1. Update on Vietnam Health Issues: Liver flukes and cancer
Jeff Whittle, MD, MPH
Staff Physician
Clement J. Zablocki VA Medical Center
Professor of Medicine, MCW Dept of Med

2. Objectives
Review why we are worried about liver flukes in Vietnam Veterans
Discuss testing for:
Opisthorchis viverrini
Cholangiocarcinoma

3. Liver fluke

4. Distribution Most common in Northeast Thailand Also present in Laos
Less common in South Vietnam, more common in the North
Rare in Cambodia
Related flukes in China and Korea

5. Liver fluke life cycle

6. Koi Pla

7. Bile ducts

8. Test for liver fluke infection
When actively infected
Look for eggs in stool
Not useful for past infection
No test for resolved liver fluke infection for clinical use in the United States
Worms are all dead after years
Immune response test could be feasible

9. Cholangiocarcinoma

10. Risk factors for this cancer
Living in Thailand
Particularly in regions with liver flukes
Working in fishing industry
Inflammation of the biliary tree
Cirrhosis of the liver
Viral hepatitis – mostly
Immune diseases like diabetes

11. Symptoms of cholangiocarcinoma
Jaundice
Pain in the abdomen
Dark urine and light stool
Nausea and vomiting
Unexplained weight loss
Generally no symptoms until too late

12. Diagnosing cholangiocarcinoma
Pictures of liver
CT scan
Ultrasound
Pictures of biliary tree
ERCP – endoscopic injection of dye
Transhepatic cholangiogram
Magnetic resonance cholangiopancreatogram
Biopsy of affected area

13. Scary study Northpoint VA Medical Center Surveyed 97 Vietnam Veterans
50 had eaten raw or undercooked fish
12 of these had antibodies to a fluke that is found in Korea and China
None of these had abnormal bile ducts
One of the 50 was known to have cancer – he did not have antibodies

14. Why we don’t screen
We can’t tell who has had liver fluke infestation with available tests
Likely could develop a test of past exposure
Cholangiocarcinoma is very hard to diagnose before it is incurable
There does not seem to be an increased risk of cholangiocarcinoma in Vietnam Veterans

15. Vietnam Veterans and Research
Military service can cause unique problems
VVA has experience advocating
Increased interest in involving Veterans
Identify important and unimportant questions
Advise regarding what data to collect, who to enroll, and how to enroll them
Help interpret results and get the word out