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Care During Chemotherapy and Beyond

Liver Problems - Liver Dysfunction (Hepatotoxicity) Brought On By Chemotherapy



Includes: Bilirubin, blood level, elevated liver enzymes, and hepatotoxicity.

COMMON LIVER EXAMINATIONS

The following are common tests or examinations that your healthcare provider may perform on you to determine whether you have liver damage caused by chemotherapy (such as hepatotoxicity):

Computerized Tomography (CT) Scan - This test is more specific than plain x-rays, as a computer takes x-rays of your chest, abdomen or pelvis region, from different angles, to show a cross-sectional view of your organs in your body. How it works:

  • As you lie on a movable table, a scanner inside of a machine moves around you. X-rays are taken at different angles, as the computer records the pictures. The computer then puts the pictures in a certain order, so that the specialist can interpret the findings.
  • Sometimes, you are required to drink a dye solution (called oral contrast), or a liquid dye is injected into a large vein. This helps to improve the picture, as the computer can then notice abnormalities as the dye passes through your body.
  • You may be required to fast (not eat) after midnight the day of the exam. Your healthcare provider will provide specific instructions to you.

ERCP (Endoscopic Retrograde Cholangiopancreatography): Using a long, narrow tube, an ERCP allows your healthcare provider to see your liver, gallbladder, pancreas and sphincter of Oddi in your body.

  • Your gall bladder, pancreas and liver are connected to your small intestine by way of the common bile duct.
  • Your pancreas is connected to the common bile duct (CBD) by way of the pancreatic duct.
  • The sphincter of Oddi is a muscular organ that opens and closes for fluid contents to pass into your small intestine. This helps with digestion.
  • You may receive this exam if you:
    • Have a stone or blockage in the CBD, or pancreatic duct.
    • If there is a suspected growth in the pancreatic or your bile duct.
    • If you have a certain form of jaundice or icterus (yellowing of the skin, eyes and mucous membranes).
  • During the procedure, after you have not eaten after midnight that day, your doctor will pass a thin tube down your throat, through your esophagus (the tube that connects your throat to your stomach). Down this long, narrow tube, your doctor will be able to visualize the liver, pancreas, gall bladder and your sphincter of Oddi.
  • Your doctor may be able to break the blockage, if present, or place a stent to redirect the bile fluid that may have accumulated.
  • Your doctor or healthcare provider will give you specific instructions on what to expect with this procedure, including the risks, benefits and alternatives of treatment.

Liver Biopsy:  A liver biopsy is where the physician takes a sample of liver tissue for examination. You may be ordered this test if your doctor or healthcare provider suspects that chemotherapy may have resulted in liver dysfunction or damage. It may tell your doctor if there is damage to the liver due to infection, or tumor, or due to another cause.

  • This procedure may be done under local or general anesthesia.
  • You will be asked to eat nothing after midnight on the day of your exam.
  • After the procedure, you will be monitored for any signs of bleeding.
  • Your doctor or healthcare provider will give you specific instructions on what to expect with this procedure, including the risks, benefits and alternatives of treatment.
  • If you have any questions or concerns, make sure to ask questions.

Note:  We strongly encourage you to talk with your health care professional about your specific medical condition and treatments. The information contained in this website is meant to be helpful and educational, but is not a substitute for medical advice.


COMMON LIVER CONDITIONS

BILIRUBIN BLOOD LEVEL

What is a bilirubin blood level?

  • Bilirubin is a chemical that is released into your blood, which results from the breakdown of red blood cells. Bilirubin is used by the liver, to make bile.
  • Normally, only a small amount of bilirubin is present in your blood. When the blood bilirubin levels are increased, it may be a sign of a liver or blood problem.
  • Because bilirubin can appear to be somewhat reddish in color, as the levels in the blood go higher, the whites of your eyes (sclerae) may turn yellow. Also, your skin may look yellow. This is called jaundice, or icterus. 
  • You may have this test performed if your healthcare provider wants to:
    • Check for blockage in your bile duct, liver or gall bladder - Bile is released into your intestines by way of the common bile duct. If there is a blockage in the gallbladder or liver, your blood bilirubin levels will rise as a result.
    • Check to see how your liver is working - if there is an infection or damage to the liver due to chemotherapy, the bilirubin levels may rise
    • See if there are certain blood problems, such as hemolytic anemia - This form of anemia results from the breaking down or destruction of red blood cells. Bilirubin is released from red blood cells. If there is increased destruction, the bilirubin levels will rise.
  • Other reasons for increased bilirubin levels:
    • You may have an infection or inflammation of your liver (hepatitis), or gall bladder.
    • Certain medications, including chemotherapy drugs, can cause increased bilirubin levels and liver dysfunction.
    • Certain genetic conditions, such as Gilbert's syndrome, may cause slightly increased bilirubin levels.
Normal Biliribin Level*
0.2-1.2 mg/dL > 3.0 jaundice may appear
*normal values may vary from laboratory to laboratory


