FREQUENTLY ASKED QUESTIONS



  • What are some of the myths about liver cancer?
  • Can pancreatic cancer be diagnosed without doing an invasive procedure?
  • Is it better to get a second opinion from another doctor before starting a new medication?
  • Why do some surgeons prefer double gloving?
  • How do other doctors feel confident in treating the patients. I am in the final phase of my internship and though I have seen a variety of cases, I don’t feel confident while treating a patient without any guidance? Will it come to me while doing PG?
  • What are the criteria for performing a surgical liver transplant where the liver is taken from a deceased person from a liver bank hospital similar to eye banks?
  • Why are some doctors remembered by their patients?
  • What are the differences between a CT, MRI, and ultrasound scan? Which one should you go for if you’re having abdominal pain or other symptoms of appendicitis?
  • Why are people strapped down during surgery if they’re already unconscious and paralyzed?
  • Do people who receive organ transplants ever feel like they don’t belong in their bodies anymore?
  • How long does it take for your liver to completely fail if you have cirrhosis?
  • My uncle is suffering from liver cancer at the 4th stage. What are some suggestions for some treatment?
  • Can cancer spread by using a lipstick of a cancer patient?
  • Does gallbladder removal decrease immunity?
  • Will abdominal ultrasound show fatty liver?
  • How is the Gilbert’s syndrome diagnosed?
  • Can I do abs exercises after 6 months of an open appendectomy?
  • Do all patients with cirrhosis have some degree of portal hypertension or is there a period of time early on where the portal pressure gradient is completely normal?
  • Can pancreatic cancer come back after 13 years?
  • Does gallbladder removal decrease immunity?
  • Is hemorrhoid a sign of cancer?
  • Which is the busiest organ – the heart or the liver?
What are some of the myths about liver cancer?

The biggest myth about liver disease including liver cancer is that only persons who consume large quantities of alcohol are affected.

Although it is true that alcohol damages the liver and can lead to liver disease including cirrhosis and liver cancer, it contributes only to a third of patients with liver failure who undergo liver transplantation. Another significant cause is infection with viral hepatitis B & C.

The emerging threat for liver disease and liver cancer today is lifestyle related. In medical terms it is called “Metabolic Syndrome” and comprises a combination of obesity, diabetes (insulin resistance), hypertension and hypercholesterolemia (dyslipidemia). It is projected that this will become the most common indication for liver transplantation in times to come. At an early stage, it is detected as fatty liver (NAFLD), followed by elevated liver enzymes (NASH), with progression to cirrhosis and liver cancer in about 10–15%.

Can pancreatic cancer be diagnosed without doing an invasive procedure?

Many intraabdominal cancers are diagnosed and staged using imaging and blood tests. There are certain peculiarities in cancer tissues that enable differentiation from normal surrounding tissues on a CT, MRI or PET scan. Additionally, there are substances (tumor markers) secreted by cancer cells into the blood that can be detected on testing.

If the cancer is curable by surgery, then this information is sufficient to plan resection. At surgery, the entire cancer bearing tissue is removed and sent for pathology evaluation. If the cancer is advanced at presentation, a biopsy is preferred before starting chemotherapy or radiation. In this day of precision oncology, advanced molecular assessment may additionally be performed to select drugs or agents that will have maximal effect on cancer cells while minimising side effects.

Is it better to get a second opinion from another doctor before starting a new medication?

If there is a reasonable doubt in your mind after discussions with your primary doctor, go ahead.

If the first doctor was clear in his/her explanation of the disease process, spent time listening to your queries and answering them to your satisfaction, the treatment plan sounds logical, a second opinion is unlikely to help and may cause more confusion.

In clinical practice, we encounter different situations when patients come seeking a second opinion. Some come because they are not clear regarding the disease process or treatment plan or don’t feel comfortable with the treating doctor. Some come for the expertise and experience we have in treatment of specific diseases. Some come for the brand or name of the hospital. But some are seeking an opinion to hear what they want to. Or because a neighbour, colleague or friend got treated and did well.

Medicine is not an exact science, it has to be individualized according to the patient’s age, disease stage, coexisting disease like diabetes, heart disease, personal habits such as alcohol or smoking. There may be different approaches to solve a complex problem and more than one may apply to a patient. You have to eventually trust a doctor and the system and follow the treatment process.

