CLINICAL SOLVING PROBLEM

1. CLINICAL SOLVING PROBLEM „I look like a Bart Simpson” Davorka Dušek, MD

2. First contact with patient • 35 yearoldpatientcomes to the ER becauseof 7 dayshistoryofmalaise, feverup to 38 °C andicterus • icteruswasnoted on thedayoftheexamination • Except from icterus pt noticed darker urine and lighter stool 3 days earlier • Pt complainsofnauseaandabdominalpain • Chiefcomplaint: „I look like a Bart Simpson” • Past medicalhistorysignificantonly for surgeryofopentibialfracture 25 years ago • Doesn’t take anymedications Your nextstep: a) detailedhistory, especiallysocialandepidemiologic data andphysicalexamination b) basiclaboratorystudies c) abdominalultrasound d) MR ofthe abdomen e) alloftheabove

3. Correct answer: a) detailed history, especially social and epidemiologic data and physical examination b) basic laboratory studies c) Abdominal ultrasound d) MR of the abdomen e) all of the above

4. Detailed history and physical exam • Socialhistory: drinks 6-8 beers on weekends, sometimestakesmarijuana • Epidemiologic data: he livesalonein urban area, deniesanysickcontacts, had unprotectedsexualintercourseinthelast 3 months • Deniesbloodtransfusion, intravenous drug use, consumptionof OTC medicationormushrooms • Physicalexamination * skinandsclerae are icteric * abdomen nontender to palpation, liverpalpable 1cm * remainderof PE unremarkable Whichlaboratory/radiologicstudieswouldyouperform : a) CBC b) glucose, urea, creatinine, bilirubin, AST, ALT, GGT, AP c) PT, INR d) abdominalultrasound e) alloftheabove

5. Correct answer: a) CBC b) glucose, urea, creatinine, bilirubin, AST, ALT, GGT, AP c) PT, INR d) abdominalultrasound e) alloftheabove

6. Basiclaboratory/radiologicstudies • E 5.08, Hb 153, MCV 88.4, WBC 12.3, ne 56, ly36, mo 4, eo 3, Plt110 • CRP19.1 mg/L • Glucose 5.4, urea 5.5, creatinine 112, Na 135, K 4.1, Cl 93 • Bilirubin 240 (conj 108), AST 4568, ALT 6724, GGT 250, AP 180, LDH 627 • PT 0.38, INR 1.62 • Abdominalultrasound: • hepatoplenomegaly • gallbladercontracted • biliary tract normal Thispatienthas: a) Hepatocelluarpatternoflivertestsabnormalities b) Cholestaticpatternoflivertestsabnormalites c) Decreasedsyntheticliverfunction d) a+c e) b+c

7. Patterns of liver tests abnormalities • Hepatocelluarpattern • Cholestaticpattern • Decreasedsyntheticliverfunction d) a+c e) b+c

8. Patternsoflivertestsabnormalities Hepatocellular pattern: •Disproportionate elevation in ALT/AST compared with AP •Serum bilirubin may be elevated •Tests of synthetic function may be abnormal Cholestatic pattern: •Disproportionate elevation in the AP compared with ALT/AST •Serum bilirubin may be elevated •Tests of synthetic function may be abnormal Isolated hyperbilirubinemia

10. Whatisthe most probablediagnosis • Alcoholinducedliverinjury • Acuteviral hepatitis • Ischemic hepatitis d) EBV infection e) hemochromatosis

11. Whatisthe most probablediagnosis • Alcoholinducedliverinjury • Acuteviral hepatitis • Ischemic hepatitis d) EBV infection e) hemochromatosis

12. Whichtestswouldyou do next: a) HBsAg, IgMantiHBc, antiHBc, antiHBs, HDV IgG b) IgManti HAV, HBsAg, IgMantiHBc, anti HCV c) IgManti HAV, HBsAg, IgMantiHBc, antiHBc, antiHBs, HBeAg, antiHBe e) IgManti HAV, HBsAg, IgMantiHBc, antiHBc, antiHBs, anti HCV, IgManti HEV, IgGanti HEV

13. Whichtestswouldyou do next: a) HBsAg, IgMantiHBc, antiHBc, antiHBs, HDV IgG b) IgManti HAV, HBsAg, IgMantiHBc, anti HCV c) IgManti HAV, HBsAg, IgMantiHBc, antiHBc, antiHBs, HBeAg, antiHBe e) IgManti HAV, HBsAg, IgMantiHBc, antiHBc, antiHBs, anti HCV, IgManti HEV, IgGanti HEV

14. Following test are positive: HBsAg, IgM anti HBc, anti HBcWhatis yourdiagnosis: • Acute hepatitis B • Acute hepatitis C • Acute hepatitis E • Clinicalcourseandlaboratoryresultsinthispatient are typical for acute hepatitis B, althoughsometimesHBsAgandIgManti HBC canbepositiveinexacerbationofchronic hepatitis B

15. Following test are positive: HBsAg, IgM anti HBc, anti HBcWhatis yourdiagnosis: • Acute hepatitis B • Acute hepatitis C • Acute hepatitis E • Clinicalcourseandlaboratoryresultsinthispatient are typical for acute hepatitis B, althoughsometimesHBsAgandIgManti HBC canbepositiveinexacerbationofchronic hepatitis B

16. Interpretationof HBV serology (CDC)

17. Patient management • You recommendfollowupin 7 daysandsymptomatictherapy • You wouldhospitalizethispatientbecauseofsignsofcoagulopathy c) You would start therapywithtenofovir d) You wouldimediatelygivefreshfrozenplasma e) b+c

18. Patient management • You recommendfollowupin 7 daysandsymptomatictherapy • You wouldhospitalizethispatientbecauseofsignsofcoagulopathy c) You would start therapywithtenofovir d) You wouldimediatelygivefreshfrozenplasma e) b+c

19. Whichofthefollowingwouldindicatesevereclinicalcourse - progression to liverfailure: a) bilirubin> 150 b) PV 0.2, INR 2.14 c) ALT 6000 d) confusion, lethargy e) b+d

20. Whichofthefollowingwouldindicatesevereclinicalcourse- progression to liverfailure: a) bilirubin> 150 b) PV 0.2, INR 2.14 c) ALT 6000 d) confusion, lethargy e) b+d

21. Treatmentofacute hepatitis B • Most patientsrequireonlysymptomatictherapy • Indications for antiviraltherapy (nucleosideanalogues) are * coagulopathy (INR>1.5) OR * protractedcourse OR * signsofacuteliverfailure • treatmentwithtenofovirdisoproxil, entecavir or lamivudin is recommended • Aniviraltreatmentdoesnotincreasetheriskofchronicity EASL guidelines, 2017.

22. Furtherclinicalcourse • Patientrecovereswithoutcomplications. Whichofthefollowing is correct: • Therapywithtenofovirshouldbestoppedafter one month • Patientwill most likelyhavechronic hepatitis B • You should test thispatientalso for HIV • Afterdiseaseregression, youwillrecomendvaccinationagainst HAV • c+d

23. Furtherclinicalcourse • Patientrecovereswithoutcomplications. Whichofthefollowing is correct: • Therapywithtenofovirshouldbestoppedafter one month • Patientwill most likelyhavechronic hepatitis B • You should test thispatientalso for HIV • Afterdiseaseregression, youwillrecomendvaccinationagainst HAV • c+d