Evidence Based Case Resume

CHRONIC HEPATITIS B (B18.1), SUSPICION OF HEPATOCELLULAR

CARSINOMA (C22.0) DIFFERENTIAL DIAGNOSIS HEPATOBLASTOMA (C22.2),
AND MODERATE MALNUTRITION (E44.0)

by: Vania Catleya Estina, MD

Co-assistant

1. Why should the patient fast?

• Gastrointestinal bleeding
2. How should be given?
• Total parenteral feeding
• After few days later, is changed to Ringer Lactate
3. When to start fasting?
• When the patient got hematemesis-melena directly

Residents

1. What is the mechanisms of pleural fluid accumulation?

a. Increased hydrostatic pressure in the microvascular circulation (Heart failure)
b. Decreased oncotic pressure in the microvascular circulation (Severe
hypoalbuminemia)
c. Decreased pressure in the pleural space (Lung collapse)
d. Increased permeability of the microvascular circulation (Pneumonia)
e. Impaired lymphatic drainage from the pleural space (Malignant effusion)
f. Movement of fluid from the peritoneal space (Ascites)
2. What is the etiology of pleural effusion?
a. Transudative Pleural Effusions:
 Congestive heart failure
 Cirrhosis
 Peritoneal dialysis
  Nephrotic syndrome
 Superior vena cava obstruction
 Myxedema
 Pulmonary thromboemboli
b. Exudative Pleural Effusions
 Infectious diseases: Tuberculosis, Bacterial infections, Fungal
 Neoplasms
 Pulmonary thromboembolization
 Gastrointestinal disease: Pancreatitis, Esophageal perforation, Intra-
abdominal abscesses
 Collagen vascular diseases: Rheumatoid arthritis, Lupus erythematosus
3. What is the causes of Hematemesis-Melena?
a. Neonates:
 Swallowed
 Maternal blood
 Stress ulcers
 Gastritis vascular
 Malformations
 Hemophilia
 Maternal ITP
 Maternal NSAID-use
b. Infants
 Esophagitis
 Gastritis
 Duodenitis
 Coagulopathy
c. Children
 Esophagitis
 Gastritis
 Peptic ulcer disease
  Mallory-Weiss tears
 Esophageal varices Pill
 Ulcers Swallowed
 Epistaxis Foreign body
 Coagulopathy
4. How Hepatitis B is transmitted?
a. Percutaneous
Exposure to infectious blood or body fluids (50 – 100 times more infectious than
HIV)
b. Perinatal
Without intervention, a mother who is positive for HBsAg has a 20% risk of passing
the infection to her offspring at the time of birth. This risk is as high as 90% if the
mother is also positive for HBeAg.
c. Sexual
d. Breast feeding
After proper immunoprophylaxis does not appear to contribute to (MTCT)
transmission of HBV.

5. How many Disease Phases in Chronic HBV Infection?

 Supervisors:

1. How to diagnose Hepatocellular Ca?

2. How to examine nodule in liver from palpation?

 Technique
With patient supine, place right hand on patient's abdomen, just lateral to the rectus
abdominis, well below lower border of liver dullness. Ask patient to take a deep
breath and try to feel the liver edge as it descends. Be sure to allow liver to pass
under the fingers of your right hand, note texture. Pressing too hard may interfere.
 Findings
Tenderness: The normal liver may be slightly tender. Greater tenderness suggests
inflammation (e.g. hepatitis) or congestion (e.g. congestive heart disease).
 Consistency
Firm, bluntness/rounding or irregularity of liver edge suggest an abnormality.
Obstructed, distended gallbladder may be palpable on the inferior liver edge.
Nodules may be palpable; rock hard and umbilicated (central dimple) nodules
suggest malignancy.

3. How many incidence of chronic HBV is lead to hepatocellular carcinoma as underlying

disease?
 Most cases of HCC (approximately 80%) are associated with chronic hepatitis B virus
(HBV) or hepatitis C virus (HCV) infections. The annual risk of HBV-induced HCC varies
according to the presence or absence of concomitant cirrhosis. In HBV carriers without
cirrhosis, the risk is 0.02-03% in Caucasians and 0.4-0.6% per year in Asians. In those with
cirrhosis, the risk is 2.2% and 3.7% respectively in Caucasians and Asians.

4. What is the laboratory diagnosis of chronic hepatocellular carcinoma?

 HBsAg positive > 6 months
 Serum HBV DNA > 20,000 IU/ml (105copies/ml)
 Lower values 2,000-20,000 IU/ml (104-105 copies/ml) are often seen in HBeAg-
negative chronic hepatitis B
 Persistent or intermittent elevation in ALT/AST levels
 Liver biopsy to asses chronic hepatitis with moderate or severe necroinflammation

5. What is etiology of Hepatocellular carcinoma other than hepatitis?

6. What is etiology of Hematemesis?

Emergencies:
 Oesophageal Varices
 Oesophageal varices refer to dilations of the porto-systemic venous anastomoses in
the oesophagus. These dilated veins are swollen, thin-walled and hence prone to
rupture, with the potential to cause a catastrophic haemorrhage
 Gastric Ulceration
Gastric Ulceration is responsible for about 60% of haematemesis cases. Ulceration
can result in erosion into the blood vessels supplying the upper GI tract (most
commonly on the lesser curve of the stomach (20%) or posterior duodenum (40%))
and can result in significant haemorrhage.
Non emergencies:
 Mallory-Weiss Tear
A Mallory-Weiss tear is a relatively common phenomenon, typified by episodes of
severe or recurrent vomiting, then followed by minor haematemesis. Such forceful
vomiting causes a tear in the epithelial lining of the oesophagus, resulting in a small
bleed.
 Oesophagitis
Oesophagitis is a condition that describes inflammation of the intraluminal
epithelial layer of the oesophagus, most often due to either gastric acid reflux
(GORD) or less commonly from infections (typically Candida Albicans),
medication (such as bisphosphonates), radiotherapy, ingestions of toxic substances,
or Crohn’s disease.
 Other causes
Other causes of haematemesis that may not require such immediate resuscitation
and intervention include gastritis, gastric malignancy, Meckel’s diverticulum, or
vascular malformations (e.g. Dieulafoy lesion)ork by Samir [CC-BY-SA-3.0], via Wikimedia
Commons

7. What is the management of acute upper gastrointestinal bleeding?

8. How to determinate of transudate versus exudate source of pleural effusion?
9. What are spider nevi?
A spider angioma (also known as a nevus araneus, spider nevus, vascular spider, and
spider telangiectasia) is a type of telangiectasis (swollen blood vessels) found slightly
beneath the skin surface, often containing a central red spot and reddish extensions which
radiate outwards like a spider's web.

10. When we give antiviral therapy for Chronic hepatitis B?

Our Preceptor,

IGN Sanjaya Putra, MD, Paediatric Consultant