Course Case Studies

Pathophysiology: The Hepatobiliary System

Course #38910 - $90-

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    • Review the course material online or in print.
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    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
Learning Tools - Case Studies

CASE ONE: ESOPHAGEAL VARICES

Present Illness

Patient A is a man, 60 years of age, who is admitted to the hospital for treatment of acute gastrointestinal bleeding. The patient had a similar episode five weeks ago. An upper endoscopic exam at that time revealed a bleeding esophageal varix for which he received band ligation therapy. He is well-known to the medical community for chronic alcohol use. He has lost several jobs for drinking in the workplace or showing up for work drunk. He has lost his driver's license for drunk driving, and his drinking has placed a significant strain on his marriage. He and his wife are currently separated. He has tried several self-help programs to stop drinking as well as Alcoholics Anonymous, all with little success.

Medical History

Patient A has been hospitalized five times during the previous 30 months. Most recently, he was discharged five weeks ago following treatment for bleeding esophageal varices. He has a 44-year history of cigarette smoking (one pack per day), was diagnosed five years ago with alcoholic cirrhosis, and currently drinks an unknown amount of liquor daily. He previously reported drinking 6 to 12 beers per day for many years.

On previous admissions, Patient A has been treated for acute pancreatitis twice, alcohol withdrawal seizures, delirium tremens, ascites, coagulopathy, esophageal varices, peptic ulcer disease, anemia, and gastritis, all of which were determined to be related to his alcohol use. Medications at last discharge included:

  • Lactulose (30 mL four times per day)

  • Spironolactone (100 mg per day)

  • Furosemide (80 mg per day)

  • Propranolol (30 mg per day)

  • Famotidine (40 mg twice per day)

Assessment and Diagnosis

Patient A was found unconscious and face down in a pool of bright red, bloody vomitus by his neighbor. He is resuscitated and taken to the hospital by ambulance and is admitted to the intensive care unit (ICU). Upon admittance to the ICU, a full physical exam is conducted (Table 1) and laboratory blood testing is ordered (Table 2). Intravenous infusion with a solution of D5W and colloid is started through a central line. Oxygen is started at 3 L/min. Octreotide is administered to help stop the bleeding. An echocardiogram is conducted.

PATIENT A'S PHYSICAL EXAM RESULTS

ParameterFindings
General appearance
Thin, unkempt White man
Height: 5 feet 10 inches (177.8 cm)
Weight: 151 pounds (68.5 kg)
Skin
Markedly jaundiced
Spider angiomas evident on arms
Normal turgor
No palmar erythema
Head and eyes
Icteric sclera
Pupils are equal, round, and reactive to light and accommodation
Extra-ocular motion intact
Oropharynx dry, with no erythema or lesions present
EarsTympanic membranes intact
Neck
Supple with no nodules
Negative for jugular vein distention, thyromegaly, and lymphadenopathy
ChestGood air exchange bilaterally
Abdomen
Soft, with mild distension and hyperactive bowel sounds
Splenomegaly
Negative for guarding or rebound tenderness
Extremities
Warm with mild (1+) edema
Pulses symmetric at 2+
Muscle tone normal
Full range of motion throughout
Genitourinary system
Normal male
Stool positive for heme
Neurologic status
Alert and oriented
Slow to answer questions
Cranial nerves II–XII intact
Deep tendon reflexes brisk and equal bilaterally
Cardiovascular system
Tachycardia with normal rhythm
Normal S1 and S2 with no additional heart sounds
No murmurs or rubs heard
Normal sinus rhythm
Vital Signs
Blood pressure90/60 mm Hg
Temperature98.0° F
Heart rate112 bpm with regular irregular rhythm
Respiratory rate14 breaths per minute