What are some symptoms to look for?

  • Some people with elevated bilirubin levels do not notice any difference in their activity or energy levels.
  • With higher bilirubin levels, you may be overly tired, or very weak (fatigued). It may be hard for you to do any kind of your normal activities.
  • You may have abdominal pain associated with your jaundice. You may not have any pain at all. Notify your healthcare provider if you have any jaundice with or without pain.
  • Your skin, eyes, mucous membranes (the moist areas of your eyes, and mouth especially), may become yellow.
  • When you have a bowel movement, your stools may be lighter in color than they normally are. Bile is released into your intestines through the common bile duct. If there is a blockage, and the bile (or bilirubin) is flowing through your blood instead of being released into the intestines, your stools may be clay colored. 

Things you can do if you suspect chemotherapy has caused liver dysfunction or damage:

  • If you notice that you are jaundiced, notify your healthcare provider immediately.
  • Make sure you tell your doctor, as well as all healthcare providers, about any other medications you are taking (including over-the-counter, vitamins, or herbal remedies).  Do not take Tylenol®, aspirin or products containing aspirin unless your healthcare provider permits this.
  • Remind your doctor or healthcare provider if you have a history of diabetes, liver, kidney, or heart disease.
  • You may be at risk for bleeding. Use an electric razor and soft toothbrush to minimize bleeding. Also notify your healthcare provider with any signs of bleeding.
  • You should avoid alcohol and acetaminophen (Tylenol®).  Alcohol and Tylenol are processed through the liver. If you have liver damage, your liver can be further damaged with alcohol and Tylenol intake. 
  • If you are ordered a medication to treat this disorder, do not stop taking any medication unless your healthcare provider tells you to. Take the medication exactly as directed. Do not share your pills with anyone. 
  • If you experience symptoms or side effects, especially if severe, be sure to discuss them with your health care team.  They can prescribe medications and/or offer other suggestions that are effective in managing such problems.
  • Keep all your appointments for your treatments.

Drugs that may be prescribed by your doctor for liver dysfunction:

  • There are no drugs to specifically treat increased bilirubin levels, unless there is an infection, blockage or tumor. Treatment is aimed at correcting the underlying cause of increased bilirubin levels, and minimizing further damage to your liver, if damage is present.
  • Many chemotherapy drugs are processed through the liver, which can cause further damage. Depending on the extent of liver damage you have experienced, and your overall health status, your doctor may recommend reducing the dose of certain medications, or avoiding them all together.  Below are a few medications that may be prescribed with severe liver damage:
    • Diuretics - May be known as "water pills" as they work to prevent or treat fluid accumulation by making you urinate out extra fluid. Some examples of this medication may include furosemide (Lasix®)and Hydrochlorthiazide. You may receive these drugs if your liver is not working properly, and you are accumulating fluid in your body. You may receive this medication alone or in combination with other medications.
    • Pain medicine- your healthcare provider may order medication for pain, if you have any. Many of these are processed through the liver, but in certain dosages are safe. You should avoid Tylenol, however, as it may worsen liver damage.
  • Do not stop any medications abruptly, as serious side effects may occur

If you begin to see signs of liver damage or dysfunction either during or after chemotherapy treatments, the following guide gives advice about when to call your doctor or health care provider:

  • Severe fatigue, or worsening jaundice
  • Abdominal pain, severe nausea and vomiting
  • Bleeding that does not stop after a few minutes
  • Any new rashes on your skin.
  • Any unusual swelling in your feet and legs, or weight gain of greater than 3 to 5 pounds in 1 week.

Note:  We strongly encourage you to talk with your health care professional about your specific medical condition and treatments. The information contained in this website is meant to be helpful and educational, but is not a substitute for medical advice.


