Case conference

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Case conference

• Presented by Intern???

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Patient profile

• Name??o?
• Age 48
• Gender female
• Chart number 04796365
• Admitted to our ward on 98/4/10

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Chief complaint

• Yellowing of the sclera was noted since 4/8

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Present illness

• This 48 years old woman is a patient of chronic
  hepatitis B, diagnosed on ??85?.
• She suffered from icteric sclera since 4/8. She
  also complained of RUQ area abdominal discomfort
  without tenderness.
• Other associated symptoms included
• fever (-), chills (-), fatigue() , body weight
  loss(-)
• mental disturbance or behavior change (-),
• general weakness (), insomnia()
• RUQ tenderness(-), anorexia(-), hunger pain (-),
  post prandial pain (-), diarrhea (-), nausea (-),
  vomiting (-) ,tarry stool(/-), bloody stool(-)
• arthralgia (-), myalgia(-)
• Yellowing of the skin(), itching of the skin(-)

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Present illness

• She denied recent blood transfusion, tattoos, or
  other Chinese herb use.
• Then she went to ?? hospital for help on 4/9,
  where elevated GOT(824), GPT(1654), total
  bilirubin(7.19), AFP(169) and PT
  prolong(17.5/10.2, INR 1.78) were found. Then she
  was transferred to our hospital for help on 4/10.
  
• At emergent department, vital sign was BP 155/92
  mmHg, HR 129 beat/min, RR 20 times/min, BT 36.7
  'C.
• Under the impression of chronic hepatitis B with
  acute exacerbation, she was admitted for further
  evaluation and management.

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Past history

• DM(-), Hypertension(-)
• Heart disease(-), renal disease(-)
• HBV, HCV chronic hepatitis B
• HBsAg(), Anti-HCV(-) (85.08.05)
• Operation history hysterectomy about 5-6 years
  ago

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Social history

• Cigarette Smoking denied
• Alcohol denied
• Occupation history ?????
• Contact history denied blood transfusion, IV
  drug or Chinese herb use, tattoo
• Travel history denied
• Allergy history no known drug allergy

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Physical examination (ER)

• Consiousness alert, E4V5M6
• Vital sign
• BP 155 / 92 mmHg, PR 129 bpm, RR 20 cpm,
  BT 36.7 ?
• Head
• Conjunctiva not pale, not injected Sclera
  icteric
• Neck
• supple, Lymphadenopathy (-), jugular venous
  distension(-)
• Chest symmetric expansion
• spider angioma(-)
• Heart sound regular heart beat without murmur
• Breath sound bilateral clear, no wheezing, no
  crackle

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Physical examination (ER)

• Abdomen soft and mild distended, caput
  medusae(-)
• Bowel sound normoactive
• Percussion tympanic, shifting
  dullness(-)
• tenderness (-) rebounding pain(-)
• Murphy sign(-) Mcberney sign(-)
• Liver / Spleen impalpable
• Extremities freely movable, lower limbs slight
  pitting edema
• Skin no rash or ecchymosis, no jaundice, palmar
  erythema(-),

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Laboratory data from ER
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Laboratory data from ER
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Tentative diagnosis

• Chronic hepatitis B with acute exacerbation,
  cause to be determined
• other causes of viral hepatitis HCV,CMV, EBV,
  HSV, VZV could not be excluded
• other causes of autoimmune hepatitis could not be
  excluded

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management

• Anti-viral drug Zeffix 1 BID PC
• supportive care
• Colin 1 TID PC
• IVF supply due to poor oral intake
• survey acute hepatitis cause
• Recheck anti-HCV Ab
• Check ANA to rule out autoimmune hepatitis
• Arrange abdominal echo
• follow up liver function
• monitor s/s of acute hepatic failure and hepatic
  encephalopathy

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Liver function data during hospitalization
ANA Negative (4/11)
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Liver function data during hospitalization
GOT
GPT
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Liver function data during hospitalization
Total bilirubin
Albumin
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Liver function data during hospitalization
PT
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management