PATIENT A LABORATORY BLOOD TEST RESULTS

Test Result
Blood typeB+
Sodium135 meq/L
Potassium4.6 meq/L
Chloride103 meq/L
Bicarbonate22 meq/L
Blood urea nitrogen (BUN)10 mg/dL
Creatinine1.1 mg/dL
Fasting blood glucose140 mg/dL
Hemoglobin9.4 g/dL
International normalized ratio (INR)2.3
Hematocrit28%
White blood cell count10,000/mm3
Platelets160,000/mm3
Total bilirubin10.4 mg/dL
Indirect bilirubin9.9 mg/dL
Amylase43 IU/L
PaO285 mm Hg
PaCO2245 mm Hg
pH7.38
NH359 mcg/dL
Prothrombin time (PT)23 seconds
Partial thromboplastin time (PTT)54 seconds
Aspartate transaminase (AST)119 IU/L
Alanine transaminase (ALT)94 IU/L
Total protein4.9 g/dL
Albumin2.9 g/dL
Calcium8.9 mg/dL
Phosphorus2.8 mg/dL
HIV RNANegative

Based on the results of the assessment, Patient A is diagnosed with acute alcohol-related pancreatitis.

Study Questions

  1. Explain the pathophysiology of each of the following clinical manifestations in this patient.

    a. Spider angiomas

    b. Splenomegaly

    c. Edema

    d. Jaundice and icteric sclera

  2. Why has the primary care provider noted the absence of asterixis?

  3. What is the significance of the renal test results?

  4. What is the significance of the liver enzyme test results?

  5. What are the pathophysiology and significance of the total and indirect bilirubin test results?

  6. Is blood clotting a concern at this time in this patient?

  7. Why might hemoglobin concentration and hematocrit be abnormal?

  8. Does this patient have an arterial blood gas problem?

  9. Give a reasonable explanation for the pathophysiology of the patient's blood glucose concentration.

  10. What evidence is provided that this episode is not associated with another attack of alcohol-induced acute pancreatitis?

  11. What is the purpose of prescribing lactulose for patients with chronic liver disease?

  12. Why are diuretics appropriate for patients with chronic hepatic disease?

Learning Tools - Case Studies

CASE STUDY TWO: CIRRHOSIS

Present Illness

Patient B is a woman, 48 years of age, who presents to the emergency department complaining of a four-week history of progressive abdominal swelling and discomfort. She has no other gastrointestinal symptoms and has a normal appetite and normal bowel habits. Her past medical history is significant only for three pregnancies, one of which was complicated by hemorrhage, requiring a blood transfusion. She has been married for 20 years, exercises, does not smoke, and drinks only occasionally. On pointed questioning, she admits that she was "wild' in her youth and did use cocaine once or twice at parties many years ago. She does not currently use illicit drugs. She tested HIV-negative at the time of the birth of her last child.

On examination, her temperature is 100.3 degrees F, her heart rate is 88 bpm, and her blood pressure is 94/60 mm Hg. She is thin, her complexion is sallow, her sclerae are icteric, her chest is clear, and her heart is regular with no murmur. Her abdomen is distended and with mild diffuse tenderness, hypoactive bowel sounds, shifting dullness to percussion, and a fluid wave. She has no peripheral edema. Laboratory studies are normal except for the following:

  • Sodium: 120 mEq/L

  • Albumin: 2.8 mg/dL

  • Total bilirubin: 4 mg/dL

  • Prothrombin time: 15 seconds

  • Hemoglobin: 12 g/dL, with a mean cell volume (MCV) of 102 fL

  • Platelet count: 78,000/mm3

Patient B is diagnosed with ascites caused by portal hypertension as a complication of hepatic cirrhosis. Paracentesis is performed to evaluate the ascitic fluid to try to determine its likely etiology, as well as evaluate for the complication of spontaneous bacterial peritonitis.

Learning Tools - Case Studies

CASE STUDY THREE: JAUNDICE

Present Illness

Patient C is a Black man, 33 years of age, who presents to the office for an acute visit with nausea and diarrhea that he has had for the past week. Along with these symptoms, he has had a low-grade fever, some right upper quadrant abdominal pain, and has noticed that his eyes seem yellow.

Medical History

Patient C has no significant medical history and takes no medications regularly. He denies alcohol, tobacco, or IV drug use. He works as a pastor in a local church that went on a mission to build a medical clinic in a rural area of Central America about five weeks ago. While there, he had a mild case of diarrhea, but otherwise has felt well.

