Happy Christmas

HAPPY CHRISTMAS

from Bollington

For those who understand Vitamin D3!

I've had a second set of Vitamin D3 results back.
We're supposed to get enough Vitamin D3 from the sun each day. But after a lifetime of northern hemisphere climate, and no vitamin supplements, my first test in April 2011 was 21ug/L (or 21mcg/L). This is right down at the bottom of 'normal' lab ranges, and within the cancer and hepatitis communities is considered below normal.
My second test in November after 7 months of supplements was 81.4 nmol/L.
Two different laboratories using different values - aargh!
I got some help from the liver forum to convert the mcg/L to nmol/L in order to compare, and it seems the first test of 21 = 53nmol/L.
I'd been prescribed the recommenced daily allowance of 600IU per day of Vit D3 as Ad-cal, but this amount wasn't enough to raise the levels, so switched to purchasing my own Solgar product taken at a daily dose of 2,500IU per day.
Even at this level of well over the RDA my level of 81.4 is still below the suggested range of Vit D3 within the cancer and hepatitis communities, which is 100-150nmol/L, so I have increased to 5,000IU per day for a further 4 months to get within this band.
Gives some idea of how likely it is that most of us don't get enough Vit D3 from the sun, and that supplements do work!

Future scans

After a bit of two-ing and fro-ing between the 3 doctors involved, it seems they have settled on 6-monthly MRI scans as my cancer monitoring for the future. First one probably around May 2012.

Thank you

Had my second '6-monthly' check at North Manchester last week.

So that's 14 months cancer free.

At the same time as starting this blog I chose to 'follow' some stories of other cancer patients. Some are in remission and have stopped blogging, or make only the occasional post.
For others the journey continues with further tests and treatment and changing prognosis.
Some have died.

Thank you to everyone who is following this blog.
Here's hoping I'm still blogging same time 2012!

November blood results

November blood results are back and looking good. AFP tumour marker is at its healthy low of 1. One of the liver inflammation markers is up again ever so slightly, but apart from that all is well.

Off to my 1 year cancer free check at North Manchester hospital next week.

Intermediary blood tests

I had a brainwave. Instead of waiting to see the GP on November 18th and then trying to get bloods drawn and results back in time for my cancer check up the following week, I asked if the GP could do the pathology forms without my seeing him in person. The secretaries obliged as usual (more chocolates due) and within a few hours a form was ready for me to pick up and take to Macclesfield hospital.

I expected to have to wait in line for ages for the blood draw, but the department was surprisingly empty and I was seen immediately. Results of the straightforward ones will be back at the GP by next week, the AFP has to be 'sent away' so will take longer. Hopefully 8 working days is ample and I can go to my North Manchester cancer check up armed with up-to-date results instead of results that are 2 months out of date.

What's going on?..

Letter on the mat when I get back from work. An appointment has been booked for me at Macclesfield Hospital for a CT abdominal scan (with contrast dye) on 29th November.

What?

By a Dr R J St***. Who is he?

I look him up.

His speciality is lung cancer.

What is going on?

I don't feel like spending time and money ringing round trying to get to the bottom of this. So I've written to heppy doc asking him if he knows about it - his last letter to me clearly states that he will be organising CT scans as I'm under his care now.
And I've made an appointment with my GP to see if he knows what it's about, as I'm due to have some bloods taken anyway for the tumour marker and my Vitamin D levels.
GP is booked up for 3 weeks, so it will be a while!

UPDATE: Wrote to heppy doc (as above) and left message on GI doc's answerphone (secretary) - but a week later, no reply from either.

CT scan review

Letter in the post today from heppy doc. copy to GP.


Reporting that though the CT showed no cancer recurrance it was, as I suspected, of limited use because of the lack of contrast dye. The contrast dye shows tumours as bright white. Without it they become grey lumps, merging with an already 'lumpy' cirrhotic liver.


Also despite my having previous CT's at Macclesfield which the radiologist should have been given to use as a comparison, nobody had felt like sharing! So they had nothing to even help compare existing grey with suspicious new grey.


Heppy doc is going to discuss what to do about future CTs at the next Hepatobilliary meeting, which makes sense, as there's no point in wasting money on useless procedures.

We need to think of a better method of imaging without using iodine.


Any ideas anyone?

Splat

A few days ago a pigeon with a bad sense of direction flew into the window downstairs with an almighty bang.

Now we have an oily bird imprint on the glass.

Result!

Copies of blood test results done at Salford have arrived in the post. Gave the secretaries at my GP practice a box of chocolates.

Baffled at first as to why the packet was so big and contained 21 pages? They've sent me the printouts from 2 previous clinics - doh. I have these already. I only asked for the September ones which run to 3 sheets. What a waste of their time.

As I suspected, things are having a bit of a wobble with results going slightly the 'wrong' way (albeit still within normal range)

I've been noticeably more tired and achey for a few weeks. This could be any of (a) tired of getting up at 7am and driving 30 miles a day for work and all I need is a holiday! (b) my immune system is having a burst of activity making me feel a bit off (c) the slight AFP rise means a new cancer is forming.

So the plan is do nothing at the moment but take another set in November and see what's what

NHS snail mail

Try as I might I dont understand the problem with sending information between different NHS trusts.

I still have my fingers crossed that after 4 weeks somebody will finally send me the 2 or 3 sheets of paper that contain my last lot of blood tests.
So far the GP secretaries and I have tried to get them via phone, via fax and via email. Apparently the last 2 methods are 'not secure' and the first is too time consuming to read them out.
I find it difficult to believe that companies such as, let's say Apple, don't use the internet for it's communication despite the supposed risk of security lapses. Perhaps they always use couriers or carrier pigeon for any new product plans.

So now I'm pinning my hopes on Dr Al's secretary deciding to break with protocol and use 2 or 3 precious sheets of paper, an envelope and a stamp to send them to my GP.

The whole hassle has decided me to ask for the whole lot to be done again at the GP in November (which will be half way between my September clinic and the January 2012 clinic) so that I can get some up-to-date results within a week.

I'm not even considering asking about the CT results. There's little point in hoping anyone will contact me about it before January. Anyway without the iodine contrast dye the chance of it being any use at detecting tiny new tumours is low. Small non-enhanced liver tumours usually aren't visible in a lumpy cirrhotic liver, so we need a new plan B for the best imaging technique for me, which isnt non enhanced CT.

