The Colon Club

Hi, I’ve posted a couple of times before about my 74 year old dad, signature has his history.

The latest scan results is bothering me. No cancer found but mild ascites picked up around liver. The doctor said it’s between the lungs and liver. As my dad had aortic heart valve replacement in mid last year and as his other valves mitral and the other (non aortic one) are leaky, the oncologist thinks it’s likely due to the heart.

The heart surgeon for the aortic valve says it’s working fine and unlikely to be the heart.

Plus, I found that he is slightly jaundiced- his biliburin is elevated at 42umol.

I’m worried that his cancer is back and in the liver, though nothing has been found. The doctor recommended another CT in 6 months. His CEA is 2.0, consistent with past checks.

Has anyone had this experience, where mild ascites and jaundice were precursor to finding spread to liver?

I think anything we say related to that would be a guess, and he had a few smart people look at him. Maybe he’s taking too much acetaminophen, possible the ascites are pushing on the liver? If he feels good, and the doctors say wait 6 months, I’d go with it and never look back. Then again, I’m stage 4 and the patient, so a bit of a different perspective.

Thank you. I’m looking for some stories and experiences that might add a perspective that I currently am not getting from doctors.

Is elevated biliburin (but no other elevated markers in liver panel), consistent with Mets in the liver?

Hey Chimney
just going to give a bit of my perspective on your topic if I may

increased bilirubin in and of itself can be due to the following liver and NON liver issues :
pre-hepatic, hepatic or post hepatic issues
SO ... the docs need to be looking and any and ALL potential causes

... also, there will be differing lab reference values for bilirubin ( conjugated and non-conjugated )
SO you would need to quote the lab normals for his own reference lab, in order for that value to be relevant
in context of discussions here... 1-2 points elevated, 10-20 points up, doubled tripled etc. ?

when you say "jaundiced" ... is he actually appearing to have a yellowish cast to his skin / whites of the eyes etc ????

IF the current Docs are not giving you answers you need ... possibly consider a second consult with an Internal Medicine specialist ????

With existing cardiac issues ... Yes, I am afraid there can be ascites issues .. AND in my own medical experience .. possibly a cardiac connection to the liver ( which would be rare but not impossible )

ALSO .. as was mentioned .. what meds is he on ??? some will have hepatic "issues"

You need to get all the docs on board and KEEP PUSHING for answers

WE are here to support you and your Dad

Harmony homie

CRguy on the journey

Thank you CRguy!

My dad is not visibly jaundiced. He is actually fine, but his appetite has not been good (he says since the heart surgery last year). The blood panel results indicated that ‘serum is mildly jaundiced’. The range for bilirubin is 7-32, and his is 41. He’s on medication for his heart arrhythmia (something like a thinner).

The heart doctor called me back today and quite firmly says it’s not the heart.

I’m waiting to hear back from the oncologist.

I’m actually quite troubled as he has just passed the 5 year mark without recurrence and we had just celebrated it after last year October’s scans.

Has your dad had a recent echo of his heart? My wife has a bad tricuspid valve and has one yearly. Cardiologist is tracking for congestive heart failure. He says if she has shortness of breath (resting) or any fluid retention, that could be an indicator. Just wondered if his cardiologist has done a recent echo, just to be sure.

Hi Tex,
Yes he had an echo I think in January.

What I’m not sure is why the oncologist didn’t mention the elevated bilirubin when I spoke to him. He only mentioned the mild ascites. I only found out when I got hold of the lab report.

From what I’ve read, if there is elevated bilirubin plus ascites, it should be taken as not trivial...or maybe that assumption is not right.

Chimney wrote:Hi Tex,
Yes he had an echo I think in January.

What I’m not sure is why the oncologist didn’t mention the elevated bilirubin when I spoke to him. He only mentioned the mild ascites. I only found out when I got hold of the lab report.

From what I’ve read, if there is elevated bilirubin plus ascites, it should be taken as not trivial...or maybe that assumption is not right.

