Cicero ( BC) Realtor Louell L. Sala MD Family Medicine Resident Batch 2010 Objectives To discuss a case of jaundice in a 22 year old female To present an algorithm for the assessment of jaundice To present the management done to this patient based on current evidences To be able to answer basic clinical questions regarding hepatitis c using the best available evidence. History of Present Illness J.C. 22 y/o female Pasig line Sta. Ana, Manila Single Right-handed Reliability 85% Chief Complaint: Icteric sclerae History of Present illness 2 months PTCicteric sclerae which the patient noted. Associated with fever (T max 38 ) and grade 2 pitting edema (-) abdominal pain (-) acholic stools (-)dysuria (-)hematuria (-) weight loss (-) nausea (-)vomiting (-) rashes (-) itchiness (-) history of walking in flood water (+) sought consult at private hospital Urinalysis: RBC: many, WBC: 8-10/hpf; albumin: trace CBC: 15.4/4.13/107/platelet 359 A> UTI t/c Nephrotic Syndrome r/o Viral Hepatitis Patient was given Furosemide for the edema and antibiotics for the UTI Given request for the following laboratories HBsAG, AST, ALT, anti HBS, FBS, BUN, Crea interim Patient claimed there was relief of the edema but there was persistence of the icteresia. There was no abdominal pain, no nausea, no vomiting and no acholic stools Few days PTC Persistence of the icteresia and patient requested for the interpretation of the laboratory request hence this eventual consult. Review of systems GENERAL: loss of muscle mass, sweats, fatigue EAR: No deafness, pain, tinnitus, discharges, NOSE: No epistaxis, discharges, obstruction, post nasal drip NECK: No stiffness, No limitation of motion, masses, sensation of lump BREAST: No masses, discharges, pain, discomfort PULMONARY: No dyspnea, shortness of breath, cough, sputum production CARDIAC: No chest pain, discomfort, palpitations, easy fatigability, shortness of breath, orthopnea, trepopnea, paroxysmal nocturnal dyspnea VASCULAR: No phlebitis, varicosities., claudication GENITOURINARY: No urine flow abnormality, dribbling, urgency, hesistancy, dysuria, hematuria, polyuria, flank pain, perineal pain, vaginal bleeding, vaginal discharge ENDOCRINE: No heat cold intolerance, diaphoresis, breast/voice changes, palpitations, somnolence HEMATOPOIETIC: No pallor, abnormal bleeding, easy bruisability NEUROLOGIC: No headache, dizziness, loss of consciousness PSYCHIATRY: No anxiety, interpersonal relationship changes, illusions, delusions, changes in mood, paranoia Past Medical History (-) Diabetes Mellitus, Hypertension, Asthma, Tuberculosis (-) no known allergies (-) Blood transfusions/Irradiations (-) Herbal medications OB/Gyne History: Go Menarche = 15 y/o Regular 6-7 days 3 ppd No dysmennorhea LMP: 3 rd week of May Coitarche: 21 (-) Oral contraceptive pills Monogamous with one male partner Personal Social History Non smoker Non alcoholic beverage drinker No history of Illicit drug use Currently unemployed works at home although she plans to work eventually to help augment the household Diet: fish and vegetables usually cooked at home Water is purified from water refilling station near their house Family Genogram Physical Examination Conscious coherent not in CP distress BP: 120/80 RR: 18 HR:84 Wt:62 Ht:157 BMI: 25 kg/m2 Pink palpebrae, icteric sclerae Fundoscopy: (+) ROR, CD 0.3, media clear (-) exudates/hemmorhages, OU Supple neck, no cervical lymphadenopathies Symmetrical chest expansion, no retractions, clear breath sounds Adynamic Precordium, normal rate regular rhythm Flabby abdomen, soft, normoactive bowel sounds, nontender (-) Murphys sign (-) caput medusae, fluid wave, shifting dullness (-) spider angiomata, No cyanosis, no edema, full and equal pulses (-) palmar erythema Neurological Examination GCS = 15 (Eye Opening=4 Verbal=5 Motor=6) Conscious, oriented to time, place and person Intact memory with good insight CN 1. able to smell coffee CN Equally reactive to light CN 3,4,6: Extra Ocular muscles intact CN 5: good masseter strength CN 7: No facial Assymetry (+) lid closure, both CN 8: intact gross hearing CN 9-10: uvula midline CN 11: (+) shoulder shrug CN 12: (+) tongue midline on protrusion 5/5 5/ Deep Tendon Reflexes : Biceps Triceps Patellar Achilles Babinski (-) (-) Cerebellar: able to perform finger to nose test Meningeal Signs : Negative Kernigs Yes Yes No Yes No No No No Yes No Yes No University of Washington Yes Division of Gastroenterology Murakami MD et.alAcute hepatocellular Injury (alk phosphatase antiHAV IgM Anti CMV IgM HBSAg Anti HCV Refer to GI Supportive. Monitor PT Refer to GI Supportive. Monitor Resolution ANA, AMA, Ceruloplasmin Chronic Hepatocellular Injury Treatment for specific agent Consider alcohol, Acetaminophen, toxins Cholestatic Liver Injury Consider Atypical presentation of Biliary Obstruction, Hepatic Mass Refer to GI Abdominal Sonography Refer to GI/Liver Go to Chronic Liver algorithm (>6 months) Harrison's Internal Medicine. 