Case Study 18:
Cirrhosis
Skylar Strobel
Overview
• Role of liver
• Scar tissue forms as
liver repairs itself
• Wide range of causes
Patient S.G.
• 46 yo white male
• History of chronic alcoholism
• Abdominal swelling and confusion
• Gained 15 lbs
• Lethargic, acting strangely
PMH
• Cirrhosis, 4 years ago
• H/O:
•
•
•
•
Uncontrolled ascites and peripheral edema
Anemia
Acute pancreatitis
E. coli-induced bacterial peritonitis
• Father died at age 52
• H/O alcohol abuse
• H/O IVDA and intranasal cocaine
• ½ ppd for many years
Review of Systems
• Increasing abdominal girth
• No complaints of abdominal pain, fever, chills,
nausea, hematemesis, tarry stools, cough, chest
pain, weakness, blood in urine, diarrhea or dry
mouth
Patient Case Question 1:
Hematemesis and tarry stools
are clinical signs of which
serious potential complication
of cirrhosis?
• Acute gastrointestinal bleeding
Physical Exam
• Skin
• Mild jaundice
• (+) spider nevi on
chest
• (-) palmar erythema
• Several ecchymoses
on lower extremities
• HEENT
• (+) icteric sclera
• Chest
• (+) gynecomastia
• Abdomen
• Moderately
distended, firm,
slightly tender
• (+) prominent veins
• (+) HSM
• Genit/Rect
• Testicles atrophied
• (+) hemorrhoids
• Neuro
• Confused, disoriented
Patient Case Question 2:
Identify 15 clinical signs and
symptoms consistent with a
diagnosis of cirrhosis
•
•
•
•
Weight gain
Lethargy
Confusion
Unusual violent
behavior
• Skin
• Mild jaundice
• (+) spider nevi on chest
• Several ecchymoses on
lower extremities
• HEENT
• (+) icteric sclera
• Chest
• (+) gynecomastia
• Abdomen
• Moderately distended,
firm, slightly tender
• (+) prominent veins
• (+) HSM
• Genit/Rect
• Testicles atrophied
• (+) hemorrhoids
• Neuro
• Confused, disoriented
Lab Test Results
Na
135 meq/L
4700/mm3
Mg
1.7 mg/dL
PT
15.6 sec
AFP
90 ng/mL
HBsAg
(-)
HIV
(-)
Anti-HCV
(+)
WBC
K
3.5 meq/L
Cl
101 meq/L
PTT
45.1 sec
HCO3
25 meq/L
NH3
250µg/dL
BUN
12 mg/dL
AST
107 IU/L
Cr
.6 mg/dL
ALT
86 IU/L
Glu
90 mg/dL
Alk phos
Hb
14.0 g/dL
Bilirubin 2.4 mg/dL
Fe
Hct
39.7%
Protein
6.6 g/dL
Ferratin
MCV
90 fL
Alb
2.7 g/dL
Transferrin saturation 38%
Plt
34500/mm3
Ca
224 IU/L
8.5 mg/dL
HCV RNA 2.8 million/mL
ANA
(-)
75 µg/dL
200 ng/mL
Ceruplasmin 37 mg/dL
3. Anemic?
Na
135 meq/L
4700/mm3
Mg
1.7 mg/dL
PT
15.6 sec
AFP
90 ng/mL
HBsAg
(-)
HIV
(-)
Anti-HCV
(+)
WBC
K
3.5 meq/L
Cl
101 meq/L
PTT
45.1 sec
HCO3
25 meq/L
NH3
250µg/dL
BUN
12 mg/dL
AST
107 IU/L
Cr
.6 mg/dL
ALT
86 IU/L
Glu
90 mg/dL
Alk phos
Hb
14.0 g/dL
Bilirubin 2.4 mg/dL
Fe
Hct
39.7%
Protein
Ferratin
MCV
90 fL
Plt
34500/mm3
Alb
Ca
224 IU/L
6.6 g/dL
2.7 g/dL
8.5 mg/dL
HCV RNA 2.8 million/mL
ANA
(-)
