Case conference

Presented by Intern:吳勝騰

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Patient profile

• 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 (-), fever (-), chills (-), fatigue(+)fatigue(+) , body weight loss(-) , body weight loss(-)– mental disturbance or behavior change (-), mental disturbance or behavior change (-), general weakness (+),general weakness (+), insomnia(+)insomnia(+) – RUQ tenderness(-), anorexia(-), hunger pain (-), post prandial RUQ tenderness(-), anorexia(-), hunger pain (-), post prandial

pain (-), diarrhea (-), nausea (-), vomiting (-) ,tarry stool(+/-), pain (-), diarrhea (-), nausea (-), vomiting (-) ,tarry stool(+/-), bloody stool(-)bloody stool(-)

– arthralgia (-), myalgia(-)arthralgia (-), myalgia(-)– Yellowing of the skin(+), Yellowing of the skin(+), itching 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),GOT(824), GPT(1654), total bilirubin(7.19), total bilirubin(7.19), AFP(169) and PT prolong(17.5/10.2, INR 1.78)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 : 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

GPT

GOT

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Liver function data during hospitalizationTotal bilirubin

Albumin

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Liver function data during hospitalizationPT

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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

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-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

Thank you very much !

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Thank you very much !

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EGD

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Abdominal echo