Download Vignette_1_Hepatocellular_Cancer_Hep_B_infection[1]

GIT MODULE Case Vignettes
CASE 1 (Hepatocellular Cancer/Chronic Hepatitis B infection)
History
Minh, aged 45 years, comes to see you for a general check up. Minh tells you that his older brother
recently died in Vietnam from liver cancer. He is worried and wants to know if he is at risk of liver
cancer.
Apart from occasional tiredness, he is asymptomatic.
Minh was born in Vietnam and came to Australia 20 years ago. He works full time as an accountant
and lives with his wife, their two children (aged 8 and 10 years) and his mother, aged 75 years. His
father died 10 years ago.
Question 1
What further questions do you ask Minh?
Further History
Minh says he had an appendicectomy in Vietnam at the age of 9. He had vaccinations at school but
does not know what they were. He had two previous sexual partners in Vietnam before he married
but can’t remember whether condoms were used. To his knowledge, there is no other family history
of liver disease or liver cancer. He has an occasional alcoholic drink at parties but is not a regular
drinker. He does not smoke and has never used injecting drugs. He takes no regular medications.
He denies other symptoms.
Question 2
Describe your examination of Minh.
Examination
No anaemia or jaundice
BMI 24
BP 130/80mmHg
PR 72 regular
Afebrile
GIT /Cardiorespiratory examinations – no abnormality detected.
Question 3
What a) initial and b) follow up blood tests would you order?
Minh’s initial and follow up blood test results
TEST
Liver function tests
Bilirubin
Albumin
Alanine aminotransferase (ALT)
Aspartate aminotransferase (AST)
Alkaline phosphatase (ALP)
Gammaglutamyl transpeptidase (GGT)
RESULT
12μmol/L (N<20)
38g/L (N 38-48)
45 U/L (N<35)
48 U/L (N<35)
60 U/L (N<130)
45 U/L (N<60)
Coagulation Studies
International normalisation ratio (INR)
APTT
1.1 (1.0 – 1.2)
26 secs (25 – 33 seconds)
Full blood examination
Hb
WCC
Platelets
143g/L (135-180g/L)
4.2 x 109/L (4-11 x 109/L)
160 x 109/L (140 – 400 x 109/L)
Thyroid Function Test
TSH
1.2mU/L (0.4 – 5.5 mU/L)
Random glucose
6.8mmol/L (3.0 – 7.5mmol/L)
Electrolytes
Sodium
Potassium
Chloride
Bicarbonate
Creatinine
Urea
137 mmol/L (135-145mmol/L)
4.0 mmol/L (3.8-5.2mmol/L)
105 mmol/L (99-110mmol/L)
26 mmol/L (22-30mmol/L)
0.06 mmol/L (0.05-0.12mmol/L)
4.3 mmol/L (3-8mmol/L)
Serology
HBsAg
Anti HBc
Anti HBs
HBeAg
Anti HBe
HBV DNA
Anti HCV
DETECTED
DETECTED
Not detected
Not detected
DETECTED
20 000 IU/ml
Not detected
Question 4
What is your interpretation of these results?
Question 5
How would you further investigate Minh’s liver disease?
Revision Points
GIT examination with particular focus on the signs of chronic liver disease
Hepatitis viruses
Acute vs chronic Hepatitis B
Hepatitis serology
LFTs
Hepatocellular carcinoma
Differential Diagnosis of a solitary liver mass noted on USS