy objects without stabilizing the abdominal muscles
• Diarrhea or constipation
• Persistent coughing or sneezing

In addition, obesity, poor nutrition, and smoking, can all weaken muscles and make hernias more likely.

A physical exam by your health care provider is often enough to diagnose a hernia. Sometimes hernia swelling is visible when you stand upright; usually, the hernia can be felt if you place your hand directly over it and then bear down. Ultrasound may be used to see a femoral hernia, and abdominal X-rays may be ordered to determine if a bowel obstruction is present.

In babies, umbilical hernias may heal themselves within four years, making surgery unnecessary. For all others, the standard treatment is conventional hernia-repair surgery (called herniorrhaphy). It is possible to simply live with a hernia and monitor it. The main risk of this approach is that the protruding organ may become strangulated — its blood supply cut off — and infection and tissue death may occur as a result. A strangulated intestinal hernia may result in intestinal obstruction, causing the abdomen to swell. The strangulation can also lead to infection, gangrene, intestinal perforation, shock, or even death.

Hernia surgery is performed under either local or general anesthesia. The surgeon repositions the herniated tissue and, if strangulation has occurred, removes the oxygen-starved part of the organ. The damaged muscle wall will frequently be repaired with synthetic mesh or tissue.

Increasingly, herniorrhaphy is being performed using a laparoscope, a thin, telescope-like instrument that requires smaller incisions and involves a shorter recovery period and less post-operative pain. Hernia repairs are usually performed as an outpatient procedure. There are usually no dietary restrictions, and work and regular activity may usually be resumed in one or two weeks. Complete recovery usually takes three to four weeks, with no heavy lifting for two to three months. Ask your surgeon for specific instructions after your surgery.

Hernias may return after surgery, so preventive measures are especially important to help avoid a recurrence.

The doctor inserts this tube into your urethra and on into the bladder. Your doctor can see areas of your bladder and urethra that usually don’t show up well on X-rays.

Your doctor can also insert tiny surgical tools through the tube to take samples of tissue (biopsy) or samples of urine.

Small bladder stones and some small growths can also be taken out this way. So the test may help keep you from having to go back for surgery.

Cystoscopy may be done to:

• Find the cause of many urinary system problems. Examples include blood in the urine, pain when you urinate, incontinence, frequent urinary tract infections, and blockages in the urinary tract.
• Remove tissue samples for testing (biopsy).
• Remove a foreign object.
• Insert a stent. This helps urine flow from the kidneys to the bladder.
• Treat certain problems. The test can be used to remove stones or growths, help stop bleeding in the bladder, or remove a blockage.
• Inject a dye that is used for a special type of X-ray of the ureter and kidney.

If you are put to sleep with a general anesthetic, you won’t feel anything during the test. After the anesthetic wears off, your muscles may feel tired and achy. The medicine gives some people an upset stomach.

If a local anesthetic is used, you may feel a burning sensation or an urge to urinate when the cystoscope tube is inserted and removed. When sterile water or saline is put in your bladder, you may feel a cool sensation, an uncomfortable fullness, and an urgent need to urinate. Try to relax during the test by taking slow, deep breaths. Also, if the test takes a long time, lying on the table can become tiring and uncomfortable.

If a spinal anesthetic is used, you may find it uncomfortable to lie curled up on your side while the anesthetic is injected. You will probably feel a brief sting when the medicine is injected. The day after the test, you may feel tired and have a slight backache.

Most people report that this test is not nearly as uncomfortable as they thought it would be.

Cystoscopy is generally a very safe test. General anesthesia has some risks. The test doesn’t affect sexual function.

The most common side effect is a short-term swelling of the urethra. This can make it hard to urinate. A catheter inserted in your bladder can help drain the urine until the swelling goes away. Bleeding sometimes occurs, but it usually stops on its own.

Diverticulosis is a condition that develops when pouches (diverticula ) form in the wall of the colon (large intestine). These pouches are usually very small (5 to 10 millimeters) in diameter but can be larger.

In diverticulosis, the pouches in the colon wall do not cause symptoms. Diverticulosis may not be discovered unless symptoms occur, such as in painful diverticular disease or in diverticulitis. As many as 80 out of 100 people who have diverticulosis never get diverticulitis.¹ In many cases, diverticulosis is discovered only when tests are done to find the cause of a different medical problem or during a screening exam.

The reason pouches (diverticula) form in the colon wall is not completely understood. Doctors think diverticula form when high pressure inside the colon pushes against weak spots in the colon wall.

Normally, a diet with adequate fiber (also called roughage) produces stool that is bulky and can move easily through the colon. If a diet is low in fiber, the colon must exert more pressure than usual to move small, hard stool. A low-fiber diet also can increase the time stool remains in the bowel, adding to the high pressure.