What was supposed to be nothing more than a regularly scheduled (although overdue) EGD has set off a chain of events that brought us back to focusing on Roy’s liver. Roy’s had an EGD before a few times. Mostly it has been a predictable procedure where the gastroenterologist pronounces that he’s about the same and should come back in __ months for another one. This time we got something a little bit different.
An EGD (much easier to say than esophagogastroduodenoscopy) is essentially having the doctor take a look down the esophagus, into the stomach, and a bit into the intestine. For a liver patient, they are usually looking for varices (these are like varicose veins but inside your esophagus or stomach) to determine how well the liver is functioning and to catch any that have developed before they burst. It’s easiest to think of these as blood vessels gone awry – they aren’t trying to cause trouble because they are actually trying to manage blood flow as best they can, but the vessels have gotten a bit bloated, maybe have started to take some new pathways, and generally are stressed. A varix is trying to do a job that it is not meant to do and is under pressure. A patient really doesn’t want to have varices develop because the ongoing pressure in the body will force a rupture eventually if they aren’t caught in time. It’s a clear sign that the liver is not functioning as well as it should.
One Monday in January, Roy’s gastroenterologist found and added two bands to a Grade 3 varix during his EGD. A grade 3 means that the vessel had enlarged so much it was blocking a third of the volume of his esophagus. The bands cut the vessel off from the circulatory system so that it no longer fills and is no longer a threat. For Roy, the varix most likely felt like he had something in his throat that he couldn’t clear (and technically he did). The team also saw that Roy had some “mild mosaic portal hypertensive gastropathy” in his stomach. He was prescribed a beta blocker to help lower the blood pressure in his esophagus and stomach.
That Wednesday, Roy had an Ultrasound for his abdomen. They concluded that he had a “non-specific lesion” on his liver, that he needed an MRI, and that they should run a tumor marker test. The full report called it a “potential hypo echoic mass” on the right lobe of his liver and noted that he had normal portal vein flow. The recommendation was made to have an AFP test every six months and an EGD every six months.
Two days later on Friday, Roy found himself having an MRI. The MRI confirmed the there was a “possible malignancy” on the right lobe of his liver. His AFP test came back as normal; it’s not unusual for the AFP to show as normal even if cancer is taking a hold.
And, then they scheduled him for a interventional radiology-guided Liver Biopsy for February 4 to confirm if the new mass was malignant. When asked, the nurse could not tell us if he would be having a standard biopsy or a trans jugular biopsy. Roy had a regular one in 2004 and a trans jugular one in 2023. Concerned, we called in his hepatologist Dr. Robert McFadden at the Conover Liver Center at Houston Methodist Hospital Medical Center to consult with the local gastroenterologist. Dr. McFadden asked that Roy come down to the Medical Center to have a second MRI.
We’ve been to the Outpatient Center for Houston Methodist regularly for some years now. And we now know what has damaged Roy’s liver after all these years. Back in 2022, we decided we wanted to get a second opinion on Roy’s condition from his original hepatologist so we tracked him down. Dr. McFadden had taken care of Roy when he was referred to Dallas back in 2004 and had seen him through that recovery in 2005 even though he had moved to a hospital in San Antonio by then. We found him again at the liver center at Houston Methodist. (The story of that and how he determined the problem will be a different post – back to that second MRI.) Methodist got him scheduled for a second MRI within a matter of days. Because his MRI was in the afternoon of January 29, we stayed overnight to discuss the results with Dr. McFadden the next morning. We went and had an early supper at the Canyon Creek Cafe Bar and Grill – fried shrimp for me and chicken-fried black bean burger for Roy.
According to Roy, the MRI machine at Methodist was a much larger, nay enormous, beast of a machine compared to the one he has experienced in College Station. The key bits of information, however, are probably that it has the capability to do 3D modeling and that the radiologists who interpret the scans there are specialists in looking at livers. These are important differences – we have good radiologists in College Station and they have good machines, but in this case, Roy had access to even better. The next morning, Dr. McFadden told Roy he didn’t need to have the liver biopsy as scheduled and he should stop taking the beta blocker (it doesn’t really help with prevention of varices and might make other things worse). With the 3D reconstruction in the MRI results and the expertise of the radiologists, Dr. McFadden confirmed that the suspicious liver lesion was actually two malignant growths on Roy’s liver. And there we have it: liver cancer.
Liver cancer, aka Hepatocellular Carcinoma (HCC), is more likely for patients that have cirrhosis and more likely for patients that have alpha-1. This was something that we knew was a possibility for Roy but something that we also hoped he would avoid (in a magic world where he would be able to get a transplant before cancer came calling). Cancer is never a word anyone wants to hear. For Roy, it’s a bad news, might turn into good news, situation. Why? Because cancer is one of the things that might give Roy a chance for a higher score toward a transplant after he beats it. He has to get through the cancer, but then, he has a chance to get his liver replaced.
We ended Roy’s appointment with Dr. McFadden with two referrals. Roy will be seen by the Liver Tumor Center at Methodist and was referred to the Liver Transplant Evaluation team at Methodist. We were told to cancel the biopsy and to expect to hear from these two new teams of medical professionals soon.
For background, please see The Great Liver Incident 2004 about how this all began and December to Remember about Liver Incident 2.0 from 2019. There was another blip on the timeline in 2023, but it hasn’t been written up as of now.
Waiting 
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