Download The Road Not Taken

Case conference
Presented by Intern:吳勝騰
Patient profile
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Name:林高o珠
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 民國85年.
• 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 輔英 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
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Cigarette Smoking : denied
Alcohol : denied
Occupation history : 櫻花蝦製作
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
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
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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-gammaglobulinemia )
• 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 <40, particularly those who have concomitant hemolytic
anemia
• ALP/bilirubin<2; ALP often low in fulminant disease
• initial screening test: reduced serum ceruloplasmin
– Kayser-Fleischer rings
– 24-hour urine copper excretion>100 mcg/day
– liver copper levels >250 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↑
=> indicative of a poor prognosis
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Thank you very much !
Thank you very much !
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EGD
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Abdominal echo
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