CT scan

Had my 6-monthly CT scan checking for liver tumours at Salford hospital yesterday. Don't know when I get the results, I'm still trying to get copies of the bloods taken nearly 3 weeks ago.

It was very quick this time as I no longer have the iodine IV inserted. My notes say I'm allergic to it. I guess the image wont be as clear as one done with contrast dye, but hey ho here's hoping it's good enough.

Very tired when I got back. Had done 2 work shifts before I went and the appointment was slap bang in the middle of city rush hour, so the traffic was awful both ways.

One year

One year today since the cancer surgery.
Another 4 to go and then I can say I'm on the right side of the 50% survival statistic.

And yes... I cleaned the fish tank! Happy fish.

I meant....

I meant to clean the fish tank on Tuesday, but went on 'Freegle' instead and recycled a mantle mirror that had been stored unused in our garage for years.

I meant to clean the fish tank on Wednesday but J invited his girlfriend for supper so I cooked a roast ham and made a macaroni cheese instead

I meant to clean the fish tank on Thursday but watched 'Educating Essex' on Channel 4 instead

I meant to clean the fish tank today but defrosted the fridge ... and then had a lovely bath using the last of my Arran Aromatics bath gel ... so went online and ordered some more instead ... just for me!!

Sorry fish. I'll clean your tank tomorrow.

Two letters

Two letters from the liver clinic arrived in the post:

1) a copy sent to my GP reviewing the July bloods done by the GP and seen by heppy doc in clinic. Heppy doc advises the GP all is well and they wont need to do monthly bloods. Monitoring to be reduced to 3-monthly, done by Salford clinic.

2) a copy of another letter typed up 2 days later - after the September bloods taken at Salford have been reviewed. Three important results are listed: a) my tumour marker; b) my liver inflammation and c) my immune system activity.
c) is stable. a) and b) have gone UP. Between 21st July and 12th September the downward/stable trend has reversed.

Darn it. Now I'll definitely get another set done by the GP in early November, as the liver clinic review in January is too far away for peace of mind.

CT Scan

The time for my 6-monthly CT has come round again. Having it done at Macclesfield and the images forwarded to Salford and North Manchester hasn't worked.

Here's a thought - how come you, and I, and Joe Public, can send each other via email the most amazing photos and images. But hospital A cant send a picture to hospital B if they belong to different NHS trusts.

So we start again and I have my scan done at Salford, which is on the same computer 'system' as North Manchester. I had a mild allergic reaction the iodine IV last March and am nervous of it happening again. It left me shaky, so I want T to be around to hold my hand and drive me home after. Heppy doc carefully wrote on the CT request slip NOT TUESDAY OR THURSDAY (those are T's busiest work days).
Appointment letter arrived today ... yes you guessed ... Thursday.
Rang radiography and explained my concerns about the iodine. Helpful radiographer looked at my notes and said 'yup, says here you have an allergy, so no iodine IV for you this time'. That's good news, this will be a walk in the park now and I'll be ok to drive myself home. I asked whether the consultant would be informed before the scan, in case he said that an image done without contrast wouldnt be good enough. 'Should be fine', said helpful radiographer, 'we can use a different methodology to interpret the scan'.
Rang appointments to cancel Thursday and re-arrange. Explained how Heppy Doc had written NOT TUESDAY or THURSDAY on the request. Ah, she said, sometimes it has to be done on the day the specialist radiographer is available ... oh no, here we are, yes we can offer you Mondays or Wednesdays.
Ha ha ha.

I shouldn't have had cancer

Three monthly check-up at Salford liver clinic yesterday. The spreadsheet of monthly blood tests over the previous 3 months looks optimistic - well MY copy does, as although both my GP and I forwarded our monthly copies to Dr Al nobody at Salford arranged to have the figures entered on his system. Monitoring will be reduced to 3-monthly. All now done at Salford. I'm sure this is an ok decision, but will be sorry to loose my easy access to results via the GP. Bet I never get sent copies from Salford. T suggested I ask my GP to do an intermediary set at 6 weeks, for my piece of mind. We just don't tell anyone else!

It seems I have become a bit of an oddity. Heppy doc asked if I would give my permission for his team to write up a publication on me. He explained that it's usually patients with a chronic active Hepatitis B virus that progress to cancer. My virus levels have been undetectable for at least 17 years, and he explained it's unusual for a liver cancer to develop that length of time after a virus has become inactive. Also it's not common for someone with autoimmune hepatitis to develop liver cancer.
So I asked "what caused the cancer then?"
"That's what we'd like to know" he said.
He gave me paperwork to authorise them (it will a joint paper by him, his registrar, O'Blimey and Dr Caravan) to publish within the stable of BMJ (British Medical Journal) publications.
By now I'm feeling self-important, and barely caught his mumble about it being 'most likely published in mumblemumble'.
"In where?"
"Gut" ..............
Yes, there is a journal called 'Gut'. Maybe it should become a guest publication on 'Have I Got News for You' alongside 'Drain trader'; 'Gas installer'; and 'World pumps'. All quite suitable digestive organ titles!
Ah well, that was the end of my 15 minutes of fame.

Visit to A&E

As a sucker for medical programmes I've watched via Channel 4OD the observational series "24 Hours in A&E" about London's King's College Hospital emergency room.
A backdrop to the high octane emergency cases are the mundane 'walk-ins' and time wasters, with their cuts and bruises that could be treated at home. Yesterday I felt like an A&E time waster.

After 10 days of patiently bandaging the persistant swelling and increasing pain in my sprained ankle T decided it was time to get a second opinion from a medic on the best strapping so I can carry on driving and working. The best place, I reckoned, was a quick visit to a nurse at my GP surgery. In and out, 5 minutes. No wasting the GP's time. But....

With apologies to A A Milne and his poem 'The King's Breakfast'

'T' asked
Me and
I asked
the receptionist:
"Could we have some strapping for
Fiona's hurty leg?"
Reception asked the Practice Nurse,
The Practice Nurse
Said, "Certainly,
I'll go and get the bandage
Now
Before she goes to bed."

The Practice Nurse
She rang us
And went and told
'T'
"Don't forget the GP must
first check out the leg."
The Practice Nurse
Said sadly:
"You'd better tell
Fiona
That no nurses nowadays
Can bandage up
a leg"

The GP
Said, "Fancy!"
And thought it might
be broken.
She turned to Fiona, and
suggested instead:
"Best to get an x-ray,
Off to emergency,
and if its broken,
they'll put a cast on instead."