Assessment and Diagnosis

On examination, Patient C is a well-developed man who appears to be moderately ill. His temperature is 99.8°F, his blood pressure is 110/80 mm Hg, his pulse is 90 beats/minute, and his respiratory rate is 14 breaths/minute. He has a prominent yellow color to his eyes and under his tongue. His mucous membranes are moist. Lung and cardiac examinations are normal. His abdomen has normal bowel sounds and tenderness in the right upper quadrant. His liver edge is palpable just below the costal margin. There are no other masses felt, no rebound, and no guarding. On rectal examination, he has clay-colored soft stool that is hemoccult negative.

Based on the examination and history, Patient C is diagnosed with jaundice, likely related to acute hepatitis A infection. Antihepatitis A IgM testing confirms infection. The most probable source of infection is ingestion of contaminated food or water while on his mission.

For this patient, treatment focuses on supportive care and palliation of symptoms. The infection is also reported to the local health department. Close household or sexual contacts are provided with hepatitis A prophylaxis.

Learning Tools - Case Studies

CASE STUDY FOUR: CHRONIC HEPATITIS C

Patient D is a paramedic, 48 years of age. Laboratory work obtained during his annual physical examination reveals hyperlipidemia; complete blood count, glucose, blood urea nitrogen (BUN), and electrolytes are within normal range. With the exception of his weight (15 pounds heavier than indicated for his height), his exam identifies no abnormalities.

After two months of a diet and exercise program, his cholesterol level is 256. Therefore, his physician elects to begin a lipid-lowering agent. A baseline liver profile is drawn prior to initiation of the medication. Because the patient is in a profession that is high-risk for bloodborne pathogen exposure, an HCV antibody test with reflex to qualitative HCV RNA is ordered. The liver profile reveals an AST of 226 Units/L and an ALT of 282 Units/L. HCV antibody and reflex quantitative HCV RNA are both positive.

The physician reviews Patient D's history and medications. He has been a paramedic for 25 years. He was immunized against HBV in 1999. During his career, he has experienced several exposures to blood (usually blood splashes, but also two needlesticks from IV needles). His most recent exposure was two years ago. An HIV test six months post-exposure was negative. He does not recall hepatitis testing being performed at that time.

Patient D's surgical history includes a hernia repair in childhood and removal of skin lesions three times in the past eight years. He has had no transfusions. He is the widowed father of two teenage children. His wife died six years ago from ovarian cancer.

The patient has never smoked. He drinks about six beers per week and rarely drinks hard liquor. He denies any history of illicit drug use. Although the patient has no current prescription medications, he uses several herbal preparations including garlic, ginkgo, and an antioxidant preparation. The patient takes ibuprofen for pain, consuming 6 to 10 tablets (200 mg each) per month.

Although alcohol consumption and herbal antioxidants can both cause liver inflammation, the degree of his liver inflammation is much higher than would be expected from limited use of these two factors. The patient is diagnosed with chronic HCV infection.

In order to evaluate the extent of liver damage and determine an appropriate treatment plan, the physician orders an HCV RNA quantitative PCR and genotype as well as a repeat hepatic panel, platelet count, and PT. Shear wave elastography is also ordered. The laboratory results are:

  • Platelets: 237 × 109/L

  • ALT: 253 Units/L

  • AST: 214 Units/L

  • PT INR: 1.0

  • HCV RNA: 350,000 IU/L

  • HCV genotype: 3

Based upon these laboratory results, the calculated Fib-4 score is 2.72. The elastography reflects a fibrosis score of F1. No masses are identified on ultrasound. Because the genotype of the virus is 3, resistance testing is ordered. Substitution mutation Y93H is not present.

Treatment options appropriate for HCV genotype 3, and the timing of therapy in relation to his degree of fibrosis and anticipated progression of disease are discussed with Patient D. He is advised to eat a nutritious, balanced diet and abstain completely from alcohol. Although he is not currently sexually active, the patient is educated about the low but present risk of sexual transmission of HCV and how to minimize the risk of transmission. A test for HAV antibody is found to be negative. Immunization against HAV is also recommended, as acquiring an acute case of HAV in a patient with pre-existing chronic hepatitis can be much more serious that either condition alone. He is also provided pneumococcal immunization, as persons with chronic liver disease are at increased risk of pneumococcal infection and complications. Because of uncertainty as to how recently he acquired the infection, the decision is made to defer treatment for three to four months while monitoring the course of the infection.

