Case Study 18: Cirrhosis Skylar Strobel. Overview Role of liver Scar tissue forms as liver repairs...

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











4. Abnormality of CBC?Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL











5. Sudden progression?Na 135 meq/L WBC 4700/mm3 Mg 1.7 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











8. Why do an ANA test?Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL











9. Hemochromatosis?Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL











10. Wilson’s disease?Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL




BUN 12 mg/dL AST 107 IU/L Anti-HCV (-)







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











12. Osteoporosis?Na 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL











13. Evidence for ascitesNa 135 meq/L WBC 4700/mm3 Mg 1.7 mg/dL











14. Hepatic encephalopathy?Na 135 meq/L WBC 4700/mm3 Mg 1.7 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











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?

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?

Case Study 18: Cirrhosis Skylar Strobel. Overview Role of liver Scar tissue forms as liver repairs...

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