The Triage nurse said
"X-ray":
In X-ray they
imaged it, and sent me back to
sit by a boy who cut his head.

.... 4 hours later ....

The Doctor said,
"Deary me!"
And then he said,
"Not broken"
So I said, "Thank Goodness,
Can you bandage my leg?'
"Nobody,"
I pleaded,
"Could call me
A fussy one;
I only want
A little bit
Of bandage for
My leg"

The Doctor said,
"There, there!"
And went to
Get some bandage
The Doctor
Said, "There, there!"
And went to get some tape,
The Doctor said,
"There, there!
I can do a bandage,
Here we are
All fixed
I’ve bandaged up your leg"

(And you know, he did it exactly how T had been bandaging it)

Leeds Festival 2011

J and friends are at Leeds Festival today. Headliners on the main stage today are the Strokes. J will be particularly thrilled I'm sure if they play the same set as at Reading Festival yesterday. The set includes 'Someday' (click Replay, below) which J recorded for his multi-track/mixing task for last years AS level for which he got an A overall.

Accident

Missed a step and twisted my ankle today.


We didn't have a handy stick of rhubarb (looks more like a baguette to me!) so I'm hobbling around using an upside-down broom for a crutch.
Embarrassingly for J (and T)my trip was in full view of a room of prospective Music Technology students at the University of Keele open day.

Cant drive, so will have to cancel my 3-monthly check with Dr Al at Salford which was scheduled for Monday. It was to review the last 3 months of bloods, but as all is looking stable at the moment I'm sure I can re-schedule.

Diet and liver disease

New edition of the British Liver Trust publication 'Diet and Liver Disease' is available as hard copy or to download online here: www.britishlivertrust.org.uk/home/order-publications/download-publications.aspx

Still in remission

AFP blood test results are back. This is my 4th cancer tumour marker test since surgery. Still at 1, well within the 'normal' range of 0-10.
Sadly a fellow 'Nomad' with Hep B was diagnosed 5 weeks ago with a cluster of HCC tumours and given 2-3 months to live. That's how agressive these sly bu**ers are. Hence my frequency of testing.

For some reason a full set of liver function tests and full blood count were done at the same time - bit of a waste of NHS resources as I had them done 2 weeks before the AFP and only need them taken monthly.

Anyway, the test that measures liver inflammation went down again, in just 2 weeks! Its now 21 instead of in the 80's. 'Normal' is between 10-50. It may be explained as things continuing to calm down after surgery, but as that was 11 months ago I doubt it. My feeling is the improvement is down to a clever herbal supplement called Milk Thistle.



The seeds of the milk thistle have been used for 2000 years to treat chronic liver disease and protect the liver against toxins. I've been drinking it as a tincture since diagnosis.

Cyber support

3-monthly AFP tumour marker blood test today. I have a love/hate relationship with this test. I want it done for the reassurance a good result gives, and I hate the moment of opening the envelope to read the results in case its gone up.

On the support forum I help administrate a member who has finally cleared Hepatitis B after a course of drug treatment has been diagnosed with multiple HCC tumours. He's waiting to find out if he can be assessed for a liver transplant. This tragic news came just after I'd posted my positive July blood results and I had to admit that his story will haunt me for a while. Within a few hours of my post, a knowledgeable HCC survivor wrote me this message:

"They excised segment 2 of your liver, apparently with good margins, and you had a single mass? Early stage 2? No lymphatic compromise? If that's the case then I wouldn't be stressing too much about the HCC coming back. It might very well down the track, perhaps a very long way down the track, but it's unlikely to be the same one. Given that you *didn't* have a cluster, and that everything remains fine, then I think your prognosis is good. Obviously I'm not qualified to make that call, but it's my (reasonably educated) opinion. Unresolved HCCs usually come back like a train. If it's been more than a year - and it has by now, surely - then you should be relaxing about it. Relaxing in this context doesn't mean not being vigilant"

Thanks Dallo, if you ever pop by and read this!

July bloods - results today

Picked up the blood test results. An improvement again on June - hurrah. The ones that show inflammation have gone down again: less inflammation. The ones that show how my liver is functioning are balancing out even better within the normal range. Whatever I'm doing in the way of diet, excercise, health supplements, work/life balance seems to be working at the moment.

T and I came home on Wednesday after a lovely few days away. J on his way back from camping, sunburnt and hungry and no doubt with a rucksack full of smelly clothes!

July bloods

Third set of bloods taken. Nurse practitioner getting to know my history now! These are sent off to Salford for Dr Al, and I have a 4th set taken when I see him in August. Quite a spreadsheet building up.

June's lot were ok. I'll be interested to see these latest, as the last few weeks I've been extra fatigued. Looked at my diary yesterday and realised that since I went back to work in February I haven't had a holiday. Silly me.


Next week we are on our hols. J to Anglesey camping with friends, T and I driving down South to visit family and then have a couple of days to ourselves.

Have collected all the stuff J needs - tent, sleeping bag, sleeping mat (thanks for the tip Dave we now have a self inflating one), cooker, pan, gas canister, plate, mug, washing stuff, boots, socks, waterproofs, basic food rations, beach stuff, spare clothes. Look at the growing pile, look at the rucksack. No way is it all going to fit!

His friend Jack came round and they practiced taking the down the tent. It's a pop-up, so no 'putting up' required - it springs to fully formed in 2 seconds! Getting it back into the carry bag requires 8 extra long arms to hold one side while the other side springs open again. There is an excellent demonstration video on YouTube showing how to fold it up again, but Jack was convinced he could work it out - which he did, it just took quite a long time.

Reason to become a donor - Number 3

Someone said recently 'if you're willing to receive an organ, then you should be willing to donate one'.

Hear hear.

J filled out his provisional driving licence form yesterday and ticked all the organ donor boxes. Not that I'm encouraging him to become a mangled wreck in a road accident, but 'Cheers J'.

Work hours reviewed

Meeting at work last week to review my hours.

I'm now settled at around 10-12 a week, excluding the drive time to, fro and in between clients.
Ironically I'm now covering for a sick colleague who has been off for 2 months with a back injury and is likely to be off for another 2 months minimum.
Makes me feel almost normally fit!


I definitely need rest in between the work shifts. But as long as I eat ok and take naps, I'm then good to go til the evening.

