Post on 19-Dec-2015
Case Study 18: CirrhosisSkylar Strobel
Overview
• Role of liver
• Scar tissue forms as liver repairs itself
• Wide range of causes
Patient S.G.
• 46 yo white male• History of chronic alcoholism• Abdominal swelling and confusion• Gained 15 lbs• Lethargic, acting strangely
PMH
• Cirrhosis, 4 years ago• H/O:• Uncontrolled ascites and peripheral edema• Anemia• Acute pancreatitis• E. coli-induced bacterial peritonitis
• Father died at age 52• H/O alcohol abuse• H/O IVDA and intranasal cocaine• ½ ppd for many years
Review of Systems
• Increasing abdominal girth
• No complaints of abdominal pain, fever, chills, nausea, hematemesis, tarry stools, cough, chest pain, weakness, blood in urine, diarrhea or dry mouth
Patient Case Question 1: Hematemesis and tarry stools are clinical signs of which serious potential complication of cirrhosis?
• Acute gastrointestinal bleeding
Physical Exam
• Skin• Mild jaundice• (+) spider nevi on
chest• (-) palmar erythema• Several ecchymoses
on lower extremities• HEENT• (+) icteric sclera
• Chest• (+) gynecomastia
• Abdomen• Moderately
distended, firm, slightly tender• (+) prominent veins• (+) HSM
• Genit/Rect• Testicles atrophied• (+) hemorrhoids
• Neuro• Confused, disoriented
Patient Case Question 2: Identify 15 clinical signs and symptoms consistent with a diagnosis of cirrhosis
• Weight gain• Lethargy• Confusion• Unusual violent
behavior• Skin• Mild jaundice• (+) spider nevi on chest• Several ecchymoses on
lower extremities• HEENT• (+) icteric sclera
• Chest• (+) gynecomastia
• Abdomen• Moderately distended,
firm, slightly tender• (+) prominent veins• (+) HSM
• Genit/Rect• Testicles atrophied• (+) hemorrhoids
• Neuro• Confused, disoriented
Lab Test ResultsNa 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL
K 3.5 meq/L PT 15.6 sec AFP 90 ng/mL
Cl 101 meq/L PTT 45.1 sec HBsAg (-)
HCO3 25 meq/L NH3 250µg/dL HIV (-)
BUN 12 mg/dL AST 107 IU/L Anti-HCV (+)
Cr .6 mg/dL ALT 86 IU/L HCV RNA 2.8 million/mL
Glu 90 mg/dL Alk phos 224 IU/L ANA (-)
Hb 14.0 g/dL Bilirubin 2.4 mg/dL Fe 75 µg/dL
Hct 39.7% Protein 6.6 g/dL Ferratin 200 ng/mL
MCV 90 fL Alb 2.7 g/dL Transferrin saturation 38%
Plt 34500/mm3 Ca 8.5 mg/dL Ceruplasmin 37 mg/dL
3. Anemic?Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL
K 3.5 meq/L PT 15.6 sec AFP 90 ng/mL
Cl 101 meq/L PTT 45.1 sec HBsAg (-)
HCO3 25 meq/L NH3 250µg/dL HIV (-)
BUN 12 mg/dL AST 107 IU/L Anti-HCV (+)
Cr .6 mg/dL ALT 86 IU/L HCV RNA 2.8 million/mL
Glu 90 mg/dL Alk phos 224 IU/L ANA (-)
Hb 14.0 g/dL Bilirubin 2.4 mg/dL Fe 75 µg/dL
Hct 39.7% Protein 6.6 g/dL Ferratin 200 ng/mL