Why do some surgeons prefer double gloving?

It is for safety reasons.

During long & complex surgeries, the chances of puncture or tear in the gloves is high. It may go unnoticed and place the surgeon and patient at higher risk of cross-infection. It is strongly recommended in surgeries where there is a high-risk of blood borne transmission, e.g. patients infected with viral hepatitis B & C , HIV etc. Even during routine surgeries, chance of needle-prick and electrocautery burn injuries are not uncommon. Some surgeons get used to double-gloving and prefer it for all surgeries as a universal precaution. Other surgeons do not prefer it routinely as it reduces the “feel” of tissue.

How do other doctors feel confident in treating the patients. I am in the final phase of my internship and though I have seen a variety of cases, I don’t feel confident while treating a patient without any guidance? Will it come to me while doing PG?

Confidence is earned over time by repetition and refinement. It is said that about 10,000 hours of practise is required to master a new skill. It is normal to feel anxious and insecure when beginning internship, which is the first time you are responsible for your patients. That is why there is a system in place, protocols to be followed and seniors to guide you. The purpose of internship is to expose the medical student to various clinical applications of medicine & surgery.

During post-graduation you undergo in-depth training in your chosen speciality. During initial days of PG, you will again go through the same feelings of anxiety and underconfidence, especially when seniors seem to know exactly what they are doing. It is important to remember that everyone has gone through the same feelings.

Just remember to put one foot in front of the other, day after day. Be a hard worker and a good observer, even in how not to do things. Don’t hesitate or be afraid to ask for help from your colleagues, and your support staff. You would be surprised at how much insight an experienced nurse or technician can offer. Read theory/lierature well, on your own, after every new or difficult patient you encounter. Over a period of time, a lot of basic skills will become second nature to you, like walking or cycling become.

Since you are responsibile for patients’ lives, you will always feel a certain tension which never goes away completely. It is not a bad feeling, as long as it doesn’t overwhelm you. In fact, it helps you prepare and perform better every time. This is how most, if not all medical professionals feel.

What are the criteria for performing a surgical liver transplant where the liver is taken from a deceased person from a liver bank hospital similar to eye banks?

Organs which need blood supply cannot be stored in banks to be transplanted when needed. They can only be maintained for short durations of time (typically a few hours upto a maximum of 12 hours for liver) under stringent controlled conditions, while the recipient is undergoing surgery to receive the donor organ.

The suitable recipient for the liver is decided and prepared for surgery before the donor operation is completed. The recipients are chosen from a waiting list maintained by the hospital, approved & shared with the appropriate government authorities e.g. Jeevandaan in Telangana, Transtan in Tamilnadu, SOTTO, NOTTO etc. The criteria for prioritisation are blood group matching, organ failure score (MELD Sodium score) and fitness on the day of surgery. This information is transparent, monitored by the government body and accessible to the public on the designated websites mentioned above.

Why are some doctors remembered by their patients?

Patients’ come in contact with doctors during a vulnerable phase of their life. They are in pain, anxiety, maybe even fearing possible death.

When treating doctors show empathy and offer reassurance and medical/surgical treatment, it removes/reduces suffering and offers hope of a fresh lease of life. This is a watershed moment in the patient’s life and they remember it for a long time. This effect is more pronounced in patients suffering from life threatening illnesses.

As a patient, i remember the doctors who were self assured with kind eyes, comforting words, spent time listening to what I had to say, explained about the disease and treatment plan. I made me feel acknowledged and helped build trust.

As a doctor, the gratitude expressed by patients goes a long way in reinforcing that we are in the right profession doing the right thing. We may not always be successful, but we are doing our best to ease the pain and offer hope for our patients and their loved ones.

What are the differences between a CT, MRI, and ultrasound scan? Which one should you go for if you’re having abdominal pain or other symptoms of appendicitis?

Based on the clinical history and physical examination, the treating doctor will narrow down possible causes for abdominal pain. Appropriate investigations are then chosen to arrive at the most likely diagnosis and plan further treatment.

The general guiding principle for choosing investigations is to start from the simplest, least expensive, least invasive test (ultrasound in this case) and progress to the more advanced, invasive , expensive imaging test that will deliver the desired result (CT or MRI). For example, for a general health check, an ultrasound is sufficient for screening abdominal organs.

