Case Study: Acute Exacerbation of Chronic Hepatitis B in a 48-Year-Old Female Patient

1. Case conference Presented by Intern:吳勝騰

2. Patient profile • Name:林高o珠 • Age: 48 • Gender: female • Chart number: 04796365 • 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(+) • 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. • 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(-) (85.08.05) • 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

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

19. Liver function data during hospitalization GOT GPT

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

23. 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

33. Thank you very much !

34. Thank you very much !

36. EGD

37. Abdominal echo