Action woman

J was recently looking at our old photo albums. As we turned the pages it was clear that page after page showed leisure time filled with strenuous outdoor activity:

Such as, walking the Lakeland fells

Climbing the highest mountain in the UK
Orienteering
Yes, that's me

Cycling holidays

Canoeing

Sailing

Horse riding

Ski-ing

Yet all the time, unknown to me, my immune system was working overtime trying to rid the virus, taking its toll on my liver.

After all the years of activity, now I would struggle to do any of the above. A 2 mile gentle walk is my limit.

Feed your family

A well known supermarket has been running TV ads claiming that by shopping with them you can feed your family for £50 a week. My earnings have taken a hit, and my bank balance is struggling to fund the grocery bill, so I took up the challenge.

Their definition of a 'family' is probably 4, but as some student finance guides allow a budget of £35 a week for one impoverished student, I stuck to the £50 for the 3 of us.

Colourful menu pictures in the leaflet showed tasty dishes with pasta and rice. But a large proportion of menus had potato wedges homemade from 'Basics' potatoes. The £50 shopping list had 5 kilos of potatoes on it. This 'family' must be eating a lot of chips! It also had 3 mega sized loaves of sliced cheap bread - presumably for sandwiches/toast. Also 5 large bags of frozen veggies. Our freezer wouldnt take all this on top of what is already in it, and anyway I dont think cheap doughy bread is very healthy.

Once you've been diagnosed with cancer, the quality of the food you buy suddenly becomes more important. You become drawn (if you hadnt been buying it already) toward organic, free range, 'free from' products.
So that ruled out the Basics fruit and veg. And the battery farmed value chicken and eggs. And the fish that wasnt sustainably farmed or caught.
Things were going awry before I even put one item in my trolley!
So I substituted quite a few things, (oh, the list excluded milk, tea and coffee??) and cheated by using local butcher bought things that were already in the freezer. And cheated by using spinach, lettuce, strawberries and raspberries that are now lush in the garden.

I made it with an overspend of £12 (having excluded the food treats J took to a friends house one day).
What did we eat for our £50. Cereals or toast for breakfast (homemade marmalade - another cheat, oops!). Sandwich or salad meals for lunch - made with bakers bread and some salads from the garden. And pasta/bolognese/rice/curry (free range chicken)/burger/stir fry type evening meals with organic veg and fruit crumble or yogurt puddings.

What did I learn? That you can do a budget shop at a top range Supermarket. But that personally I wouldnt want to eat half of the budget range due to bulking with additives or the product not being grown/fed in a chemical additive free way.

Next challenge - see what J and I can buy and cook on the hob for one week of student 'quick' healthy easy meals for £35.

Latest results

Under my hepatologist's new careplan I'm having blood taken every month. Liver function, red and white blood cell count, clotting speed and a check on my immune system.

I'm not on any medication. I take a herbal liver supplement called Milk Thistle, Vitamin D3, a multi-vitamin and mineral tablet and some extra calcium and magnesium for 'dem bones. I eat no red meat, avoid saturated fats and vegetable oils and have cut right back on salt.

My 3rd and most recent lot of blood tests under this new monitoring regime are looking good.

The tests that monitor inflammation in my body have dropped further and are in the normal range. My liver tests are 'normal', which for me just means 'stable' as we know from the tissue biopsy that the liver isn't 'normal'.

The only thing way out of range is the tests monitoring my immune system, which show its still operating at twice the business it should be, trying to clear an imaginary disease. It needs a rest!

Profile update

Have updated my profile pic to this one. The old one was taken after cancer diagnosis but pre-surgery. This one was taken by my brother, after everything (!) in June 2011.

Update

All quiet on the health front at the moment. Am into the routine of monthly blood tests now. Had May's done, June's are booked at the doctor's for next week, I have the paperwork ready for July, and then August sees me back having them done at Salford.

These blood tests will check my clotting, my levels of inflammation in my body, how well my liver is dealing with toxins and fluid balance, and how much it's managing to store in the way of vitamins and minerals to keep me healthy. We know at the moment that I'm low in Vitamin D, iron, calcium and sodium.

I've been added as a member of the Admin team on the hepatitis support forum mentioned earlier. A good excuse to be 'busy' while sitting down in front of the PC! There have been a few members with scary moments recently - one with liver failure, one with gastric bleeding, and one where ascitic fluid build up in the abdomen got infected. All examples of why liver disease needs close monitoring and decisive action from the medics if things start to go awry.

Had a lovely day on Wednesday when I met family for a day out here:

With an old fashioned steam carousel

Work has got busy. My hours have doubled for a couple of weeks, as they need cover for sickness and holidays within the care packages I'm part of. Should ease off again eventually.

Happy Birthday J

Now you are old enough to drive one of these:



Instead of this!

Love Mum and Dad

Gastroscopy Part II

Tomorrow (25th) I go to hospital for the 2nd attempt at a gastroscopy procedure. That's where they put a camera down my throat and into my stomach to check the state of both and assess the likelihood of internal bleeding.

This time I'm getting the same sedation as Part I, plus an anaesthetic throat spray, plus a drug called Fentanyl which I've only come across as strong pain relief for cancer patients - so not sure what the thinking is behind this last one.

I guess I'll be zonked senseless and sensation-less. I hope I can swallow as soon as I come round or it will freak me out.

At least it's at 8.30am instead of 5.30pm so I dont have to starve myself all day or get more and more anxious.

Will report back once home again.

Home again. Procedure completed this time. My GI consultant did the procedure himself, with the tube designed for babies - how cute!
No varices in the oesophagus. Signs of mildly dilated blood vessels in my stomach caused by the blood pressure changes. No immediate action needed, follow up in clinic.
So a relief to get that out the way and to know it doesnt need to be done again for 2-3 years.

I was heavily sedated with a variety of morphine based products so came home, had some porridge and went to bed for a few hours. I'm still 'not all there' and under hospital instructions not to cook (hurrah) for 24 hours as well as the usual no driving or using heavy machinery!

Have taken 2 days off work, so plenty of time to rest and be pampered.

Hep C Nomads

HepCNomads are an online group of friendly people that have or had hepatitis C. Some of them have been through a treatment programme and cleared the virus, some have not. Some are supporters or carers of family/friends with the virus. Significantly, they provide a lot of online emotional support from people who understand what it is like to have hepatitis.
It's also an educational forum where people planning on starting treatment can learn about treatment, how to prevent side effects and how to maximise their chances of achieving treatment success. Those not going down the treatment route can learn how to care for their liver.
Nomads are well thought of by The British Liver Trust.