Hi Chimney,

I’m not sure of the units your quoting, most hospitals (and I’ve been to many around the world) report bilirubin in milligrams per deciliter. The upper end of the reference range is around 1.2 mg/dL. I’m not familiar with that units youre using, but assuming that it’s <2 UNL (Upper Normal Limit) it’s not really that concerning. Some people have benign elevations of billirubin. Diagnosing the cause is actually quite complex because there are many potential causes (drugs being number one). The oncologist likely isn’t familiar enough with this and would require a hepatologist. In any case, it’s not really consistent with METs to the liver - so I wouldn’t worry too much about this at this stage. I think the ascites are more worrisome than the mildly elevated bilirubin. (At these levels BTW it really isn’t called jaundice).

Hard for me to say what the best protocol would be here. In addition to my oncologist, I have a world renowned hepatologist that I see. For me, i would get her opinion on if it requires more investigation and follow her advice - but I trust her (she is one of the few docs whom I don’t really second guess).

My recommendation would be to not wait 6 months for the next scans. I’d suggest asking your oncologist to consult with a hepatologist/GI doc to see what they think. I would repeat lab work at the latest within 4 weeks to check the trend. The next step could be a liver MRI or MRCP, which is far more sensitive for liver tumors and should be able to say if there is anything wrong with the bile ducts (malignant or otherwise). However, at this point it’s probaply okay to wait a month to see if it worsens or resolves on its own. Differentiating between direct/indirect bilirubin would also be helpful to rule out non-hepatic causes. If you’re really worried push for the MRCP - it’s non invasive after all.

Thank you Pyro and everyone who has given their views!

With your advice, I’ve gotten in contact with the oncologist who acknowledged that while he still did not think this points to cancer, he suggested my dad do a repeat liver panel, and he will assess that and refer to a liver specialist. He thought that it could be fatty liver/fibrosis, if it wasn’t the heart.

My dad went for the blood test today (though it’s a bit close to the previous one) and we will follow up with the oncologist next week when he’s back from leave.

Thank you for all your support and advice! I will keep you posted on developments.

Hi everyone, thank you for your earlier advice.
The repeat liver function test showed the bilirubin levels to have normalised, at 22umol/l which is equivalent to 1.28mg/dl. I’m not sure what caused the elevation so shortly before, but I’m relieved.

For now, the Doctors are not very concerned about the mild ascites on its own.

Great News! I too had elevated bilirubin for about 4 months. They couldn't figure it out but last month is was down to low end of normal. I think chemo and meds can really do a number on your liver functions. Hope your Dad's ascites clear up next!

FWIW, my husbands liver was riddled with tumors in just about every lobe (11+ tumors) and he had no ascites. His bilirubin was slightly up, I think like a 1.5 but all his other liver function numbers were elevated (he was stage 4 at diagnosis, so nothing to previously compare to). If you are still concerned now or at his next scan, as for an MRI done of the liver as well as a CT. DH gets both, and the MRI has been so much better at picking up liver mets.

Thank you Bearmstrong and Kandj and everyone here for your kind words and advice. This forum is full of such nice supportive people and I love that there are so many caregivers here as well.

Will keep posted on the ascites situation.

Just to keep all posted- my dad has had weight gain, 3kg in 2 weeks. So we are worried that the ascites is progressing. However he has good improved appetite (he now eats 3 meals instead of 2 meals like he used to after the heart surgery last year) and feeling normal, no other symptoms of ascites like breathlessness or fatigue or tightness around the stomach.

Tomorrow we are bringing him back to the oncologist to check it out. I’m a little worried that they will continue to say there’s no basis for further checks. We are flying to the UK for 2 weeks on Friday and I feel anxious about whether we can handle things if it gets worse while overseas.

Will keep you posted.

Main Findings
In this older population-based Rancho Bernardo study cohort, small but incremental increases in bilirubin occurred with increasing age. This association between age and bilirubin was observed in the cross-sectional analyses of the baseline cohort and over time in longitudinal analyses. Moreover, even though the majority of the values are within the normal ranges for bilirubin, higher levels are directly associated with higher all-cause mortality. This relationship was eliminated with adjustment for age, supporting the finding that rising bilirubin is a marker of increasing age.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4017193/