Different maging modalities (USG/CT/MRI) have varying sensitivity, specificity & accuracy for organs eg. Ultrasound for gallbladder, MRI for liver tumors, MRCP for biliary imaging, CECT for vascular anatomy etc. Hence, the treating doctor or specialist is best placed to decide the appropriate imaging modality.

Why are people strapped down during surgery if they’re already unconscious and paralyzed?

It is precisely because the patients are unconscious and paralyzed that they need to be supported during surgery under general anaesthesia.

When we are conscious, sensory inputs of balance and pressure/pain alert us to correct/change position and protect us from harming ourselves. Pressure on bony prominence’s results in decreased blood supply and if prolonged, cause pressure sores. To prevent this from happening during surgery, adequate padding to elbows, knees is provided. Changes in patient position required for access during surgery (head up, head down or lateral tilts/turns) can lead to slips/falls unless patients are adequately restrained. These maneuvers are done once patient is under anesthesia before starting surgery.

Do people who receive organ transplants ever feel like they don’t belong in their bodies anymore?

In my interactions with thousands of liver transplant recipients, i have come across a few instances, especially early (within the first 3 months) after transplant surgery, when patient’s families have reported changes in patient behaviour (usually being irritable or short-tempered) or a newfound appetite for some food item they didn’t taste/like before. These instances have been too few and far in between to establish a pattern, and can be more logically attributed to the stress of prolonged sickness and dietary restrictions than more metaphysical reasons. Over a period of time, recipients accept transplanted organs as part of their bodies and don’t think about it as a separate attachment on a daily basis. They do remember it on occasions, such as the day of their transplant which is a life-changing event and are grateful for the new lease of life.

How long does it take for your liver to completely fail if you have cirrhosis?

It varies depending on the cause of liver cirrhosis and underlying health condition (age, comorbid illnesses) of the person.

When there is evidence of cirrhosis on radiological imaging e.g. ultrasound scan, and biochemical tests (liver function tests) without any manifestations of liver failure, it is medically called “compensated cirrhosis”. The liver still has adequate functional reserve capacity to meet the body’s requirements. The possibility of developing liver failure at this stage is ~10%/ year.

Once the functional liver reserve is depleted, clinical symptoms and signs of liver failure become evident. This may include one or more of the following;

  1. Bleeding into the gastrointestinal tract manifesting as vomiting of blood and/or black, tarry stools.
  2. Accumulation of fluid in the abdomen and tissues (commonly presenting as swelling of feet).
  3. Alterations in consciousness levels (confusion, disorientation, drowsiness).
  4. Jaundice (yellowing of the skin & eyes), dark yellow-orange/red coloured urine.

This phase is medically called “decompensated cirrhosis”. From here on, the annual risk of death is 20–50% without appropriate intervention such as liver transplantation.

My uncle is suffering from liver cancer at the 4th stage. What are some suggestions for some treatment?

Liver cancer can be primary i.e. cancer originating from the liver or metastatic i.e. cancer spread from another organ in the body.

Stage 4 cancer implies that the cancer is not confined to the liver alone and either involves major blood vessels around the liver or organs outside the liver. At this stage, treatment options are limited.

Depending on the type and grade of cancer which will be determined by a liver biopsy, the appropriate medication (chemotherapy, immunotherapy) will be chosen. A medical oncologist will help the patient with decision making. Unfortunately, survival is generally limited to a few months with stage 4 disease.

Can cancer spread by using a lipstick of a cancer patient?

No, absolutely not.

Cancer is the body’s own cells which have turned rogue. It is not an infectious condition and cannot spread from person to person. Environmental carcinogens such as toxins (smoking, alcohol, aflatoxin) can be common to a group of people living in the same area with similar cultural, dietary habits etc.

Does gallbladder removal decrease immunity?

Gall bladder removal does not have any impact on immunity or digestion.

Bile is produced by the liver and carried to the intestine by the bile duct. The gallbladder is an organ for storage of bile in the inter-digestive period. After gallbladder removal, bile continues to be produced by the liver as before. The bile duct adapts to store bile by increasing in diameter thus increasing storage capacity.

Will abdominal ultrasound show fatty liver?