17 th ed. Chapter 296. Evaluation of Liver Function. Mcgraw Hill Copyright. DisorderBilirubinAminotransferasesAlkaline phosphatase AlbuminProthrombin time Hemolysis/GilbertsNormal to 86 mol/L (5 mg/dL) Normal Acute Hepatocelluar Necrosis(viral and drug hepatitis) Both fractions may be elevated Elevated ALT >AST Normal to (+) icteric sclerae, no fever, no edema, no abdominal pain O> HBsAg = NR Anti HAV IgM = NR AST = 129 (H) ALT = 263 (H) > Alk.phosphatase = (N) HBeAg = NR Anti HCV = Reactive Albumin = 61 (L) Crea = 72.5 (N) BUN = 5.5 (N) Potassium = 2.5 (L) t/c Hepatitis C Hypokalemia Dx: HBT UTZ, Potassium Tx: Kalium durule TID Refer to IDS Refer to GI NP: Incorporate banana in the diet Alcohol Avoidance HBT Ultrasound 7/12/10 IDS Notes: (-) jaundice, (-) abdominal pain E/N PE AST = 52 (from 129) ALT = 83 (from 263) Hepatitis C infection Repeat AST, ALT in 6 months TCB with HBT UTZ Kailangan ko ba uminom ng gamot doc? Standard Indications for therapy Elevated ALT Activity AST = 52 (from 129) ALT = 83 (from 263) Fibrosis or moderate to severe hepatitis on liver biopsy Detectable HCV RNA Page 1749 Harrisons Principles of Internal Medicine 17 th ed. Mcgraw Hill. 2001 Antiviral Therapy not recommended Decompensated Cirrhosis Normal ALT Activity Page 1749 Harrisons Principles of Internal Medicine 17 th ed. Mcgraw Hill. 2001 Pwede pa ba ako makipagtalik sa bf ko? Recommendations:Persons infected with HCV should be counseled on how to avoid HCV transmission (Class I, level C) HCV infected persons should be counseled to avoid toothbrush and dental or shaving equipments Persons should be counseled to stop using illicit drugs HCV infected persons should be advised not to donate blood, blood organs, other tissue or semen HCV infected persons should be counseled that the risk for sexual transmission is low, and the infection itself is not a reason to change sexual practices (i.e. Long term relationships need not start using barrier precautions but others should always practice safer sex. Adapted from Recommendations for prevention and control of hepatitis C Virus and HCV related chronic disease Centers for Disease Control and Prevention. MMWR Recomm Rep 1998;47 (RR-19):1-39 Approved by the American Association for the study of Liver Diseases (AASLD) and the American Gastroenterological Association Policy Statement Mamamatay na ba ako doc? Harrison's Internal Medicine 17 th ed. Chapter 298. Acute Viral Hepatitis. Copyright The McGraw-Hill Companies. After acute HCV infection, the likelihood of remaining chronically infected approaches 8590%. Although many patients with chronic hepatitis C have no symptoms, cirrhosis may develop in as many as 20% within 1020 years of acute illness; in some series of cases reported by referral centers, cirrhosis has been reported in as many as 50% of patients with chronic hepatitis C. Anu ang kailangan kong gawin doc? 1. Avoidance of alcohol There is an association between the use of excessive alcohol and the development and progression of liver fibrosis and even the development of Hepatocellular carcinoma Bedossa et. al. Natural History of liver fibrosis progression in patients with chronic hepatitis C. The OBSVRC, METAVIR, CLINIVIR and DOSVIRC groups. Lancet 1997: 349; Harris et.al. The relationship of hepatitis c to the development of cirrhosis in the presence of alcohol abuse. Ann Intern Med 2001;134: 2. Weight loss for Obese patients Obesity and its associated nonalcoholic fatty liver disease are believed to play a role in the progression of fibrosis in HCV-infected individuals. It is therefore appropriate to counsel those with BMI >=25 kg/m2 to attempt to lose weight Hourigan et.al. Fibrosis in Hepatitis C correlates significantly with Body Mass Index and steatosis. HEPATOLOGY 1999; 29: Ortiz et.al. Contribution of Obesity to Hepatitis C-related fibrosis progression. Am J Gastroenterol 2002:97: 3. Vaccination against Hep A and B A single report suggested that the superimposition of hepatitis A virus in persons with chronic liver disease particularly with hep c was associated with fulminant hepatitis No specific recommendation against Hep B but evidence against those co-infected with Hep B and C have worse prognosis than Hep C alone hence Hep B vaccination should be offered. Vento et.al. Fulminant Hepatitis associated with Hepatitis A virus superinfection in patients with chronic Hepatitis C. N Eng J Med 1998; 338; Tsai et.al. Independent and additive effect modification of hepatitis C and B virus infection on the development of Chronic Hepatitis. J Hepatol 1996; 24: 4. Use of Silymarin (milk thistle extract) The benefit of Silymarin and or other herbal therapies for Hepatitis C has not been established. Currently, the NIH is conducting a well designed scientific study of a standardized formulation of silymarin to determine its effectiveness Of concern, Some herbal mixtures have been associated with hepatotoxicity, fulminant hepatitis and death. Strader et.al. Use of complementary and alternative medicine in patients with liver disease. Am J Gastroenterol 2002;97: Seef LB. Herbal Hepatotoxicity. Clin Liver Dis 2007; 577 596, vii. Pwede pa ba ako makapagtrabaho doc? Should there guidelines about Hepatitis C in the workplace? Section 6. Code of Ethics in Medical Profession The medical practitioner should guard as a sacred trust anything that is confidential in nature that he may discover or be communicated to him, except when it is in the interest of justice, public health, or public safety. Where do we draw the line between privacy and public health?