ELEVATED LIVER ENZYMES

What are elevated liver enzymes?

  • Liver enzymes are proteins made by the liver that are measured in the blood, with a blood draw. Liver enzymes tell us how well your liver is functioning.
  • Your liver is an organ in your body that helps to:
    • Process drugs and toxins
    • Eliminate waste products and fats from your body
    • Store and regulate blood sugar levels
  • There are many different enzymes in the body that have different tasks. Your doctor or healthcare provider may order a liver (hepatic) function panel, to see if there is damage to any one area of your liver.  These are the proteins (or enzymes) that are measured:
    • Alkaline phosphatase (ALP, AP, or Alk Phos)
    • Alanine aminotransferase (ALT), formerly known as serum glutamic pyruvic transaminase (SGPT)
    • Aspartate aminotransferase (AST), formerly known as serum glutamic oxaloacetic transaminase (SGOT)
    • Lactate dehydrogenase (LDH)
Liver Enzymes (normal values)*
Alkaline Phosphatase (ALP) 20-120 U/L
ALT 5-50 U/L
AST 7-40 U/L
Lactate Dehydrogenase (LDH, LD) 100-220 U/L
*normal values may vary from laboratory to laboratory
  • Other tests of liver function include:
    • Bilirubin level - indicates bile production and metabolism. Normal bilirubin levels are 0.2 to 1.2 mg/dL of blood. If chemotherapy has caused liver damage or dysfunction, you may notice a yellowing of the skin, called jaundice or icterus, when the bilirubin level reaches 3.0 mg/dL.
    • Bleeding times - such as Prothombin time (PT) - may be prolonged if there is liver damage. This means it may take longer for your blood to form a blood clot, or for you to stop bleeding if you are injured.
  • Each of these enzymes or proteins, if elevated, will tell your doctor if there is a problem with a certain area of your liver. It will also suggest if there is a problem elsewhere in the blood.
  • Your liver enzymes may be elevated if:
    • You have an infection, blockage or damage to your liver.
    • There may be a blockage to the liver, gall bladder or the common bile duct, such as gallstones, tumor, or infection.
    • Certain drugs or medications may have damaged your liver. These may include alcohol, Tylenol®, certain types of chemotherapy, and medications to treat high blood cholesterol levels, such as atorvastatin (Lipitor®), or simvastatin (Zocor®).  Sometimes liver enzyme elevations may be temporary. 
  • Your liver enzymes may be elevated, even if there is no damage to the liver at all. For example, ALP is made by the bones and the liver. Your blood ALP levels may be elevated due to damaged the bones, not a damaged liver. 
  • ALT, AST levels may be elevated if there is damage to the heart.

What are some symptoms to look for?
If you have elevated liver enzymes, you may experience many symptoms. These may include:

  • Some people with elevated liver enzyme levels do not notice any difference in their activity or energy levels.
  • With higher liver enzyme levels, you may be overly tired, or very weak (fatigued). It may be hard for you to do any kind of your normal activities.
  • You may bleed easier if your blood clotting factors are affected by the liver damage (it may take your blood longer to form a blood clot).
  • You may have abdominal pain associated with a yellowish coloring to your skin, eyes and mucous membranes (the moist areas of your eyes and mouth); also known as jaundice or icterus.  You may not have any pain at all. Notify your healthcare provider if you have any jaundice with or without pain.
  • If your bilirubin levels are elevated, when you have a bowel movement, your stools may be lighter in color than they normally are. Bile is released into your intestines through the common bile duct. If there is a blockage, and the bile (or bilirubin) is flowing through your blood instead of being released into the intestines, your stools may be clay colored. 
  • Your legs may be swollen, especially in your feet and ankles. You may gain "water" weight easily, or feel bloated.