Having browsed the internet and not found a good online support forum for Hep B, I joined Nomads. And was welcomed into the community without question.

So if you are reading this blog because you have, or know someone who has, hepatitis click this link
http://hepcnomads.co.uk/phpBB3/index.php

Finish line

Sometime today (not sure exactly due to US time difference) Running Man crosses the finish line having completed his chemo marathon.

Well done Steve.

Now I have osteopenia

So I had this DEXA scan thing on 19th April and then completely forgot about it.

Letter arrived today telling me my 'T score' (whatever that is) is -1.9 and is in keeping with osteopenia. Which seems to be a sort of pre-osteoporosis. And that I must go to my GP for meds.

Sigh.

I hope I can treat it with extra Vit D (ha ha, already am) and calcium. I really really do not want to take bisphosphonates. They do horrible things to your oesophagus and digestive tract - not a good idea if your oesophagus is already compromised with the cirrhosis.

So more research into alternatives before going back to the Doc for his opinion.

Is there anything to treat?

Saw my hepatologist yesterday.

He'd had time to mull over his original treatment plan for his diagnosis of ‘probable’ autoimmune hepatitis alongside the chronic inactive Hep B. He'd also had time to do what I did which is research existing/previous cases. And like me, only came up with 2 documented. So it's rare to have co-infection of Hep B and Autoimmune.

He spoke to his ex-boss and his mentor, both at the Freeman Liver Unit in Newcastle and between them they came up with 2 options:
1) no treatment but monitor more closely than I am being at the mo;
2) treat with a combination of drugs for the low level inflammation and some more drugs to protect againt the risk of the Hep B reactivating.

They've gone over both the 1st and 2nd biopsy, and all the blood tests, and tissue slides and it's still not possible to say anything more definite than there is some 'autoimmune' activity but not very much and difficult to quantify if it is stable or increasing.

Tom asked if either treatment plan would give any protection against the cancer recurring, and I asked if either would give a better life expectancy.
Heppy doc said neither would improve the statistics of a de-novo (new) tumour, and it wasn’t possible to say re the life expectancy.

So I opted for the choice that gives me the better current quality of life, which is option (1) as there will be side effects using immunosuppressants etc long term.

The good news for me is that heppy doc says my cirrhosis is very early stage and that my liver is performing well. O'Blimey the surgeon (who is the only one to have seen the state of my liver first-hand) had been somewhat gloomy and I'd assumed I was worse than it seems I am.

Heppy doc thinks that although I’m chronic inactive hep B I probably have a history of periodic reactivation that went unnoticed due to lack of monitoring. He plans to monitor my bloods monthly and have me back in clinic in 3 months. The idea is to build up a picture of everything that tracks the inflammation and spot immediately any deviation from my current 'normal'. The way things are at the moment my cirrhosis should remain fairly stable, but a flare would accelerate it.

As always when faced with a new path to follow I spend a lot of time mulling it over, consequently I'm a bit tired today. Also I had a long work shift this morning and am out at a book club meeting tonight. So I'm off to pull the duvet over my head for a few hours.

Life expectancy

Saw my GP today.

Asked for his advice on the different diagnosis and treatment plans on the table.

The 'do no treatment but watch for and deal with future symptoms and side effects of worsening liver damage' option versus the 'make an educated guess as to the cause and treat the liver inflammation with lifelong medication plus follow up checks to monitor any effect' option.

His advice was add to the mix your age, your current state of health, your personal circumstances and your family situation and ask 'which of these options gives me the best life expectancy'.

Choose that.

Obvious really.

Even the best made plans

This is the route between home and the North Manchester hospital where my liver surgeon sees me once every 6 months. Part of the drive is through busy built up areas chokka block with traffic most of the day, so it can take up to 2 hours despite the AArouteplanner optimistically estimating 38 minutes!

Normal clinic procedure would be the patient returning to NM hospital about a week prior to clinic for a CT scan and bloods, so that the surgeon gets to see them before pronouncing his verdict on my health face to face.

Due to kind hearted Macmillan Nurse Clare, the team decided O'Blimey's buddy Dr S, my GI at Macclesfield, could be trusted to organize the CT and the bloods. As you see from the map the distance between the word 'Macclesfield' and the green flag of home is conveniently tiny. So tiny that I'm fine to get myself there and back for the CT without needing support. The IV part of the procedure tends to leave me a bit shaky and certainly not up to a 2 hour drive on my own. The results of the CT and bloods to then be sent electronically/by courier/by carrier pigeon *(delete as applicable) to NM hospital.

Dr S was highly organized and carefully booked my CT for 3rd March - PLENTY of time - 2 months - to get the resulting image and report snail-mailed 26.8miles??

Fail.

At least I'd taken a copy of the summarized report. And a copy of my AFP blood test result. I almost offered to hole punch them and file them in my file!

So he asked how I was and I said the results suggested I was fine thanks and he said bye see you in 6 months. About 5 minutes out of the 5 hours (including the late running of the clinic).

Still in remission

AFP blood test results are back. This is my 3rd cancer tumour marker test since surgery. Still at 1, well within the 'normal' range of 0-10.

Great news.

Does bad luck come in 3's

Started the day with one of my recurring sinus headaches and a spontaneous nosebleed. Not sure why these happen, as my clotting factor is fine.

Things improved with a walk to see this lovely bluebell wood.


On return, slammed my finger in the car door - ow ouch! Steri-strips, paracetamol, arnica, ice pack and a cuppa tea (if only all our ills could be cured with a cuppa!) sorted that, but I'm fumbly typing with one hand.

For my finale, spilt a packet of sugar on the kitchen floor. Scrunch, crackle, crunch as we walk on it.

That's my 3 so should be safe now.

Happy birthday to me

AFP time again

Nearly 11 months since the start of this blog. Nearly 3 months since my previous AFP tumour marker test. Where has the time gone?

A little early taking the test this time, but I have my 6 month cancer check-up with the surgical team at the beginning of May. What with Easter and then 'Will 'n Kate's' Bank Holiday I'm allowing plenty of time for these results to come back in time for Mr O'Blimey's appointment.

Hope everyone is enjoying the gorgeous sunshine. I have a bottle of 'Liquid Sunshine' in the fridge with a Vitamin D3 supplement in it. Research suggests that many of us in the northern hemisphere (and those in the southern who apply sunscreen) are deficient in Vitamin D.
I've been taking twice the recommended daily allowance for a while now and got my blood test back today. I'm 'normal', but low normal. Looks like I can up my daily intake again to more like x4 the RDA and still be 'normal'.
Anyone out there feeling a bit tired, or achey, for no particular reason, try taking extra Vit D3 and I'm pretty sure you will feel better.

