Case conference Presented by Intern : 吳勝騰

2 Patient profile Name: 林高 o 珠 Age: 48 Gender: female Chart number: 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 (-), fatigue(+), body weight loss(-) –mental disturbance or behavior change (-), general weakness (+), insomnia(+) 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(-)

5 Present illness She denied recent blood transfusion, tattoos, or other Chinese herb use. GOT(824), GPT(1654),total bilirubin(7.19), AFP(169) and PT prolong(17.5/10.2, INR 1.78)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.

6 Past history DM(-), Hypertension(-) Heart disease(-), renal disease(-) HBV, HCV: chronic hepatitis B –HBsAg(+), Anti-HCV(-) ( ) 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

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18 Liver function data during hospitalization ANA : Negative (4/11)

19 Liver function data during hospitalization GPT GOT

20 Liver function data during hospitalization Total bilirubin Albumin

21 Liver function data during hospitalization PT

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 !

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36 EGD

37 Abdominal echo