1. Case-based Learning Department of Gastroenterology and Hepatology Yi-Cheng Chen

2. 案例簡介 Mr. Lo was a case of chronic hepatitis B since teenage without regular follow-up. He used to drink sorghum wine 200 ml everyday for more than 5 years. He suffered from yellowish skin and tea-colored urine for 3 days. He was admitted for evaluation of jaundice and liver function. Treatment of the complications of chronic hepatitis B will be discussed.

3. 學習目標 (1) To identify the etiology and pathophysiology of jaundice (hyperbilirubinemia) To understand the natural course of chronic hepatitis B and its complications To identify the significant findings of physical examination in cirrhotic patients To identify the significant findings of laboratory examination in chronic hepatitis B cirrhotic patients

4. 學習目標 (2) To learn the indication of antiviral therapy in patients with acute exacerbation on chronic hepatitis B. To learn how to confirm the status of liver cirrhosis To learn the treatment of hepatocellular carcinoma To simulate how to discuss with patient and family about the liver transplantation

5. 場景 (1) ：病史 (1) Mr. Lo has been a hepatitis B carrier since teenage. He suffered from general malaise for one month and yellow skin and tea-colored urine for 3 days. He paid little attention to these symptoms and attributed them to hard work. However, the symptoms got worse and anorexia, general weakness abdominal fullness with poor appetite developed.

6. 場景 (1) ：病史 (2) He also suffered from right upper quadrant discomfort without association with food. It was like dull pain, intermittent, with variable duration, without radiation, no specific relieving or precipitating factor noted. The body weight increased 5 kg in one month. No drug history except antacid. No travel history. No tarry stool, no bowel habit change, no skin rashes in recent one month. He was admitted for further evaluation.

7. 案例討論 (1) Identify Mr. Lo’s problems. Make diagnostic hypotheses that account for one or more of Mr. Lo’s problems. List your hypotheses with priority. What further information is needed to prove or disprove the hypotheses? What are your preliminary impressions and treatment plans

8. 場景 (2) ：身體檢查 (1) Vital signs: BP 135/76 mmHg, HR 78/min, RR 16/min, BH 166cm, BW 75.5kg, BT 36.8 o C. Ill and anxious looking Consciousness: clear, E4V5M6 Eye: pink conjunctiva, icteric sclera Neck: supple, no JVE, no palpable lymph node Chest: clear breathing sound, some spider nevi, breast with gynecomatic looking Heart: regular heart beat without murmur

9. 場景 (2) ：身體檢查 (2) Abdomen: soft, distended, neither superficial vein engorgement nor purpura, normoactive bowel sound, palpable lower tip of spleen, liver impalpable, liver span 10cm at right mid- clavicular line, no rebounding pain, no muscle guarding, shifting dullness(+) Back: no costo-vetebral angle knocking pain Extremities: mild pitting edema, palmar erythema on both hands Digital examination: yellow stool, external hemorrhoid

10. 案例討論 (2-1) What are the major findings of physical examination of Mr. Lo? What laboratory examinations do you need to confirm your diagnostic hypotheses?

11. 場景 (2) ：檢驗檢查 (1) ValueUnitReferences RBC4.0 10 6 /  L 4.5-5.9 Hemoglobin14.0g/dL13.5-17.5 Hemotocrit40.2%41-53 Platelet74 10 3 /  L 150-400 WBC5.3 10 3 /  L 3.9-10.6 Segment57.3%42-74 Lymphocyte30.9%20-56 Prothrombin time13.5/10.8Sec INR1.3sec1.2

12. 場景 (2) ：檢驗檢查 (2) ValueUnitReferences BUN15mg/dL6-21 Creatinine0.75mg/dL0.64-1.27 Na139mg/dL134-148 K4.2mg/dL3.0-4.8 Total bilirubin6.8mg/dL0-1.3 Direct bilirubin2.9mg/dL0-0.4 AST392U/L0-34 ALT536U/L0-36 Alkaline phosphatase 130U/L28-94 g-GT245U/L10-71 Albumin3.3g/dL3.5-5.5

13. 場景 (2) ：檢驗檢查 (3) AFP, 287.1 ng/ml HBsAg, reactive 57.8/1.0 Anti-HCV, non-reactive HBeAg, non-reactive Anti-HBeAg, reactive HBV DNA, 219000 copies/mL, 37700 IU/mL

14. 場景 (2) ：影像與專科檢查 (1) Chest X-ray: no active lesions are found in lungs, mediastinum, heart, airway, diaphragm and cheat wall Abdominal ultrasound: coarse liver parenchyma, uneven surface, splenomegaly (splenic index 32 cm 2 ), moderate ascites, a 2.5cm hypoechoic nodule at segment 5, normal gallbladder and biliary tracts, patent portal vein.

15. 場景 (2) ：影像與專科檢查 (2) CT of liver (with and without contrast/dynamic study): a 2.8cm liver tumor with hyper-density in arterial phase and hypo-density in portal phase and delay phase, cirrhotic liver parenchyma, ascites and splenomegaly were also found Esophago-gastro-duodenoscopy (EGD): Some form-1 blue color varices without red color sign at lower third of esophagus, no gastric varices, no peptic ulcer found

16. 案例討論 (2-2) What are the major findings of the laboratory examination of Mr. Lo? What are the major findings of the image studies of Mr. Lo? What do you want to do for the patient now?

17. 場景 (2) ：治療與後續追蹤 Day 1Day 3Day 7Dya 14 Total bilirubin (mg/dL)6.85.74.92.6 ALT (U/L)53636827865 Albumin (g/dL)3.33.02.93.2 Platelet (10 3 /  L) 74939684 Prothrombin time (sec)13.513.912.311.0 AscitesModerate Body weight (kg)75.573.670.2 ICG 15 study54% After preliminary medical treatment, Mr. Lo’s clinical condition was improving.

18. 案例討論 (2-3) What are your main diagnoses of this patient? What are your further treatment and health education plans?

19. 場景 (3) ：確認診斷與治療計畫 Major diagnoses –Chronic B hepatitis with acute exacerbation –Hepatocellular carcinoma (HCC) Entecavir 0.5mg daily Diuretics with furosemide 40mg/day and spironolactone 50mg/day, water and salt restriction Liver transplantation? Radiofrequency ablation (RFA) for HCC

20. 場景 (4): 醫病溝通 Decompensated liver cirrhosis with HCC was diagnosed and the patient could not accept the truth. At the time of initial diagnosis, liver transplantation was suggested. However, there was short of organ donation and no family could be the liver donor. The patient and family were in depressed mood. Alcoholic abstinence is necessary. Long-term antiviral therapy is needed.

21. 案例討論 (3) How to handle this miserable situation in patient and his family? How to explain the necessity of long-term antiviral therapy and importance of life-style change (alcohol abstinence, salt restriction)?