Things you can do to minimize liver damage during or after chemotherapy:

  • If you notice that you are jaundiced, notify your healthcare provider immediately.
  • Make sure you tell your doctor, as well as all healthcare providers, about any other medications you are taking (including over-the-counter, vitamins, or herbal remedies).  Do not take Tylenol®, aspirin or products containing aspirin unless your healthcare provider permits this.
  • Remind your doctor or healthcare provider if you have a prior history of diabetes, liver, kidney, or heart disease.
  • You should avoid alcohol and acetaminophen (Tylenol®).  Alcohol and Tylenol are processed through the liver. If you have liver damage, your liver can be further damaged with alcohol and Tylenol® intake. 
  • If you are ordered a medication to treat this disorder, do not stop taking any medication unless your healthcare provider tells you to. Take the medication exactly as directed. Do not share your pills with anyone.
  • If you experience symptoms or side effects, especially if severe, be sure to discuss them with your health care team.  They can prescribe medications and/or offer other suggestions that are effective in managing such problems.
  • Keep all your appointments for your treatments.

Drugs that may be prescribed by your doctor:

There are no drugs to specifically treat increased liver enzyme levels, unless there is an infection, blockage or tumor. Treatment is aimed at correcting the underlying cause of increased liver enzyme levels, and minimizing further damage to your liver.  Many drugs are processed through the liver, which can cause further damage your liver. Depending on the extent of liver damage you have experienced, and your overall health status, your doctor may recommend reducing the dose of certain medications, or avoiding them all together.

  • Diuretics - may be known as "water pills" as they work to prevent an overload of fluid by making you urinate out extra fluid. Some examples of this medication may include furosemide (Lasix®), and hydrochlorthiazide. You may receive this medication alone or in combination with other medications.
  • Pain medicine- your healthcare provider may order medication for pain, if you have any. Many of these are processed through the liver, but in certain dosages are safe. You should avoid Tylenol®, however, as it may worsen liver damage.
  • Do not stop any medications abruptly, as serious side effects may occur

When to call your doctor or health care provider:

  • Severe fatigue, or worsening jaundice
  • Abdominal pain, severe nausea and vomiting
  • Bleeding that does not stop after a few minutes
  • Any new rashes on your skin.
  • Any unusual swelling in your feet and legs, or weight gain of greater than 3 to 5 pounds in 1 week.

Note:  We strongly encourage you to talk with your health care professional about your specific medical condition and treatments. The information contained in this website is meant to be helpful and educational, but is not a substitute for medical advice.


HEPATOTOXICITY

What is hepatotoxicity?

  • Simply stated, hepatotoxicity is when a condition or a treatment (such as medications or chemotherapy) has caused damage to your liver.
  • There are mild forms of hepatotoxicity, and severe forms of hepatotoxicity, both of which cause damage to the liver. The severe form of hepatotoxicity may result in hepatitis, or an inflammation of your liver.
  • Your liver is the largest organ in your body, which sits in the right upper side of your abdomen. The liver's most important task is to filter toxic substances from your body, including many different medications such as chemotherapy drugs, antibiotics, Tylenol, and alcohol.
  • Other important tasks that the liver performs may include:
    • With help from the spleen, the liver removes old red blood cells from circulating in the blood
    • The liver makes bile to digest fats
    • The liver is responsible for processing vitamins, minerals, proteins and glucose (sugar) - all-important to our survival.
  •  When the liver is damaged by chemotherapy treatments, it doesn't work as well. Your healthcare provider may order certain blood work to determine the extent of liver damage. These tests may include:
  • Bilirubin - a chemical that is released into your blood, which results from the breakdown of red blood cells. Bilirubin is used by the liver, to make bile.
    • Normally, only a small amount of bilirubin is present in your blood. When the blood bilirubin levels are increased, it may be a sign of a liver or blood problem.
    • Because bilirubin can appear to be somewhat reddish in color, as the levels in the blood go higher, the whites of your eyes (sclerae) may turn yellow. Also, your skin may look yellow. This is called jaundice, or icterus.  
    • Normal bilirubin levels are 0.2 to 1.2 mg/dL of blood. You may notice jaundice when the bilirubin level reaches 3.0 mg/dL.
  • Alkaline phosphatase (ALP, AP, or Alk Phos)
  • Alanine aminotransferase (ALT), formerly known as serum glutamic pyruvic transaminase (SGPT)
  • Aspartate aminotransferase (AST), formerly known as serum glutamic oxaloacetic transaminase (SGOT)
  • Lactate dehydrogenase (LDH)
  • Bleeding times - such as Prothombin time (PT) - may be prolonged if there is liver damage. This means it may take longer for your blood to form a blood clot, or for you to stop bleeding if you are injured.
  • Each of these enzymes or proteins, if elevated, will tell your doctor if there is a problem with your liver. It will also suggest if there is a problem elsewhere in the blood. 
  • Elevated enzyme levels do not necessarily mean that chemotherapy has caused liver dysfunction. Your liver enzymes may be elevated, even if there is no damage to the liver. In example, ALP is made by the bones and the liver. Your blood ALP levels may be elevated due to damaged the bones, not a damaged liver. 
  • ALT, AST levels may be elevated if there is damage to the heart.