Another scan

I had a Dexa scan today. It looks like this:

Something to do with checking my bone density. The machine is very expensive and is in our private BUPA hospital. A deal is done between the NHS and BUPA to pay for the scan.

After lunch took J for a first appointment to a new homeopath. For his eczema. Which hadn't been too bad for a long time but flared up on his arms and neck when he got taken surprise by sunburn in March. He has 2 pillules and instructions not to use mint toothpaste for a week (mint destroys the delicate balance of the remedy) so it's fennel toothpaste instead - yuk. Also no caffeine.

See saw

This is for my Nomad forum friend Ceesaw. Thanks for bringing some much needed clarity to my state of indecision. You can never been down for long with a see-saw or a Ceesaw.

Looking for clues

Letter today from Dr Al, the heppy doc at Salford.

Reassuringly long, detailed and thorough.

His conclusion:
"It is difficult to judge exactly what is going on"
"I am a bit reluctant to start treatment at this stage"
"I would like to look again at both biopsies from the cancer resection and the histology from February to look for further clues"
"I don't think we have all the information needed to make a decision and would like to discuss further at our next MDT meeting"

My surgery

..... was at the hospital featured in this Channel 4 'Dispatches' programme

www.channel4.com/programmes/dispatches/episode-guide/series-88/episode-1

Ain't no maybe

The more medics that get involved the more opinions there are!

Hep B has a definitive set of blood tests and definite look to tissue cells under a microscope.
There's no doubt that I do have hep B viral cells in my liver.

There's also no doubt that I have white blood cells actively bashing something in my liver.

Where the doubt comes in is what are they bashing?

Are they encircling the remaining hep B viral cells to stop them replicating and escaping back into my blood stream.
Or are they bashing an active autoimmune virus.

Unfortunately there is no definitive blood test for autoimmune. Its a collection of jigsaw pieces and an educated guess!
My GP cousin made an educated guess last November.
So did a British Liver Trust hepatologist.

So at the moment its 3-1 in favour of autoimmune.
4-1 if you count my gut feeling and insistence on the second biopsy.

I found some guidelines on the internet published by the American Association for the Study of Liver Disease and I score 14/17 or a 'Probable' diagnosis of autoimmune.
Having concurrent Hep B is very rare and makes it impossible to make 'Definite' diagnosis of autoimmune.

Should I start lifetime treatment, based on a rare probable?
Whether I do or dont, there will always be some white blood cell activity in my liver encircling the remaining Hep B cells, and slowly slowly progressing the cirrhosis.

Disagreement

Saw Dr S in clinic yesterday.
He disagrees with Dr Al's diagnosis.

Dr S diagnosis is inactive Hep B with active polymyalgia
Dr Al diagnosis is inactive Hep B with active autoimmune hepatitis

Dr S treatment is no treatment for the Hep B and treatment if required for the myalgia
Dr Al treatment is suppress the Hep B while treating the autoimmune.

How do you get two consultants to agree?
Put them in a room with my GP as referee and let them thrash it out til they come to a consensus?

Fifteen

I've just typed up my scribbled note which listed the tests ordered by Dr Al on Monday. I want to take the list to my clinic appointment with Dr S tomorrow. There are FIFTEEN! No wonder my veins were sore.

For Steve

This is Patterdale in the Lake District last week, in between April showers.

I'm putting this on my blog for Steve, one of my followers, who is just over half way through his post surgery chemo for rectal cancer. Now that it's April May won't seem so far away.

Steve this is to cheer you up as I know you like photos of lil ol' England!

T took the photo whilst supervising a group of Undergrads who are there learning practical, in the field, surveying. He's gone back again today, and goes a 3rd time next week. There are so many students they have to do it in shifts

Dr Al drops a bombshell

Those who have followed my blog through 2010 may remember that in November I was asking for help confirming what I thought might be a diagnosis of autoimmune hepatitis. A British Liver Trust hepatologist and my GP cousin came to my aid with a yes, the phrase ’persistent florid activity’ in my first biopsy report could be suggestive of autoimmune.

In December I saw Dr S in clinic, and voiced concern over my continuing fatigue, aches, pains and occasional feverishness. I’d made notes about autoimmune and highlighted some of my blood tests. On my blog of 7th Dec I wrote "We went through my Hepatitis blood tests and he looked at the notes I’d made about autoimmune. He still feels that Hep B is the most likely cause of all the problems, including the persistent inflammation".

He ordered a second biopsy, the one I had in February. This was discussed at the medical team meeting on 9th March. I scrounged the report from the GP last Friday and it was the reason for today’s appointment with Dr Al, the new hepatologist at Salford.

He read the reports and underlined bits, so I asked him what he was underlining. He said my history, including the speedy response to steroids plus the biopsy evidence of inflammation in the liver is suggestive of autoimmune hepatitis, and that was why I was there.

That left me speechless! I’d put autoimmune to the back of my mind and had been told by O’Blimey’s secretary that the referral was for cirrhosis.

Dr Al took another bucket load of blood tests – just to be doubly, trebly sure. I’ve had about 8 vials taken today, as I’d been to the GP in the morning to have Vit D and iron levels checked. Sore arms – argh!

It’s back to see him in a month to get the results and confirm treatment.

Co-infection with autoimmune and viral hepatitis is tricky. Standard treatment for autoimmune is immunosuppressants – just the ticket for bringing those pesky little hep B cells trapped in my liver back to life . Dr Al’s method is to give me an anti-viral to keep the hep B down, at the same time giving me immunosuppressants to treat the autoimmune. For life – b**ger.

The good news is, yes there is good news, that Dr Al doesn’t think the liver damage is too bad and that treating the autoimmune will stop its progress. It’s the Hep B, he thinks, that triggered the cancer.

I'm a 'Silent Witness' fan

I've got as far as I can translating my liver biopsy pathology report. I'm amazed how much information can be got from a tiny sliver about the length of your little fingernail (10mm).

First; what they didn't find. The biopsy ruled out 9 different things. Did that mean 9 tests on this sliver?

It ruled out 'mass cell death' - that's got to be good!
It ruled out in 3 different ways evidence of pre-malignancy or abnormal cells suggestive of HCC cancer.
It ruled out iron overload (common in liver disease)
It ruled out Wilson's disease and primary biliary cirrhosis, 2 other forms of liver disease
It ruled out choleastis which is a blockage of the bile ducts

Second; what it did find.