75 µg/dL
200 ng/mL
Transferrin saturation 38%
Ceruplasmin 37 mg/dL
4. Abnormality of CBC?
Na
135 meq/L
4700/mm3
Mg
1.7 mg/dL
PT
15.6 sec
AFP
90 ng/mL
HBsAg
(-)
HIV
(-)
Anti-HCV
(+)
WBC
K
3.5 meq/L
Cl
101 meq/L
PTT
45.1 sec
HCO3
25 meq/L
NH3
250µg/dL
BUN
12 mg/dL
AST
107 IU/L
Cr
.6 mg/dL
ALT
86 IU/L
Glu
90 mg/dL
Alk phos
Hb
14.0 g/dL
Bilirubin 2.4 mg/dL
Fe
Hct
39.7%
Protein
6.6 g/dL
Ferratin
MCV
90 fL
Alb
2.7 g/dL
Transferrin saturation 38%
Plt
34500/mm3
Ca
224 IU/L
8.5 mg/dL
HCV RNA 2.8 million/mL
ANA
(-)
75 µg/dL
200 ng/mL
Ceruplasmin 37 mg/dL
5. Sudden progression?
Na
135 meq/L
4700/mm3
Mg
1.7 mg/dL
PT
15.6 sec
AFP
90 ng/mL
HBsAg
(-)
HIV
(-)
Anti-HCV
(+)
WBC
K
3.5 meq/L
Cl
101 meq/L
PTT
45.1 sec
HCO3
25 meq/L
NH3
250µg/dL
BUN
12 mg/dL
AST
107 IU/L
Cr
.6 mg/dL
ALT
86 IU/L
Glu
90 mg/dL
Alk phos
Hb
14.0 g/dL
Bilirubin 2.4 mg/dL
Fe
Hct
39.7%
Protein
6.6 g/dL
Ferratin
MCV
90 fL
Alb
2.7 g/dL
Transferrin saturation 38%
Plt
34500/mm3
Ca
224 IU/L
8.5 mg/dL
HCV RNA 2.8 million/mL
ANA
(-)
75 µg/dL
200 ng/mL
Ceruplasmin 37 mg/dL
6. Four risk factors
1. Alcohol Abuse
2. Hepatitis C
• Anti-HCV test +
3. Overweight
• Height: 5’7”
• Weight: 171 lbs
• BMI = 26.8  overweight
4. Liver Cancer
• AFP test – 90 ng/mL
• Normal – 0-15 ng/mL
7. Bacterial peritonitis?
Na
135 meq/L
4700/mm3
Mg
1.7 mg/dL
PT
15.6 sec
AFP
90 ng/mL
HBsAg
(-)
HIV
(-)
Anti-HCV
(+)
WBC
K
3.5 meq/L
Cl
101 meq/L
PTT
45.1 sec
HCO3
25 meq/L
NH3
250µg/dL
BUN
12 mg/dL
AST
107 IU/L
Cr
.6 mg/dL
ALT
86 IU/L
Glu
90 mg/dL
Alk phos
Hb
14.0 g/dL
Bilirubin 2.4 mg/dL
Fe
Hct
39.7%
Protein
6.6 g/dL
Ferratin
MCV
90 fL
Alb
2.7 g/dL
Transferrin saturation 38%
Plt
34500/mm3
Ca
224 IU/L
8.5 mg/dL
HCV RNA 2.8 million/mL
ANA
(-)
75 µg/dL
200 ng/mL
Ceruplasmin 37 mg/dL
8. Why do an ANA test?
Na
135 meq/L
4700/mm3
Mg
1.7 mg/dL
PT
15.6 sec
AFP
90 ng/mL
HBsAg
(-)
HIV
(-)
Anti-HCV
(+)
WBC
K
3.5 meq/L
Cl
101 meq/L
PTT
45.1 sec
HCO3
25 meq/L
NH3
250µg/dL
BUN
12 mg/dL
AST
107 IU/L
Cr
.6 mg/dL
ALT
86 IU/L
Glu
90 mg/dL
Alk phos
Hb
14.0 g/dL
Bilirubin 2.4 mg/dL
Fe
Hct
39.7%
Protein
6.6 g/dL
Ferratin
MCV
90 fL
Alb
2.7 g/dL
Transferrin saturation 38%
Plt
34500/mm3
Ca
224 IU/L
8.5 mg/dL
HCV RNA 2.8 million/mL
ANA
(-)
75 µg/dL
200 ng/mL
Ceruplasmin 37 mg/dL
9. Hemochromatosis?
Na
135 meq/L
4700/mm3
Mg
1.7 mg/dL
PT
15.6 sec
AFP
90 ng/mL
HBsAg
(-)
HIV
(-)
Anti-HCV
(+)
WBC
K
3.5 meq/L
Cl
101 meq/L
PTT
45.1 sec
HCO3
25 meq/L
NH3
250µg/dL
BUN
12 mg/dL
AST
107 IU/L
Cr
.6 mg/dL
ALT
86 IU/L
Glu
90 mg/dL
Alk phos
Hb
14.0 g/dL
Bilirubin 2.4 mg/dL
Fe
Hct
39.7%
Protein
6.6 g/dL
Ferratin
MCV
90 fL
Alb
2.7 g/dL
Transferrin saturation 38%
Plt
34500/mm3
Ca
224 IU/L
8.5 mg/dL
HCV RNA 2.8 million/mL
ANA
(-)