Four months after the initial diagnosis, there has been no improvement in Patient D's liver function tests: the ALT is 318 Units/L and AST is 287 Units/L. The HCV RNA remains detectable in the blood, and the viral load has increased to 450,000 phages/cc. He is advised to begin antiviral treatment; therapeutic options are discussed in relation to efficacy, potential drug interactions, and cost reimbursement priorities, bearing in mind that he is a treatment-naïve patient with no evidence of cirrhosis. The recommended course of therapy is the 12-week, two-drug oral regimen of sofosbuvir (400 mg) and velpatasvir (100 mg) for a duration of 12 weeks (reported SVR rate: 95% in clinical trials for genotype 3).

On treatment, the patient experiences transient nausea and persistent mild fatigue, but is compliant with the recommended duration of therapy. At 12 weeks, the ALT and AST are both within normal range and HCV RNA is undetectable. Patient D is asked to return in three months to continue his hyperlipidemia treatment follow-up.

Learning Tools - Case Studies

CASE STUDY FIVE: PANCREATITIS – GALLSTONE-INDUCED

Present Illness

Patient E is a Hispanic woman, 42 years of age, who presents to the emergency department complaining of 24 hours of severe, steady epigastric abdominal pain, radiating to her back, with several episodes of nausea and vomiting;. She has had similar painful episodes in the past, usually in the evening following heavy meals, but they always resolved spontaneously within an hour or two. This time, the pain has not improved, so she is seeking medical attention.

Medical History

Patient E has no prior medical history and takes no medications. She is married, has three children, and does not drink alcohol or smoke cigarettes.

Assessment and Diagnosis

On examination, Patient E is afebrile. She is experiencing tachycardia, with a heart rate of 104 beats per minute. Her blood pressure is 115/17 mm Hg, and she has shallow respirations of 22 breaths per minute. She is moving uncomfortably on the stretcher, her skin is warm and diaphoretic, and she has scleral icterus. Her abdomen is soft and mildly distended, with marked right upper quadrant and epigastric tenderness to palpation, hypoactive bowel sounds, and no masses or organomegaly appreciated. Her stool is negative for occult blood. Laboratory studies are significant for:

  • Total bilirubin: 9.2 g/dL, with a direct fraction of 4.8 g/dL

  • Alkaline phosphatase: 285 IU/L

  • Aspartate aminotransferase (AST): 78 IU/L

  • Alanine aminotransferase (ALT): 92 IU/L

  • Amylase: 1,249 IU/L (elevated)

  • Leukocyte count: 16,500/mm3, with 82% polymorphnuclear cells and 16% lymphocytes

Right upper quadrant abdominal ultrasonography shows a distended gallbladder, with several stones.

Based on the assessment, Patient E is diagnosed with acute pancreatitis resulting from choledocolithiasis. The patient is started on systemic antibiotics and prepared for removal of the stones.

Learning Tools - Case Studies

CASE STUDY SIX: HIV AND CHRONIC HBV COINFECTION

Patient C is a man, 32 years of age, with a history of injection drug use, who participated in a free HIV testing day. His screening test was found to be positive. A confirmatory test conducted at the health department was also positive. He has therefore been referred to the Infectious Disease Clinic of a large university medical center for follow up.

During his first visit, the patient indicates that he injected drugs off and on beginning at 19 years of age. His first two experiences with rehabilitation failed, but he has been "clean" for two years, since his best friend died of an overdose. He reports that he also snorted cocaine occasionally during the years he used injected drugs.

The patient's medical history includes a hospitalization for a motorcycle accident at age 24, with surgery on his right leg both on that admission and again about a year later. He received 2 units of blood during the first admission. The patient denies a history of heart disease, neurologic disorders, or endocrine disorders. He has had pneumonia both in adolescence and again last year.

The patient's parents are living and in good health. Grandparents all have hypertension, and maternal grandmother has type 2 diabetes. The patient smokes 1/2 to 1 pack of cigarettes per day and consumes two or three drinks per day. The patient's current medications include acetaminophen or ibuprofen as needed for leg pain and paroxetine for anxiety and depression.

