What is jaundice? correlation with hepatitis? can it lead to Hepatocellular Carcinoma? what is Liver Failure? What is treatment?

2. DEPT. OF MEDICINE CPC

3. Biodata:
 Name: MRS. Parveen siddique
 Age: 65 years
 Sex: female
 Address: new karachi
 Occupation: house wife
 Mode of admission: OPD
 Date of admission: 17-april-2012

4. Presenting complains:
 yellow discoloration of scelera
and skin for 25 days

5. History of presenting
complains:
 My patient was in her usual state of health 25 days
back then she started having yellow discoloration of
skin, which was gradual in onset and progresive.
 No hx of vomiting and fever .
 she was also complaining of itching on body.Her
stool color was light brown and urine was yellow.

6. Yellow discoloration of skin associated with
pain in right hypochondrium for 20 days
Which was moderate that she had able to
continue her work, gradual in onset and
continuous and throbbing in nature
non radiating and shifting

7. . There was no other aggravating factor like
meals,exertion.
Relieved by taking anelgesic injection
by local GP( patient does not know the name
of injection).

8.  She was also complaining of general
weakness,
loss of appetite and weight loss for 3
months.
 There was no hx of smoking , drinking
alcohol, eating pan and chewing betelnuts.
 There is no history of dyspnea, chest pain,
cough, blood in sputum,
urinary complains, headache and motor
weakness

9. Past medical history:
 she is known hypertensive for last five
years.
 There is no history of diabetes mellitus,
allergies, tuberculosis, asthma, transfusion
and hospital admission.
PAST SURGICAL HISTORY:
not significant
DRUG HISTORY:
captopril for hypertension

10. Family history:
 There is no family disease, both parents
are dead, cause not known. All siblings
are healthy.

11. Personal history:
 Bowel habits = no alter
 addiction: no hx
 Sleep: not changed
 Micturation: normal
 Apetite: loss

12. Socioeconomic history:
 She is married. Have one house with 4
rooms, well ventilated with good
hygiene.

13. General physical examination:
 65 years old woman of thin
built and average height lying
uncomfortably on bed , is
conscious well oriented with
time place & person.
 Vitals
 Pulse=81 b/min with normal
rate rhythm and volume
 Blood pressure= 150/80
 Temperature= 980f
 Respiratory rate= 14/min

14.  She is anemic and have jaundice.
There is generalized pitting
edeme.There is no cyanosis,
clubbing and koilonychia. There are
no osler’s node and heberden’s
nodes; no splinter haemorrhage or
palmer erythema.
 Virchow’s node not
palpable.Cervical,axillary and
inguinal lymph node are not
palpable.
 JVP not raised..umbilical node are
not palpable.No palmar sweating.
thyroid gland not palpable.no
proptosis

15. Abdominal examination:
 In GIT orodental hygiene was satisfactory
 On inspection shape of abdomen was
distended, moving evenly with respiration.
 There were no visible veins and scar
marks, striae, pulsating mass and no
swelling at hernial orifices. Umbilicus was
centerally placed and inverted.

16.  On palpation there was mild tenderness in the
right hypochondrium .
 Liver is palpable 2cm below the costal margin
and tender with irregular border firm
consistency.upper border of liver is in 5th
intercostal space.
 No other organ palpable.
 No ascites
 abdomen was resosnant on percussion.
 on auscultation bowel sounds were audible.

17. Investigations:

18. complete blood count (CBC)
21/4/2012
 Hb = 9.7 gm/dl
WBC= 4300 /mm3
 Platelets= 275000/mm3
 MCV= 75 fl
 Morphology of RBC= hypochromic
anisocytosis

19. Liver function test 24/4/2012
 Bilirubin total 10.2 (<1.0 mg/dl)
 Bilirubin direct 8.2 ( <0.25mg/dl)
 Bilirubin indirect 2.0 (<1.0 mg/dl)
 ALT 32 ( f= upto 31U/l)
 ALK phosphatase 2192 (adult <258)
 Gama-GT 387 (f= <38U/l)

20. 24/4/2012
 Random blood sugar =126 mg/dl
 Urea= 53mg/dl
 Creatinine= 1.42mg/dl
electrolyte:
 s.sodium= 134m.eq/l
 s.potassium= 4.7m.eq/l
 chloride= 102m.eq/l

21.  HBs Ag-----------non reactive
 HCV Ab-----------non reactive
 Prothombin time-----13.7 sec (13-16sec)
 PT control--------------13 sec
 albumin---------------3.0 gm/dl (3.5-5.2 g/dl)

22. ULTRASOUND REPORT:
 Conclusion:
Hepatomegaly with heterogenous
texture and multiple iso to hypoechoic foci
most likely metastatic deposits.
A hypoechoic focus is in the head of
pancreas measuring 3.1×2.1 cm
Dilated common bile duct and portal vien.
Tortous vessel are at porta hepatic

23.  Dilated intrahepatic vessel and ducts.
 Enlarged lymph node in region of porta
hepatic and peripancreatic region.
 Spleen is bulky
 Bilateral renal parenchyma change
 Would recommend C.T scan for further
evaluation.

24. 27/4/2012
C.T scan of whole abdomen with or without
contrast:
IMPRESSION:
Finding are most likely due to neoplastic
lesion of hepatic origin extending into
porta hepatis with hepatic and bony
metastasis.correlation with biopsy
advised.

25. C.T SCAN:

27. FURTHER INVESTIGATION
 α-fetoprotien--------pending
 HBc IgG ----------- pending
 Liver biopsy ??

28. Differential diagnosis:
 Hepatocellular carcinoma
 Hepatocellular adenoma
 Cholangiocarcinoma
 Metastatic liver disease
 Autoimmune
 Viral hepatitis

29. Provisional Diagnosis:
 hepatocellular carcinoma

30. Treatment:
Overview
The optimal management
of hepatocellular carcinoma depends on a
variety of factors including the size, number, and
distribution (unilobar vs. bilobar ) of tumors, the
relationship of the tumor to hepatic vasculature,
the status of distant metastases, the severity
Of liver disease (child pugh score), the suitability of
the patient for liver transplantation,
the functionalstatus of the patient, and local
expertise.

31.  Hepatocellular carcinoma is relatively
insensitive
to systemic chemotherapy or radiotherapy

32. Management of HCC
 Liver transplantation
 Resection
 Tumor ablation
 Radiofrequency thermal ablation
 Alcohol injection
 Chemoembolization
 Targeted molecular therapy
 Chemotherapy
 Regional/systemic
Potentially
curative

33. Staging and treatment strategy
according to the Barcelona
Clinic Liver Cancer group
(BCLC).

35. Discussion
Epidemiology
 Liver cancer in men is the fifth most
frequently diagnosed cancer worldwide,
and is the second leading cause of
cancer-related death in the world .
 In women, it is the seventh most
commonly diagnosed cancer and the sixth
leading cause of cancer death

36. causes:
1. postnecrotic cirrhosis due to HBV and
HC V
2. Alcoholic cirrhosis
3. Hereditary hemochromatosis
4. Primary biliary cirrohsis
5. A1-antitrypsin deficiency

39. Prevention:
 Childhood vaccination against hepatitis B
may reduce the risk of liver cancer in the
future.
If you have chronic hepatitis or known
cirrhosis, periodic screening with liver
ultrasound or measurement of blood alpha
fetoprotein levels may help detect this
cancer early.

40. 40
Queries???