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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

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 = 1.1 HAV negative

AlkPhos = 130 HBsAgreactive

AST = 228 HCV 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 = 23 Grade 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 = 18 C3 = 67 L
    • AST = 20 C4 = 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.