Yes. An abdominal ultrasound scan is one of the most widely available, economical and least invasive diagnostic procedure performed for screening abdominal organs including liver. Fatty liver, gallbladder stones are commonly diagnosed on ultrasound. In most patients, no further diagnostic imaging is required and treatment is directed at the underlying cause (obesity, diabetes, dyslipidemia, alcohol abstinence etc). However in certain cases, further tests to evaluate fat content and associated changes such as inflammation may be required. These are performed using Liver Elastography (Fibroscan or MR) or a biopsy.

How is the Gilbert’s syndrome diagnosed?

The diagnosis of Gilbert’s is usually clinical as it is a benign liver condition that does not affect normal lifespan or general health. Genetic testing is available but not generally indicated as the cost-benefit ratio is low.

Mild hyperbilirubinemia (usually not exceeding 3–4 mg/dl) with predominant elevation of the indirect bilirubin component with normal liver enzymes is suggestive of Gilbert’s syndrome. It is usually detected incidentally on a medical checkup and and persists with minor fluctuations over time. Imaging of the liver is normal and screening for other common causes of jaundice such as viral hepatitis is negative.

Can I do abs exercises after 6 months of an open appendectomy?

Yes, you can.

Open appendectomy incision involves a muscle splitting rather than a cutting incision. Even after routine abdominal surgeries, abdominal exercises are allowed (in fact, recommended to maintain muscle tone and strength), after a reasonable period of time to allow for healing (~3 months). It is important to take it slow and easy to begin with and increase the intensity over time according to your tolerance.

Do all patients with cirrhosis have some degree of portal hypertension or is there a period of time early on where the portal pressure gradient is completely normal?

Cirrhosis causes increased resistance to the flow of blood through the liver resulting in portal hypertension. Compensatory mechanisms are activated to maintain adequate portal blood flow. The clinical term for this stage is compensated cirrhosis. Although clinically not apparent, the resistance to blood flow through the liver is higher than normal.

With worsening cirrhosis, there is increasing portal hypertension and compensatory mechanisms are overwhelmed resulting in decompensated cirrhosis. This becomes apparent with the onset of ascites (accumulation of fluid in the abdomen or legs) or bleeding from ruptured gastrointestinal varices.

Can pancreatic cancer come back after 13 years?

Yes, cancers can recur at any time during the patient’s lifetime.

The possibility of recurrence varies depending on the location and extent of the cancer (pancreatic cancer is traditionally aggressive), effectiveness of the treatment applied (curative or palliative), biologic behaviour of the cancer as assesed on pathology analysis of the biopsy or surgical specimen (well, moderate or poorly differentiated, vascular and lymphatic involvement etc). Additional treatment such as chemotherapy may be recommended after complete surgical removal of the cancer to kill micrometastases and reduce the likelihood of recurrence.

A less agressive cancer that is well contained and is completely removed at surgery has a lower chance of recurrence than one that is not. Surveillance with periodic blood tests for tumor marker levels and imaging is recommended after curative treatment to detect recurrence early and manage them effectively. Longer the recurrence free duration, lower the likelihood of recurrence. However, there are no features or time duration that can rule out cancer recurrence completely.

Does gallbladder removal decrease immunity?

Gall bladder removal does not have any impact on immunity or digestion.

Bile is produced by the liver and carried to the intestine by the bile duct. The gallbladder is an organ for storage of bile in the inter-digestive period. After gallbladder removal, bile continues to be produced by the liver as before. The bile duct adapts to store bile by increasing in diameter thus increasing storage capacity.

Is hemorrhoid a sign of cancer?

Hemorrhoids are not a sign of cancer.

However, hemorrhoids and colorectal cancer can coexist in a patient. Since both conditions present with bleeding after passing stools, it is possible to identify hemorrhoids as the cause and overlook the cancer. Hence there are guidelines that prescribe colonoscopy or sigmoidoscopy for patients presenting with lower gastrointestinal bleeding.

Which is the busiest organ – the heart or the liver?

Visibly, the heart…but in the background, the liver is the busiest organ.

The heart can be understood as a pump and it’s function is to circulate blood throughout the body, it is composed largely of muscle. There are artificial machines that can take over the function of the heart, at least temporarily.

The liver on the other hand has many types of specialised cells performing several functions from digestion, assimilation of nutrients to immune surveillance, detoxification etc. There is no machine in clinical use, that can take over all the functions performed by the liver..


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