75 µg/dL
200 ng/mL
Ceruplasmin 37 mg/dL
10. Wilson’s disease?
Na
135 meq/L
4700/mm3
Mg
1.7 mg/dL
PT
15.6 sec
AFP
90 ng/mL
HBsAg
(-)
HIV
(-)
Anti-HCV
(-)
WBC
K
3.5 meq/L
Cl
101 meq/L
PTT
45.1 sec
HCO3
25 meq/L
NH3
250µg/dL
BUN
12 mg/dL
AST
107 IU/L
Cr
.6 mg/dL
ALT
86 IU/L
Glu
90 mg/dL
Alk phos
Hb
14.0 g/dL
Bilirubin 2.4 mg/dL
Fe
Hct
39.7%
Protein
6.6 g/dL
Ferratin
MCV
90 fL
Alb
2.7 g/dL
Transferrin saturation 38%
Plt
34500/mm3
Ca
224 IU/L
8.5 mg/dL
HCV RNA 2.8 million/mL
ANA
(-)
75 µg/dL
200 ng/mL
Ceruplasmin 37 mg/dL
11. Why can autoimmune
hepatitis and primary biliary
cirrhosis be ruled out as
contributing factors to this
patient’s condition?
Na
135 meq/L
4700/mm3
Mg
1.7 mg/dL
PT
15.6 sec
AFP
90 ng/mL
HBsAg
(-)
HIV
(-)
Anti-HCV
(-)
WBC
K
3.5 meq/L
Cl
101 meq/L
PTT
45.1 sec
HCO3
25 meq/L
NH3
250µg/dL
BUN
12 mg/dL
AST
107 IU/L
Cr
.6 mg/dL
ALT
86 IU/L
Glu
90 mg/dL
Alk phos
Hb
14.0 g/dL
Bilirubin 2.4 mg/dL
Fe
Hct
39.7%
Protein
6.6 g/dL
Ferratin
MCV
90 fL
Alb
2.7 g/dL
Transferrin saturation 38%
Plt
34500/mm3
Ca
224 IU/L
8.5 mg/dL
HCV RNA 2.8 million/mL
ANA
(-)
75 µg/dL
200 ng/mL
Ceruplasmin 37 mg/dL
12. Osteoporosis?
Na
135 meq/L
4700/mm3
Mg
1.7 mg/dL
PT
15.6 sec
AFP
90 ng/mL
HBsAg
(-)
HIV
(-)
Anti-HCV
(-)
WBC
K
3.5 meq/L
Cl
101 meq/L
PTT
45.1 sec
HCO3
25 meq/L
NH3
250µg/dL
BUN
12 mg/dL
AST
107 IU/L
Cr
.6 mg/dL
ALT
86 IU/L
Glu
90 mg/dL
Alk phos
Hb
14.0 g/dL
Bilirubin 2.4 mg/dL
Fe
Hct
39.7%
Protein
6.6 g/dL
Ferratin
MCV
90 fL
Alb
2.7 g/dL
Transferrin saturation 38%
Plt
34500/mm3
Ca
224 IU/L
8.5 mg/dL
HCV RNA 2.8 million/mL
ANA
(-)
75 µg/dL
200 ng/mL
Ceruplasmin 37 mg/dL
13. Evidence for ascites
Na
135 meq/L
4700/mm3
Mg
1.7 mg/dL
PT
15.6 sec
AFP
90 ng/mL
HBsAg
(-)
HIV
(-)
Anti-HCV
(-)
WBC
K
3.5 meq/L
Cl
101 meq/L
PTT
45.1 sec
HCO3
25 meq/L
NH3
250µg/dL
BUN
12 mg/dL
AST
107 IU/L
Cr
.6 mg/dL
ALT
86 IU/L
Glu
90 mg/dL
Alk phos
Hb
14.0 g/dL
Bilirubin 2.4 mg/dL
Fe
Hct
39.7%
Protein
6.6 g/dL
Ferratin
MCV
90 fL
Alb
2.7 g/dL
Transferrin saturation 38%
Plt
34500/mm3
Ca
224 IU/L
8.5 mg/dL
HCV RNA 2.8 million/mL
ANA
(-)
