Ask the professor hepatitis b and c clinical vignettes
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Ask the Professor: Hepatitis B and C Clinical Vignettes. The Oregon Gut Club October 2 nd , 2011. Case 1. 66 year old male with history of NIDDM and obesity. Seen by PCP for 1 month fatigue No history of liver disease or risk factors for viral hepatitis Laboratory studies:

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Ask the Professor: Hepatitis B and C Clinical Vignettes

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Ask the professor hepatitis b and c clinical vignettes

Ask the Professor:Hepatitis B and C Clinical Vignettes

The Oregon Gut Club

October 2nd, 2011


Case 1

Case 1

  • 66 year old male with history of NIDDM and obesity. Seen by PCP for 1 month fatigue

  • No history of liver disease or risk factors for viral hepatitis

  • Laboratory studies:

    Tot Bil = 1.1HAV negative

    AlkPhos = 130HBsAgreactive

    AST = 228HCV negative

    ALT = 601

    INR = 1.2

    plt = 92


Case 1 continued

Case 1 - continued

  • Additional Labs

    HBcAbIgMreactive

    HBeAgreactive

    HBeAb negative

    HBV DNA >170,000,000 IU/mL

  • Abdominal Ultrasound

    Liver mildly enlarged with diffuse increased

    echogenicity. Spleen is normal.


Case 1 continued1

Case 1 - continued

  • Wait and watch or treat?

  • After initial consultation with Gastroenterology the patient was seen by cardiology and underwent a coronary angiogram which showed obstructive 3 vessel coronary artery disease. CABG recommended.


Case 2

Case 2

  • 32 year old male from Ghana referred to gastroenterology for hepatitis B

  • No history of jaundice, encephalopathy, or ascites

  • Risk factors for chronic viral hepatitis

    • Country of birth

    • Blood transfusion at 12 years old

    • Negative family history for chronic HBV

    • No history of IVDU


Case 2 continued

Case 2 - continued

  • Laboratory studies:

    • Tbil = 0.5

    • AlkPhos = 60

    • AST = 41

    • ALT = 43

    • INR = 1.3

    • Plt = 172

  • Abdominal US

    • Normal liver and spleen. No ascites.

  • HBV DNA 153 million IU/mL

  • HBeAgreactive


Case 2 continued1

Case 2 - Continued

  • What Next?

  • Liver Biopsy

    • Chronic hepatitis grade 1 stage 2


Case 3

Case 3

  • 30 year old Vietnamese female in second trimester of pregnancy

  • Referred to GI by her obstetrician for positive hepatitis B surface antigen

  • Presumed vertical transmission based on family history

  • No history of jaundice, ascites, encephalopathy, or GIB


Case 3 continued

Case 3 - continued

  • Laboratory Studies

    • Tbil = 0.2

    • AlkPhos = 43 Liver Biopsy 1 year prior

    • AST = 23Grade 1 Stage 1

    • ALT = 33

    • Plt = 220

    • INR = 1.0

    • HBV DNA 89,000 IU/mL

    • HBeAgpositive


Case 4 second opinion

Case 4 – second opinion

  • 32 year old Chinese femalewith a history of chronic HBV diagnosed after emigrating to the United states.

  • Presumed vertical transmission

  • No history of liver ascites/encephalopathy/GIB

  • Referred to GI in 2006

    • ALT = 195 AST =99

    • HBeAgpositive

    • HBV DNA 19,400,000 IU/mL Genotype C


Case 4 continued

Case 4 - Continued

  • Several months later was found to be HBeAg negative and HBeAbpositive.

  • Started on Entecavir due to rising transaminases

  • Liver tests normalized and HBV became undetectable within 6 months.

  • Labs have remained normal for 2 years.

  • Most recent studies

    • HBsAgpositive, HBeAb positive, HBV DNA neg, ALT =16


Case 4 continued1

Case 4 - continued

  • Next step?

    • Wait for surface antigen loss or stop Entacavir?


Case 5

Case 5

  • 63 year male with Chronic HCV, genotype 1, diagnosed in 2004

  • No history of ascites, encephalopathy, or GIB

  • Liver biopsy 3/3/04 showed grade 1, stage 1 disease

  • Developed acute renal failure with nephrotic range proteinuria and anasarca in 2011. Kidney biopsy showed glomerular changes suggestive of possible membranoproliferative glomerulonephritis

  • Started on plasmapheresis and sent to GI for possible HCV treatment


Case 5 continued

Case 5 - continued

  • Pertinent laboratory studies

    • HCV PCR 1,710,000 IU/mL

    • Tbil = 0.2

    • AlkPhos = 62

    • ALT = 18C3 = 67 L

    • AST = 20C4 = 27

      RF = <10

    • Plt = 204 Cryoglobulin = neg

    • INR = 1.1

    • Creat = 2.0


Case 6

Case 6

  • 35 year female with history of heavy alcohol use, depression with active suicidal ideation, and chronic HCV genotype 1.

  • Biopsy in 2010: Grade 2 Stage 3 disease.

  • Therapy deferred in 2010 due to poor social support, mental illness, and ongoing alcohol use.

  • Now sober for 1 year and returns to clinic to discuss the “new” hepatitis C medications.


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