Case conference
Presented by Intern:吳勝騰
2
Patient profile
• Name:林高 o 珠• Age: 48
• Gender: female
• Chart number: 04796365
• Admitted to our ward on 98/4/10
3
Chief complaint
• Yellowing of the sclera was noted since 4/8
4
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(-)
5
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.
6
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
7
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
8
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
9
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(-),
10
Laboratory data from ER
11
Laboratory data from ER
12
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
13
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
14
15
16
17
18
Liver function data during hospitalization
ANA : Negative (4/11)
19
Liver function data during hospitalization
GPT
GOT
20
Liver function data during hospitalizationTotal bilirubin
Albumin
21
Liver function data during hospitalizationPT
22
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
24
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
25
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
26
• 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.
27
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
28
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
29
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
30
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
31
Etiology-6
– acute fatty liver of pregnancy – HELLP syndrome– Reye's syndrome– malignant infiltration of the liver, heat stroke,
sepsis
32
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 !
34
Thank you very much !
35
36
EGD
37
Abdominal echo