1. Medical Grand Rounds Department of Gastroenterology 2005 년 6 월 21 일

2. Patient information Chief complaint Abdominal distension, generalized weakness (onset : several months ago) Present illness 1.M/50, 91 년 Chronic HBV infection 진단. 2.2000 년 Chronic HBV infection 에 의한 LC 진단. 3.2004 년 4 월 국립암센터 (NCC) 방문 HCC 진단, TACE #1 차 시행. 4.2005 년 3 월 abdominal CT 에서 recurred HCC 진단, elder brother 가 donation 약속하여 LT 계획하에 w/u 진행후 NCC 에서 퇴원. 5.2005 년 5 월 5 일 NCC 방문, hepatic encephalopathy 로 치료받음. 6.2005 년 5 월 23 일 상기 주소로 본원 LT w/u 및 conservative management 원해 본원 ER 경유 admission.

3. Past medical history DM(+) – LC 진단받을 당시 알게됨, 이후 poorly controlled HTN(-), Pul. TB(-), HBV(+) Personal history Alcohol(+) – social drinking, Smoking(+) – 30 pack yrs Review of systems Generalized weakness (+) Yellowish skin discoloration (+) Cough (-), sputum (-), dyspnea (-) Anorexia (+), nausea (-), vomiting (-), loose stool (+) : 2~3 회 Constipation (-), abdominal discomfort (+) : diffuse

4. Physical examination (V/S 110/70mmHg-67 회 /min-20 회 /min-36.7 ℃ ) Alert consciousness Chronically ill-looking appearance Isocoric pupil with PLR (+/+) Yellowish sclera No pale conjunctiva Symmetric chest expansion Clear breathing sound without other adventitious sound Regular heart beat without murmur No pretibial pitting edema ** Abdomen : Tense and distended abdomen Decreased bowel sound Diffuse abdominal discomfort without definite tender point No palpable abdominal mass

5. Initial imaging data 1.Abdominal dynamic CT (2005 년 4 월 26 일 ) Advanced liver cirrhosis, large amount of ascites. Suspected HCC, Lt. lobe lateral segment. Dysplastic nodule at Rt. Lobe dome. Compact lipiodol uptake; Rt.Lobe dome & Lt. lobe lateral segment. 2.Chest dynamic CT : Unremarkable finding. 3. PET-CT : Reactive nodule, phrenic LN. 4. Gastroscopy : Esophageal varix, Lm F3 Cb RC+ 5. Colonoscopy : Unremarkable finding.

6. Initial lab data 1.CBC/DC 5,160/mm 3 – 9.5g/dL – 28.3% - 60,000/mm 3 2.PT (%) INR : 21.8sec (43%) 1.92 3.aPTT : 51 C 33 4.Blood chemistry Total bil./Direct bil. 5.0/2.0 mg/dL Total cholesterol 46 mg/dL Protein/Albumin 6.5/2.6 g/dL AST/ALT 136/102 IU/L BUN/Creatinine 80/1.3 mg/dL Na/K/Cl 121/4.2/91 mmol/L Ammonia 289 ug/dL 5. U/A : RBC 2~4/HPF, WBC 0~1/HPF

7. Child-Turcotte-Pugh classification (CTP) score : class C Model for End-stage Liver Disease (MELD) score : 10 {0.957 Ln(Scr) + 0.378 Ln(Tbil) + 1.12 Ln(INR) + 0.643} = 32 → Status 2a : CTP score ≥10; end-stage chronic liver disease; severely ill patient, should be hospitalized in an ICU

8. Diagnosis list 1.HCC, Right and Left lobe of liver s/p TACE #1 2.B-viral liver cirrhosis (CTP score class C, MELD score status 2a) 3.Type 2 diabetes mellitus

9. Plan Longterm plan : liver transplantation Problem list 1.R/O hepatic encephalopathy → Ammonia level F/U check Lactulose 투여하여 하루 2~4 회의 diarrhea 유도 Electrolyte imbalance 교정 및 hydration (FENa 0.5) Infectious cause 교정, antibiotics 사용 2.Poorly controlled ascites → Diuretics ; 현재 dehydrated state 이면서 BUN/Cr 상승 소견있으므 로 general condition 고려하여 사용 3. R/O DM nephropathy → HbA1c level check, DM control ; LT 후 DM complication evaluation

10. Hospital day #4(5 월 28 일 ) S> Hypersomnolence (+), generalized weakness (+) O> Asterixis (+) - flapping tremor Abdomen palpation 시 tenderness (+)/rebound tenderness (-) 100/60mmHg-62 회 /min-20 회 /min-37.7 ℃ BUN/Creatinine 59/1.1 mg/dL Na/K/Cl 132/3.7/106 mmol/L Ammonia 384 ug/dL A> Hepatic encephalopathy R/O SBP P> Lactulose enema Diagnostic paracentesis Antibiotics

11. Clinical course HDMental status P/EAmmonia level(ug/ dL) TxResponse to Tx 5/28Drowsy, pain response (+) Abdomen palpation 시 얼굴 찡그림 384Lactulose enema q 1 hr Mentality change (-) 5/29LethargicAbd. Tendernes s(+) 289Lactulose enema tid, cefotaxime 1 g q 8 hrs Verbal response(+), 알아듣기 힘든 반응 5/30AlertHypersom nolence(+) 198Lactulose enema tid, cefotaxime 1 g q 8 hrs Verbal response(+), 의사소통 가능 5/31AlertHypersom nolence 감 소 163Lactulose 30 mL PO tid Diarrhea 2~4 회 /day, BT 36.5 ℃ Peritoneal fluid study RBC 840/mm 3 WBC 210/mm 3 (Seg. 24%)

12. Hospital day #21(6 월 13 일 ) S> Day time sleep increased, nausea (+), abdominal pain (-) O> Drowsy mental status 100/60mmHg-61 회 /min-20 회 /min-36.5 ℃ BUN/Creatinine 78/2.4 mg/dL Na/K/Cl 130/6.3/103 mmol/L Ammonia 818 ug/dL ** 이전의 culture study 상 모두 negative finding. A> Hepatic encephalopathy P> Lactulose enema Encephalopathy 지속시 PO antibiotics (neomycin or metronidazole) Ammonia level F/U check Liver transplantation

13. → 2 일뒤 (6 월 15 일 ) 아침부터 mentality clear 해지고 orientation 정상화됨 Ammonia level : 195 ug/dL ** Hepatic reserve 의 감소로 인한 잦은 encephalopathy attack : urgent liver transplantation 계획중 urgent liver transplantation 계획중