MCV 90 fL Alb 2.7 g/dL Transferrin saturation 38%
Plt 34500/mm3 Ca 8.5 mg/dL Ceruplasmin 37 mg/dL
4. Abnormality of CBC?Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL
K 3.5 meq/L PT 15.6 sec AFP 90 ng/mL
Cl 101 meq/L PTT 45.1 sec HBsAg (-)
HCO3 25 meq/L NH3 250µg/dL HIV (-)
BUN 12 mg/dL AST 107 IU/L Anti-HCV (+)
Cr .6 mg/dL ALT 86 IU/L HCV RNA 2.8 million/mL
Glu 90 mg/dL Alk phos 224 IU/L ANA (-)
Hb 14.0 g/dL Bilirubin 2.4 mg/dL Fe 75 µg/dL
Hct 39.7% Protein 6.6 g/dL Ferratin 200 ng/mL
MCV 90 fL Alb 2.7 g/dL Transferrin saturation 38%
Plt 34500/mm3 Ca 8.5 mg/dL Ceruplasmin 37 mg/dL
5. Sudden progression?Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL
K 3.5 meq/L PT 15.6 sec AFP 90 ng/mL
Cl 101 meq/L PTT 45.1 sec HBsAg (-)
HCO3 25 meq/L NH3 250µg/dL HIV (-)
BUN 12 mg/dL AST 107 IU/L Anti-HCV (+)
Cr .6 mg/dL ALT 86 IU/L HCV RNA 2.8 million/mL
Glu 90 mg/dL Alk phos 224 IU/L ANA (-)
Hb 14.0 g/dL Bilirubin 2.4 mg/dL Fe 75 µg/dL
Hct 39.7% Protein 6.6 g/dL Ferratin 200 ng/mL
MCV 90 fL Alb 2.7 g/dL Transferrin saturation 38%
Plt 34500/mm3 Ca 8.5 mg/dL Ceruplasmin 37 mg/dL
6. Four risk factors
1. Alcohol Abuse2. Hepatitis C • Anti-HCV test +
3. Overweight• Height: 5’7”• Weight: 171 lbs• BMI = 26.8 overweight
4. Liver Cancer • AFP test – 90 ng/mL• Normal – 0-15 ng/mL
7. Bacterial peritonitis?Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL
K 3.5 meq/L PT 15.6 sec AFP 90 ng/mL
Cl 101 meq/L PTT 45.1 sec HBsAg (-)
HCO3 25 meq/L NH3 250µg/dL HIV (-)
BUN 12 mg/dL AST 107 IU/L Anti-HCV (+)
Cr .6 mg/dL ALT 86 IU/L HCV RNA 2.8 million/mL
Glu 90 mg/dL Alk phos 224 IU/L ANA (-)
Hb 14.0 g/dL Bilirubin 2.4 mg/dL Fe 75 µg/dL
Hct 39.7% Protein 6.6 g/dL Ferratin 200 ng/mL
MCV 90 fL Alb 2.7 g/dL Transferrin saturation 38%
Plt 34500/mm3 Ca 8.5 mg/dL Ceruplasmin 37 mg/dL
8. Why do an ANA test?Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL
K 3.5 meq/L PT 15.6 sec AFP 90 ng/mL
Cl 101 meq/L PTT 45.1 sec HBsAg (-)
HCO3 25 meq/L NH3 250µg/dL HIV (-)
BUN 12 mg/dL AST 107 IU/L Anti-HCV (+)
Cr .6 mg/dL ALT 86 IU/L HCV RNA 2.8 million/mL
Glu 90 mg/dL Alk phos 224 IU/L ANA (-)
Hb 14.0 g/dL Bilirubin 2.4 mg/dL Fe 75 µg/dL
Hct 39.7% Protein 6.6 g/dL Ferratin 200 ng/mL
MCV 90 fL Alb 2.7 g/dL Transferrin saturation 38%
Plt 34500/mm3 Ca 8.5 mg/dL Ceruplasmin 37 mg/dL
9. Hemochromatosis?Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL
K 3.5 meq/L PT 15.6 sec AFP 90 ng/mL
Cl 101 meq/L PTT 45.1 sec HBsAg (-)
HCO3 25 meq/L NH3 250µg/dL HIV (-)
BUN 12 mg/dL AST 107 IU/L Anti-HCV (+)
Cr .6 mg/dL ALT 86 IU/L HCV RNA 2.8 million/mL
Glu 90 mg/dL Alk phos 224 IU/L ANA (-)