What are some symptoms to look for?
If you have developed hepatotoxicity, you may experience many symptoms. These may include:

  • Some people with mild forms of hepatotoxicity do not notice any difference in their activity or energy levels.
  • With higher liver enzyme levels, and more damage to the liver, you may be overly tired, or very weak (fatigued). It may be hard for you to do any kind of your normal activities.
  • You may bleed easier if your blood clotting factors are affected by the liver damage (it may take your blood longer to form a blood clot).
  • You may have abdominal pain associated with jaundice. You may not have any pain at all. Notify your healthcare provider if you have any jaundice with or without pain.
  • Your skin, eyes, mucous membranes (the moist areas of your eyes, and mouth especially), may become yellow.
  • If your bilirubin levels are elevated, when you have a bowel movement, your stools may be lighter in color than they normally are. Bile is released into your intestines through the common bile duct. If there is a blockage, and the bile (or bilirubin) is flowing through your blood instead of being released into the intestines, your stools may be clay colored. 
  • Your legs may be swollen, especially in your feet and ankles. You may gain "water" weight easily, or feel bloated.

Things you can do to minimize hepatotoxicity during or after chemotherapy:

  • If you notice that you are jaundiced, notify your healthcare provider immediately.
  • Make sure you tell your doctor, as well as all healthcare providers, about any other medications you are taking (including over-the-counter, vitamins, or herbal remedies).  Do not take Tylenol®, aspirin or products containing aspirin unless your healthcare provider permits this.
  • Remind your doctor or healthcare provider if you have a history of diabetes, liver, kidney, or heart disease.
  • You should avoid alcohol and acetaminophen (Tylenol®). Alcohol and Tylenol® are processed through the liver. If you have liver damage, your liver can be further damaged with alcohol and Tylenol® intake. 
  • If you are ordered a medication to treat this disorder, do not stop taking any medication unless your healthcare provider tells you to. Take the medication exactly as directed. Do not share your pills with anyone.
  • If you experience symptoms or side effects, especially if severe, be sure to discuss them with your health care team.  They can prescribe medications and/or offer other suggestions that are effective in managing such problems.
  • Keep all your appointments for your treatments.

Drugs that may be prescribed by your doctor:

  • There are no drugs to specifically treat hepatotoxicity. Treatment is aimed at avoiding what caused the damage, and correcting the underlying cause of increased liver enzyme and bilirubin levels, minimizing further damage to your liver.
  • Many drugs are processed through the liver, which can cause further damage your liver. It is important if you have liver damage, that your healthcare provider avoids drugs that will further damage your liver. Depending on the extent of liver damage you have experienced, and your overall health status, your doctor may recommend reducing the dose of certain medications, or avoiding them all together. 
  • Diuretics - May be known as "water pills" as they work to prevent or treat fluid accumulation by making you urinate out extra fluid. Some examples of this medication may include furosemide (Lasix®), and hydrochlorthiazide. You may receive these drugs if your liver is not working properly, and you are accumulating fluid in your body. You may receive this medication alone or in combination with other medications.
  • Pain medicine- your healthcare provider may order medication for pain, if you have any. Many of these are processed through the liver, but in certain dosages are safe. You should avoid Tylenol, however, as it may worsen liver damage.
  • Do not stop any medications abruptly, as serious side effects may occur.

If you suspect hepatotoxicity or other liver dysfunction during or after chemotherapy, the following list suggests when to call your doctor or health care provider:

  • Severe fatigue, or jaundice
  • Abdominal pain, severe nausea and vomiting
  • Bleeding that does not stop after a few minutes
  • Any new rashes on your skin
  • Any unusual swelling in your feet and legs, or weight gain of greater than 3 to 5 pounds in 1 week.

Note:  We strongly encourage you to talk with your health care professional about your specific medical condition and treatments. The information contained in this website is meant to be helpful and educational, but is not a substitute for medical advice.