Physical examination reveals no acute distress. Vital signs are within normal limits, and sclerae are non-icteric. Oral cavity is free from thrush and leukoplakia. Cervical lymph nodes are palpable but moveable and nontender. Heart sounds are normal; lungs are clear. Abdomen is soft; both liver and spleen are palpable. Neurologic exam is normal. The patient has full function in upper extremities and left leg; right leg has a slight decrease in strength and a moderate decrease in range of motion.

Initial laboratory tests ordered by the nurse practitioner (NP) include an HIV PCR viral load, a CD4 count, a CBC, a chemistry panel, and a liver profile. Because of the high incidence of HCV and/or HBV coinfection in persons whose HIV was acquired percutaneously, the NP also orders a hepatitis profile. Baseline tuberculosis testing is also recommended for persons with HIV who are entering care. Therefore, a T-SPOT interferon gamma release assay is also ordered. The patient is instructed to return in 72 hours to review lab results and formulate a treatment plan.

Upon his return, all results except the HIV PCR are available. His CD4 count is 246. Hematocrit is 44%, hemoglobin 15 gm/dL, and WBC is 3,800. The liver profile reveals an alkaline phosphatase of 143 Units/mL, AST 358 Units/L, ALT 383 Units/L, total bilirubin 1.2 mg/dL, and albumin 2.8 gm/dL. The remainder of the chemistry panel is unremarkable. Hepatitis profile is positive for HBsAg, HBeAg, and total anti-HBc. The anti-HAV, anti-HCV and anti-HBc IgM are negative. The T-SPOT TB test is negative.

The NP informs Patient C that he is coinfected with HIV and HBV and instructs him about the problems associated with HIV/HBV coinfection. He is given HAV and pneumococcal immunizations and options for antiretroviral therapy are discussed. Because of its effectiveness against both HIV and HBV, a medication regimen including tenofovir with lamivudine or tenofovir with emtricitabine should be utilized. A third medication for HIV viral suppression should be added, with consideration of the hepatotoxicity profile of the medication. After discussing available options with limited hepatotoxicity, an integrase inhibitor is selected as the third active agent in the combination. A single tablet medication containing bictegravir, emtricitabine, and tenofovir alafenamide in a once daily formulation was therefore selected to treat both HIV and HBV.

Information is provided to Patient C regarding safe sex practices. He is also instructed to abstain from alcohol and to use ibuprofen (or no more than 2 g acetaminophen in 24 hours) for pain control. The NP also orders a PT to be drawn; in addition, the patient is referred to hepatology for a liver biopsy to be performed in order to evaluate the progression of the liver disease. The patient is scheduled for a follow-up visit in four weeks, with a repeat HIV PCR performed at that time. In the interim, his baseline HIV PCR is found to be 123,000.

Upon his return to the office, Patient C is advised that the liver biopsy revealed periportal inflammation with focal necrosis and bridging fibrosis. PT is 15.6 seconds (control: 12 seconds). These findings indicate severe, advanced liver disease and the guarded prognosis. Because of the severity of his liver disease, he is not a good candidate for PegIFN therapy. The patient's current HIV status precludes his being a transplant candidate at the time. The recommended treatment plan for Patient C is to maximize his HIV suppression while minimizing his continued liver damage. If he is compliant with his therapy, he should be able to maintain a fairly good quality of life and postpone liver failure for three years or more. Prolonging the time until liver failure also provides the opportunity to improve immunocompetency. Some liver transplant centers now accept HIV-positive patients, provided that HIV viral loads are undetectable and CD4 counts are sufficiently high (usually >500). Patient C's future, therefore, depends upon his tolerance of the regimen, his compliance with the treatment plan, and his body's response to therapy.

The patient will initially be followed on a monthly basis. The viral load will be checked one month after the initiation of therapy, then every three months thereafter. Liver profile, CBC, and amylase will be assessed after one month, then bimonthly. After three months, HIV and HBV quantitative PCRs will be measured. If both are well suppressed, follow-up will be extended to every two to three months. If the patient's liver function significantly deteriorates, supportive therapy for end-stage liver disease will be instituted.

  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.