It found evidence of cirrhosis - no surprises there - and categorised it as 'moderate' disease progression, in most but not all sections.
It went on to stage the cirrhosis by 4 different scores for inflammation.
I won't categorise the types of inflammation as they are gobbledygook, but think of it as 4 exam papers where the marks total 18, but you want a low not high score. I score 2/4; 0/6; 2/4 and 3/4 which totalled 7/18.
My guess is that when you reach 18/18 your liver is a gonner.
It found evidence of bile duct destruction (you need bile to digest food) which is reflected in my 3 out of 4 score, above.
It found evidence that the liver was having trouble digesting fats.
The above 2 findings re-inforce my belief in a healthy, low fat, easy to digest diet.
It found 'patchy positive' evidence of hepatitis surface antigen HBsAg - this is the marker that says 'this person has or had hepatitis B'.

What will be significant, is if the tissue tells whether the hepatitis is ACTIVE or INACTIVE. I've not fully understood this.

The good news is:- there is no evidence of a cell called a 'ground glass' cell (because of the way it looks). The presence of ground glass cells says WARNING: acute infection.
There is 'occasional' or 'patchy' evidence of various white blood cells. White blood cells are part of our immune system, and get busy when there are bugs invading us. Finding white blood cells in my liver might mean they are the remnants of Dads Army (see post 'War is Over') still knocking out any stragglers of hep B. Or it might mean they are attacking a new uprising. I dont know and it's on my list of questions for the hepatologist on Monday.

The good news (I think) is there is no evidence of something called 'granuloma' which is when the immune system encircles its enemy. Think John Wayne and a wagon train being encircled by indians.

Summary: Question to ask hepatologist - is the evidence of hep B in my liver cells suggestive of active or inactive hepatitis.
If the answer is inactive, good, I guess we continue to monitor.
If the answer is active, the next question will be 'what are we going to do about it before it makes the cirrhosis worse'.

Reason to become a donor - No 2

http://news.bbc.co.uk/1/hi/england/8141459.stm

April Fool was on me

Back in November last year I was hunting a hepatologist. Ended up carrying on with Dr S, my GP and the surgical team.

Now that the February liver biopsy report (more on this in another post) has been looked at by the MultiDisciplinaryTeam responsible for my care, the decision has been made to refer me to a hepatologist - AT LAST.

A new clinic has opened at Salford Royal hospital, which is about 20 miles away.
It's led by a hepatologist transferred from the Freeman Hospital in Newcastle, a specialist liver transplant unit.
I'm hopeful he brings with him expert knowledge and it's a joint post with North Manchester hospital where my surgical team and the MDT team are based.

The appointment came as a shock. The MDT met and made this referral on March 9th, but forgot to tell me. Hey ho, why should I presume I matter!
A Salford hospital appointment lady rang out of the blue on Friday 1st April to check I was available on Monday 4th. April Fool of course.

Me: 'appointment, what appointment? You must have the wrong patient'
Her: 'Can I check your date of birth, yes that's correct'
Me: 'appointment, what for?'
Me: Panic - do I have to go to Salford for the second attempt at the endoscopy? Oh no, I don't want to do that.
Me: 'Who made the appointment?'
Her: 'Mr O'Blimey'
The fog starts to clear and I call his secretary, who explains. Phew.

I still don't have the Biopsy report, or the CT report, and would very much like to be up-to-date with myself (!) before I see this new guy. Hence my rush to the GP and the secretaries, yet again, coming up trumps by printing everything off for me, including a copy of the referral letter I never got.

These ladies are due some Easter egg treats.

CT result

After 4 weeks of no news I got frustrated with waiting, so got the report from my GP.

"There is no evidence of hepatocellular carcinoma" - Hurray

"Lung bases clear" - Hurray hurray

"No evidence of renal obstruction. Bone review negative" - Hurray hurray hurray

PS I also got the biopsy report, but that is 7 paragraphs of scientific and medical jargon which will take me all weekend to translate. However, the last line says "appearance is not considered diagnostic of autoimmune hepatitis" - cautious hurray.

Reason to become a donor - No 1.

Three people die in the UK every day because not enough organs are donated.

Last 5 days

Five days since my last post. Little change healthwise. The last time I spoke to Dr S he said he would cancel my clinic appointment due 5th April and instead write to me with the results of the biopsy (done 25th Feb) and CT scan (done 3rd March). By 22nd March I'd heard nothing, so wrote to him instead, asking that he enclose a copy of the biopsy report and a copy of the CT scan report with his letter. Surprise surprise, 3 days later a new clinic appointment arrives in the post, booked for 8th April.

I've put on a couple of lbs weight while trying to stick to mainly 'mediterranean' foods. I've only managed one walk and had a few very tired days when I've had to go to bed for a few hours. I've worked more and done extra driving, so that might be causing the fatigue.
Monday I did 2 shifts back to back, covering for a colleague with a medical appointment. The second shift was with a favourite client, a 97 year old lady who I worked with before for 18 months but then 'lost' while off sick. It was lovely to be with her again and a neighbour made a point of stopping to congratulate me on making it back, which was nice.
Wednesday and Thursday I did routine shifts. My Thursday client insists we sit and chat over a cuppa and a cake, usually a cream cake. As she is blind I can serve myself a tiny morsel without her noticing, as cream or high fat cakes are off my menu.
J had a mock English AS level exam.

The Spring sunshine has prompted me into housework and window cleaning away the winter filth, though T has done the first weeding, lawn mowing and vegetable plot digging of the season.

Sister-in-law came over from Yorkshire for the day on Friday, which was lovely. She and I had a pub lunch but I excused myself from the 6 mile walk that followed with T.
J came home early from 6th form with a nasty flare up of eczema, so whizzed him down to the doctors for the end of Friday surgery. A course of antibiotics and some fresh steroid cream is beginning to calm things down. He's now £98 poorer, having bought a ticket for Leeds Festival, and is looking for a job!
Saturday was our 29th wedding anniversary.
Saturday and Sunday I worked shifts. A new client, currently struggling with sudden hearing loss. It takes 10-15 minutes to get into the house, as he can't hear the door or the phone. The neighbours must think me mad, knocking on the window and flapping my arms to attract his attention! I do have key access, but I think I would terrify him suddenly appearing in the room. It's slow work communicating by writing everything down or using signs.
British Summer time and clock changes confuse the older clients and I have to work out fast how to change their digital clocks, heating systems, microwaves and anthing else with an electronic timer!