75 µg/dL
200 ng/mL
Ceruplasmin 37 mg/dL
14. Hepatic encephalopathy?
Na
135 meq/L
4700/mm3
Mg
1.7 mg/dL
PT
15.6 sec
AFP
90 ng/mL
HBsAg
(-)
HIV
(-)
Anti-HCV
(-)
WBC
K
3.5 meq/L
Cl
101 meq/L
PTT
45.1 sec
HCO3
25 meq/L
NH3
250µg/dL
BUN
12 mg/dL
AST
107 IU/L
Cr
.6 mg/dL
ALT
86 IU/L
Glu
90 mg/dL
Alk phos
Hb
14.0 g/dL
Bilirubin 2.4 mg/dL
Fe
Hct
39.7%
Protein
6.6 g/dL
Ferratin
MCV
90 fL
Alb
2.7 g/dL
Transferrin saturation 38%
Plt
34500/mm3
Ca
224 IU/L
8.5 mg/dL
HCV RNA 2.8 million/mL
ANA
(-)
75 µg/dL
200 ng/mL
Ceruplasmin 37 mg/dL
15. Grade this encephalopathy?
• 0: Minimal HE
• Hard to detect, changes in memory, concentration and temper
are minimal
• 1: Mild HE
• Short attention span, noticeable mood changes, sleep problems
• 2: Moderate HE
• Forgetfulness worsens, lethargic, exhibit inappropriate behavior,
slurred speech, and difficulty with mental tasks
• 3: Severe HE
• Confused as to where you are or what day it is, extremely sleepy,
unable to do basic mental tasks, extremely anxious, act strangely
• 4: Coma
• Unconscious, slip into coma
16. Patient’s CTP score?
Na
135 meq/L
4700/mm3
Mg
1.7 mg/dL
PT
15.6 sec
AFP
90 ng/mL
HBsAg
(-)
HIV
(-)
Anti-HCV
(-)
WBC
K
3.5 meq/L
Cl
101 meq/L
PTT
45.1 sec
HCO3
25 meq/L
NH3
250µg/dL
BUN
12 mg/dL
AST
107 IU/L
Cr
.6 mg/dL
ALT
86 IU/L
Glu
90 mg/dL
Alk phos
Hb
14.0 g/dL
Bilirubin 2.4 mg/dL
Fe
Hct
39.7%
Protein
6.6 g/dL
Ferratin
MCV
90 fL
Alb
2.7 g/dL
Transferrin saturation 38%
Plt
34500/mm3
Ca
224 IU/L
8.5 mg/dL
HCV RNA 2.8 million/mL
ANA
(-)
75 µg/dL
200 ng/mL
Ceruplasmin 37 mg/dL
17. One year survival?
• Based on his class C CTP score, this patient has a
45% probability of surviving another year
18. Does the patient have any
signs of dehydration or
hepatorenal syndrome?
Na
135 meq/L
4700/mm3
Mg
1.7 mg/dL
PT
15.6 sec
AFP
90 ng/mL
HBsAg
(-)
HIV
(-)
Anti-HCV
(-)
WBC
K
3.5 meq/L
Cl
101 meq/L
PTT
45.1 sec
HCO3
25 meq/L
NH3
250µg/dL
BUN
12 mg/dL
AST
107 IU/L
Cr
.6 mg/dL
ALT
86 IU/L
Glu
90 mg/dL
Alk phos
Hb
14.0 g/dL
Bilirubin 2.4 mg/dL
Fe
Hct
39.7%
Protein
6.6 g/dL
Ferratin
MCV
90 fL
Alb
2.7 g/dL
Transferrin saturation 38%
Plt
34500/mm3
Ca
224 IU/L
8.5 mg/dL
HCV RNA 2.8 million/mL
ANA
(-)
75 µg/dL
200 ng/mL
Ceruplasmin 37 mg/dL
19. The patient’s primary care
provider has decided to
conduct extensive clinical
studies for the diagnosis of
liver cancer. Which single
abnormal laboratory value has
raised a concern that
hepatocellular carcinoma may
have developed?
Na
135 meq/L
4700/mm3
Mg
1.7 mg/dL
PT
15.6 sec
AFP
90 ng/mL
HBsAg
(-)
HIV
(-)
Anti-HCV
(-)
WBC
K
3.5 meq/L
Cl
101 meq/L
PTT
45.1 sec
HCO3
25 meq/L
NH3
250µg/dL
BUN
12 mg/dL
AST
107 IU/L
Cr
.6 mg/dL
ALT
86 IU/L
Glu
90 mg/dL
Alk phos
Hb
14.0 g/dL
Bilirubin 2.4 mg/dL
Fe
Hct
39.7%
Protein
6.6 g/dL
Ferratin
MCV
90 fL
Alb
2.7 g/dL
Transferrin saturation 38%
Plt
34500/mm3
Ca
224 IU/L
8.5 mg/dL
HCV RNA 2.8 million/mL
ANA
(-)
75 µg/dL
200 ng/mL
Ceruplasmin 37 mg/dL