Hb 14.0 g/dL Bilirubin 2.4 mg/dL Fe 75 µg/dL
Hct 39.7% Protein 6.6 g/dL Ferratin 200 ng/mL
MCV 90 fL Alb 2.7 g/dL Transferrin saturation 38%
Plt 34500/mm3 Ca 8.5 mg/dL Ceruplasmin 37 mg/dL
10. Wilson’s disease?Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL
K 3.5 meq/L PT 15.6 sec AFP 90 ng/mL
Cl 101 meq/L PTT 45.1 sec HBsAg (-)
HCO3 25 meq/L NH3 250µg/dL HIV (-)
BUN 12 mg/dL AST 107 IU/L Anti-HCV (-)
Cr .6 mg/dL ALT 86 IU/L HCV RNA 2.8 million/mL
Glu 90 mg/dL Alk phos 224 IU/L ANA (-)
Hb 14.0 g/dL Bilirubin 2.4 mg/dL Fe 75 µg/dL
Hct 39.7% Protein 6.6 g/dL Ferratin 200 ng/mL
MCV 90 fL Alb 2.7 g/dL Transferrin saturation 38%
Plt 34500/mm3 Ca 8.5 mg/dL Ceruplasmin 37 mg/dL
11. Why can autoimmune hepatitis and primary biliary cirrhosis be ruled out as contributing factors to this patient’s condition?
Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL
K 3.5 meq/L PT 15.6 sec AFP 90 ng/mL
Cl 101 meq/L PTT 45.1 sec HBsAg (-)
HCO3 25 meq/L NH3 250µg/dL HIV (-)
BUN 12 mg/dL AST 107 IU/L Anti-HCV (-)
Cr .6 mg/dL ALT 86 IU/L HCV RNA 2.8 million/mL
Glu 90 mg/dL Alk phos 224 IU/L ANA (-)
Hb 14.0 g/dL Bilirubin 2.4 mg/dL Fe 75 µg/dL
Hct 39.7% Protein 6.6 g/dL Ferratin 200 ng/mL
MCV 90 fL Alb 2.7 g/dL Transferrin saturation 38%
Plt 34500/mm3 Ca 8.5 mg/dL Ceruplasmin 37 mg/dL
12. Osteoporosis?Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL
K 3.5 meq/L PT 15.6 sec AFP 90 ng/mL
Cl 101 meq/L PTT 45.1 sec HBsAg (-)
HCO3 25 meq/L NH3 250µg/dL HIV (-)
BUN 12 mg/dL AST 107 IU/L Anti-HCV (-)
Cr .6 mg/dL ALT 86 IU/L HCV RNA 2.8 million/mL
Glu 90 mg/dL Alk phos 224 IU/L ANA (-)
Hb 14.0 g/dL Bilirubin 2.4 mg/dL Fe 75 µg/dL
Hct 39.7% Protein 6.6 g/dL Ferratin 200 ng/mL
MCV 90 fL Alb 2.7 g/dL Transferrin saturation 38%
Plt 34500/mm3 Ca 8.5 mg/dL Ceruplasmin 37 mg/dL
13. Evidence for ascitesNa 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL
K 3.5 meq/L PT 15.6 sec AFP 90 ng/mL
Cl 101 meq/L PTT 45.1 sec HBsAg (-)
HCO3 25 meq/L NH3 250µg/dL HIV (-)
BUN 12 mg/dL AST 107 IU/L Anti-HCV (-)
Cr .6 mg/dL ALT 86 IU/L HCV RNA 2.8 million/mL
Glu 90 mg/dL Alk phos 224 IU/L ANA (-)
Hb 14.0 g/dL Bilirubin 2.4 mg/dL Fe 75 µg/dL
Hct 39.7% Protein 6.6 g/dL Ferratin 200 ng/mL
MCV 90 fL Alb 2.7 g/dL Transferrin saturation 38%
Plt 34500/mm3 Ca 8.5 mg/dL Ceruplasmin 37 mg/dL
14. Hepatic encephalopathy?Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL
K 3.5 meq/L PT 15.6 sec AFP 90 ng/mL
Cl 101 meq/L PTT 45.1 sec HBsAg (-)
HCO3 25 meq/L NH3 250µg/dL HIV (-)
BUN 12 mg/dL AST 107 IU/L Anti-HCV (-)
Cr .6 mg/dL ALT 86 IU/L HCV RNA 2.8 million/mL
Glu 90 mg/dL Alk phos 224 IU/L ANA (-)