• supportive care
• Hold possible toxic medication (arcoxia?)
• Procam 1 TIDPC
• IVF supply due to poor oral intake
• survey acute hepatitis cause
• Check HCV RNA
• Check ANA to rule out autoimmune hepatitis
• Arrange abdominal echo
• follow up liver function
• monitor s/s of acute hepatic failure and hepatic
  encephalopathy

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Topic Acute liver failure
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Definition

• definitions of the time course
• The development of encephalopathy within 8 weeks
  of the onset of symptoms in a patient with a
  previously healthy liver
• The appearance of encephalopathy within 2 weeks
  of developing jaundice, even in a patient with
  previous underlying liver dysfunction

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Etiology-1

• acute viral hepatitis
• HAV, HBV, HCV(rare), HDV coinfection or
  superinfection, HEV (especially in pregnant
  women), EBV, CMV, HSV, and varicella zoster
• Hepatitis B is probably the most common viral
  cause
• Viral serologies
• Hepatitis A IgM antibody
• Hepatitis B surface antigen
• Hepatitis B core IgM antibody
• Hepatitis C viral RNA

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• Acute hepatitis C
• account for approximately 20 of acute viral
  hepatitis in the United States
• marker
• Serum HCV RNA detectable by PCR days to 8 weeks
  following exposure
• Serum aminotransferases elevated 6 to 12 weeks
  after exposure
• Anti-HCV ELISA tests positive eight weeks after
  exposure
• The risk of chronic infection after an acute
  episode of hepatitis C is high, especially in
  asymptomatic patient.

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Etiology-2

• shock liver (ischemic hepatitis)
• prolonged period of systemic hypotension (such as
  patients with severe heart failure)
• Striking increases in serum aminotransferases and
  lactic dehydrogenase
• Other vascular cause
• acute Budd-Chiari syndrome, hepatic sinusoidal
  obstruction syndrome, hepatic infarction.
• Diagnostic ultrasound, abdominal CT, Doppler

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Etiology-3

• acute drug- or toxin-induced liver injury
• Predictable/ Unpredictable(idiosyncratic)
• medication/toxin
• Dose-dependent acetaminophen
• NSAID, antibiotics, statins, antiepileptic drugs,
  and antituberculous drugs, herbal preparations
• CCl4, fluorinated hydrocarbons, Amanita
  phalloides

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Etiology-4

• autoimmune hepatitis
• primarily in young to middle-aged women
• elevated serum aminotransferases, the absence of
  other causes of chronic hepatitis, and
  serological and pathological features
• screening test
• serum protein electrophoresis (hyper-gammaglobulin
  emia )
• ANA, SMA, and liver-kidney microsomal antibodies
  (LKMA)
• Liver biopsy
• Treatment long-term prednisone /- azathioprine

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Etiology-5

• Metabolic
• Wilson's disease
• genetic disorder of biliary copper excretion
• patients lt40, particularly those who have
  concomitant hemolytic anemia
• ALP/bilirubinlt2 ALP often low in fulminant
  disease
• initial screening test reduced serum
  ceruloplasmin
• Kayser-Fleischer rings
• 24-hour urine copper excretiongt100 mcg/day
• liver copper levels gt250 mcg/gm of dry weight
• Treatment
• Chelation therapy with penicillamine pyridoxine

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Etiology-6

• acute fatty liver of pregnancy
• HELLP syndrome
• Reye's syndrome
• malignant infiltration of the liver, heat stroke,
  sepsis

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Prognosis

• The mortality in FHF
• higher for idiosyncratic drug reactions, Wilson's
  disease, and non-A and non-B hepatitis and
• lower for cases of FHF caused by hepatitis A,
  hepatitis B, and acetaminophen
• the height of the aminotransferase elevation
  generally has no prognostic value.
• AST and ALT ??, plasma bilirubin?and prothrombin
  time?
• gt indicative of a poor prognosis

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Thank you very much !
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Thank you very much !
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EGD
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Abdominal echo