Case-based Learning

Department of Gastroenterology and Hepatology

Yi-Cheng Chen

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.

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

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

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.

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.

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

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 oC.

• 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

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

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?

場景 (2) ：檢驗檢查 (1)

Value Unit References

RBC 4.0 106/mL 4.5-5.9

Hemoglobin 14.0 g/dL 13.5-17.5

Hemotocrit 40.2 % 41-53

Platelet 74 103/mL 150-400

WBC 5.3 103/mL 3.9-10.6

Segment 57.3 % 42-74

Lymphocyte 30.9 % 20-56

Prothrombin time 13.5/10.8 Sec

INR 1.3 sec 1.2

場景 (2) ：檢驗檢查 (2)

Value Unit References

BUN 15 mg/dL 6-21

Creatinine 0.75 mg/dL 0.64-1.27

Na 139 mg/dL 134-148

K 4.2 mg/dL 3.0-4.8

Total bilirubin 6.8 mg/dL 0-1.3

Direct bilirubin 2.9 mg/dL 0-0.4

AST 392 U/L 0-34

ALT 536 U/L 0-36

Alkaline phosphatase

130 U/L 28-94

g-GT 245 U/L 10-71

Albumin 3.3 g/dL 3.5-5.5

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

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 cm2), moderate ascites, a 2.5cm hypoechoic nodule at segment 5, normal gallbladder and biliary tracts, patent portal vein.

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

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?

場景 (2) ：治療與後續追蹤

Day 1 Day 3 Day 7 Dya 14

Total bilirubin (mg/dL) 6.8 5.7 4.9 2.6

ALT (U/L) 536 368 278 65

Albumin (g/dL) 3.3 3.0 2.9 3.2

Platelet (103/mL) 74 93 96 84

Prothrombin time (sec) 13.5 13.9 12.3 11.0

Ascites Moderate

Body weight (kg) 75.5 73.6 70.2 70.2

ICG15 study 54%

After preliminary medical treatment, Mr. Lo’s clinical condition was improving.

案例討論 (2-3)

• What are your main diagnoses of this patient?• What are your further treatment and health

education plans?

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

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.

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)?