Hb 14.0 g/dL Bilirubin 2.4 mg/dL Fe 75 µg/dL
Hct 39.7% Protein 6.6 g/dL Ferratin 200 ng/mL
MCV 90 fL Alb 2.7 g/dL Transferrin saturation 38%
Plt 34500/mm3 Ca 8.5 mg/dL Ceruplasmin 37 mg/dL
15. Grade this encephalopathy?• 0: Minimal HE• Hard to detect, changes in memory, concentration and temper
are minimal• 1: Mild HE• Short attention span, noticeable mood changes, sleep problems
• 2: Moderate HE• Forgetfulness worsens, lethargic, exhibit inappropriate behavior,
slurred speech, and difficulty with mental tasks• 3: Severe HE• Confused as to where you are or what day it is, extremely sleepy,
unable to do basic mental tasks, extremely anxious, act strangely• 4: Coma• Unconscious, slip into coma
16. Patient’s CTP score?Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL
K 3.5 meq/L PT 15.6 sec AFP 90 ng/mL
Cl 101 meq/L PTT 45.1 sec HBsAg (-)
HCO3 25 meq/L NH3 250µg/dL HIV (-)
BUN 12 mg/dL AST 107 IU/L Anti-HCV (-)
Cr .6 mg/dL ALT 86 IU/L HCV RNA 2.8 million/mL
Glu 90 mg/dL Alk phos 224 IU/L ANA (-)
Hb 14.0 g/dL Bilirubin 2.4 mg/dL Fe 75 µg/dL
Hct 39.7% Protein 6.6 g/dL Ferratin 200 ng/mL
MCV 90 fL Alb 2.7 g/dL Transferrin saturation 38%
Plt 34500/mm3 Ca 8.5 mg/dL Ceruplasmin 37 mg/dL
17. One year survival?
• Based on his class C CTP score, this patient has a 45% probability of surviving another year
18. Does the patient have any signs of dehydration or hepatorenal syndrome?
Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL
K 3.5 meq/L PT 15.6 sec AFP 90 ng/mL
Cl 101 meq/L PTT 45.1 sec HBsAg (-)
HCO3 25 meq/L NH3 250µg/dL HIV (-)
BUN 12 mg/dL AST 107 IU/L Anti-HCV (-)
Cr .6 mg/dL ALT 86 IU/L HCV RNA 2.8 million/mL
Glu 90 mg/dL Alk phos 224 IU/L ANA (-)
Hb 14.0 g/dL Bilirubin 2.4 mg/dL Fe 75 µg/dL
Hct 39.7% Protein 6.6 g/dL Ferratin 200 ng/mL
MCV 90 fL Alb 2.7 g/dL Transferrin saturation 38%
Plt 34500/mm3 Ca 8.5 mg/dL Ceruplasmin 37 mg/dL
19. The patient’s primary care provider has decided to conduct extensive clinical studies for the diagnosis of liver cancer. Which single abnormal laboratory value has raised a concern that hepatocellular carcinoma may have developed?
Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL
K 3.5 meq/L PT 15.6 sec AFP 90 ng/mL
Cl 101 meq/L PTT 45.1 sec HBsAg (-)
HCO3 25 meq/L NH3 250µg/dL HIV (-)
BUN 12 mg/dL AST 107 IU/L Anti-HCV (-)
Cr .6 mg/dL ALT 86 IU/L HCV RNA 2.8 million/mL
Glu 90 mg/dL Alk phos 224 IU/L ANA (-)
Hb 14.0 g/dL Bilirubin 2.4 mg/dL Fe 75 µg/dL
Hct 39.7% Protein 6.6 g/dL Ferratin 200 ng/mL
MCV 90 fL Alb 2.7 g/dL Transferrin saturation 38%
Plt 34500/mm3 Ca 8.5 mg/dL Ceruplasmin 37 mg/dL