Oh, and the water went off again today so I looked back through the blog and it last went off 7th November.

This time it's personal

Since my return to work on 27th January I've been slowly adding clients and hours. I'm now visiting one client each day on Mondays, Tuesdays, Wednesdays, Thursdays and Sunday. Although the shifts are no more than 2 hours, with the driving to and fro I'm probably working around 10 hours, which pathetic though it sounds I sense is now my limit.

Physically it's slightly easier than before, as my employer has been careful to assign me jobs that don't need manual handling or heavyweight household tasks. Emotionally I'm finding it harder than before because of the nature of the clients health. Alongside age related dementia (which I dont find a problem) I've ironically been allocated cancer patients so this time round it's more personal!

Stars and sparkles

"Tonight all, I'm going to be 'reviewing Burnt Shadows by Kamila Shamsie."

Our monthly Book Club meeting is at my house this evening. Better tidy up. There's enough food debris under the sofa seat cushions for an army of mice and what I find on the floor under the sofa itself is indescribable. OMG there are dust cobwebs drifting across the ceiling. 2 of the ladies have dust allergies and it's embarassing if it's your house that makes them sneeze! Anyone else bought these magic cleaning e-cloths that claim 'perfect cleaning with just water'. Why use magic e-cloth? It will save you time, money (at £5 a cloth??) and give better results with a sparkling smear free finish. I'm taken in by this vision of sparkling smear free windows letting in the sparkling Spring sun. They forget to add that you still need someone with elbow grease. Better wait for my servants to get home from school/work.

The book we've all read moves from Nagasaki 1945 to Delhi and Indian independence and partition, to Karachi, to Pakistani-Afghan training camps and thence to New York after the 9/11 attacks ending with a scene at Guantánamo Bay. With the current affairs in Japan no doubt tonight will include some debate about the nuclear industry.

Next month's book is "The Anatomy of Ghosts" by Andrew Taylor.

PS. 9 out of the 10 book club ladies came, an excellent turnout. Lynette I hope your husband has forgiven you for forgetting it was his birthday the same day! Oh, and nobody sneezed.

Weight

J and I are both trying to put on a bit of weight.

He's 5ft 10" and was down to 8 stone 7lbs after half-term. This was caused by lying in bed until lunchtime, thereby missing breakfast, and then lying on the sofa for most of the day in a teenage-sort-of-way instead of getting meals from the kitchen. Since then he has been force feeding himself currys and pizzas and fruit crumbles and donuts and all sorts of pretty unhealthy stuff (no fruit crumble does NOT count as one of your 5-a-day, nor do the tomatoes on a pizza). After 3 weeks of such hardship (not) he is now 9st.
I'm 5ft 6" and 8st 12lbs. I can eat vegetable currys and tiny bits of pizza but fruit crumbles and donuts are a no no. I cant see pictures of them in my Mediterranean pyramid. After 3 weeks of grains and fruit and veg and rye bread I've put on 1/2 lb - yay!

My big fat Greek diet

I've never had any professional dietary or nutrition advice. When the cirrhosis was confirmed, my surgical team just advised 'eat a healthy diet' (do we all have the same concept of what that is?). When I asked my GP for a referral to a dietician he said 'there won't be anyone with that level of speciality at the local NHS hospital'. So that was that.

Left to myself I researched a bit, and asked around a bit. The majority of cirrhotic patients on the hepatitis forums are in the same boat. No advice and making it up as they go along. The consensus seems to be: frequent small meals and snacks instead of 2 or 3 large meals. Plenty of low GI carbohydrates, plenty of fruit and veg, protein mainly from non red meat sources, low salt, not too much saturated fat. Pretty much fits the Mediterranean way of eating.


Anybody with tasty recipes that dont need more than 5 or 6 ingredients, have protein from mainly non animal sources and around 20 mins preparation/cooking time, please send. I get peckish but quickly bored in the kitchen!
By coincidence I've been asked to help on a second British Liver Trust leaflet. This time their 'diet and liver disease' one.

On the health front:
The biopsy results are back but have been passed on to a hepatologist for a second opinion. I've been told verbally that they confirm chronic Hepatitis B and established cirrhosis. Nothing we didnt know already. The second opinion is to look for evidence of active hepatitis.
The CT scan was 2 weeks ago, but not heard anything on that. Probably give it another week before I ring to check.
The gastroscopy I have to wait for a new appointment through the post.
My GP is writing to the consultant to get his opinion on the use of steroids should I have a myalgia flare. He's also telling him about my anxiety over the gastroscopy to see if they will consider a general anaesthetic.
He's ordered another complete set of blood tests (to be done on March 29th) including iron (with liver disease you can store too much) and Vitamin D3 which I'm currently taking as a supplement.

Homer Simpson yellow

Other bloggers are familiar with the sometimes surprising comments made by members of our medical teams.
NB: Carole:- This comes nowhere near the if-you-don't-laugh-you'd-cry level of your "Hello...where is the wound on your finger?" nurse. For those not in the know this will explain http://caroleandcancer.blogspot.com/2011/02/just-quick-rant.html

For yesterdays (non)procedure I'd been sent a pre-appointment questionnaire covering current state of health, medical history (am I likely to have a heart attack or go into a diabetic coma), allergies, current medications, etc. You give this to the clerking-in nurse, and then she takes out her own sheet and asks you the same questions all over again (Why?) She asks if I understand what procedure I'm in for. I say yes, I've got cirrhosis of the liver and it's to check for possible esophageal varices. She looks at me quizzically and says 'you don't look like a drinker'. Then points at a Sharps bin (Carole knows about these too) and says 'most of our cirrhosis patients look more that colour'

Sigh.
I should have taken in that British Liver Trust leaflet. The one that lists the 19 different liver diseases, of which alcoholic liver disease is but 1/19th of the sum. The one that explains people at risk of cirrhosis are not just those who drink but those who have any long-term liver infection; those who have an inherited liver disease, such as haemochromatosis; those who have an immune system problem that leads to liver disease and those with a fatty liver.

PS. Despite the procedure failing, I can't fault the professional, patient and sympathetic treatment by the specialist nurse and her assistants.
Today Dr S rang me to say I would be booked in for a second attempt and this time he would do it. Also he has the results of the biopsy but has asked for yet another opinion from a hepatologist.