Cicero (106-43 BC)
Realtor Louell L. Sala MD
Family Medicine Resident
Batch 2010
Objectives
 To discuss a case of jaundice in a 22 year old female
 To present an algorithm for the assessment of
jaundice
 To present the management done to this patient
based on current evidences
 To be able to answer basic clinical questions
regarding hepatitis c using the best available
evidence.
History of Present Illness
 J.C.
 22 y/o female
 Pasig line Sta. Ana, Manila
 Single
 Right-handed
 Reliability 85%
Chief Complaint:
Icteric sclerae
History of Present illness
2 months PTC
icteric sclerae which the patient
noted. Associated with fever
(T max 38 ) and grade 2 pitting
edema
(-) abdominal pain (-) acholic
stools (-)dysuria (-)hematuria
(-) weight loss (-) nausea
(-)vomiting (-) rashes
(-) itchiness







(-) history of walking in flood water
(+) sought consult at private hospital
Urinalysis: RBC: many, WBC: 8-10/hpf; albumin: trace
CBC: 15.4/4.13/107/platelet 359
A> UTI
t/c Nephrotic Syndrome r/o Viral Hepatitis
Patient was given Furosemide for the edema and
antibiotics for the UTI
 Given request for the following laboratories
 HBsAG, AST, ALT, anti HBS, FBS, BUN, Crea
interim
 Patient claimed there was relief of the edema but there
was persistence of the icteresia. There was no
abdominal pain, no nausea, no vomiting and no
acholic stools
Few days PTC
 Persistence of the icteresia and patient requested for
the interpretation of the laboratory request hence this
eventual consult.
Review of systems
 GENERAL: loss of muscle mass, sweats, fatigue
 EAR: No deafness, pain, tinnitus, discharges,
 NOSE: No epistaxis, discharges, obstruction, post





nasal drip
NECK: No stiffness, No limitation of motion, masses,
sensation of lump
BREAST: No masses, discharges, pain, discomfort
PULMONARY: No dyspnea, shortness of breath,
cough, sputum production
CARDIAC: No chest pain, discomfort, palpitations,
easy fatigability, shortness of breath, orthopnea,
trepopnea, paroxysmal nocturnal dyspnea
VASCULAR: No phlebitis, varicosities., claudication
 GENITOURINARY: No urine flow abnormality,
dribbling, urgency, hesistancy, dysuria, hematuria,
polyuria, flank pain, perineal pain, vaginal
bleeding, vaginal discharge
 ENDOCRINE: No heat cold intolerance,
diaphoresis, breast/voice changes, palpitations,
somnolence
 HEMATOPOIETIC: No pallor, abnormal bleeding,
easy bruisability
 NEUROLOGIC: No headache, dizziness, loss of
consciousness
 PSYCHIATRY: No anxiety, interpersonal
relationship changes, illusions, delusions, changes
in mood, paranoia
Past Medical History
 (-) Diabetes Mellitus, Hypertension, Asthma,
Tuberculosis
 (-) no known allergies
 (-) Blood transfusions/Irradiations
 (-) Herbal medications
OB/Gyne History:
 Go
 Menarche = 15 y/o
 Regular
 6-7 days
 3 ppd
 No dysmennorhea
 LMP: 3rd week of May
 Coitarche: 21
(-) Oral contraceptive pills
 Monogamous with one male partner
Personal Social History
 Non – smoker
 Non alcoholic beverage drinker
 No history of Illicit drug use
 Currently unemployed works at home although she
plans to work eventually to help augment the
household
 Diet: fish and vegetables usually cooked at home
 Water is purified from water refilling station near their
house
Family Genogram
Physical Examination
Conscious coherent not in CP distress
BP: 120/80 RR: 18 HR:84 Wt:62 Ht:157 BMI: 25 kg/m2
Pink palpebrae, icteric sclerae
Fundoscopy: (+) ROR, CD 0.3, media clear
(-) exudates/hemmorhages, OU
Supple neck, no cervical lymphadenopathies
Symmetrical chest expansion, no retractions, clear breath
sounds
Adynamic Precordium, normal rate regular rhythm
Flabby abdomen, soft, normoactive bowel sounds,
nontender (-) Murphy’s sign
(-) caput medusae, fluid wave, shifting dullness
(-) spider angiomata,
No cyanosis, no edema, full and equal pulses
(-) palmar erythema
Neurological Examination
GCS = 15 (Eye Opening=4 Verbal=5 Motor=6)
Conscious, oriented to time, place and person
Intact memory with good insight
CN 1. able to smell coffee
CN 2. 2-3 Equally reactive to light
CN 3,4,6: Extra Ocular muscles intact
CN 5: good masseter strength
CN 7: No facial Assymetry (+) lid closure, both
CN 8: intact gross hearing
CN 9-10: uvula midline
CN 11: (+) shoulder shrug
CN 12: (+) tongue midline on protrusion
5/5
5/5
100
5/5
5/5
100
100
100
Deep Tendon Reflexes :
Biceps
Triceps
Patellar
Achilles
++
++
++
++
++
++
++
++
Babinski
(-)
(-)
Cerebellar: able to perform finger to nose test
Meningeal Signs : Negative Kernig’s
Acute
hepatocellular
Injury
(<6 months)

Yes
Elevation of AST
and ALT >alk
phosphatase
Yes
antiHAV IgM
Anti CMV IgM
Refer to GI
No
Supportive.
Monitor PT
Yes
Resolution
HBSAg
No
Go to Chronic Liver
algorithm
(>6 months)
No
Cholestatic Liver
Injury
Anti HCV
No
University of Washington
Division of Gastroenterology
Murakami MD et.al
www.uwgi.org/guidelines
No
Yes
Consider alcohol,
Acetaminophen,
toxins
Consider Atypical
presentation of Biliary
Obstruction, Hepatic
Mass
Refer to GI
Supportive.
Monitor
Yes
ANA, AMA,
Ceruloplasmin
No
Refer to GI
Yes
Chronic
Hepatocellular Injury
Treatment for specific
agent
Abdominal Sonography
Refer to GI/Liver
Resolution
No
Disorder
Bilirubin
Aminotransferases
Alkaline
phosphatase
Albumin
Prothrombin
time
Hemolysis/Gilbert’s
Normal to 86
mol/L (5
mg/dL)
Normal
Normal
Normal
Normal
Acute
Hepatocelluar
Necrosis(viral and
drug hepatitis)
Both fractions
may be
elevated
Elevated
ALT >AST
Normal to <3 times
normal elevation
Normal
Usually
normal
Chronic
hepatocellular
disorder
Both fractions
may be
elevated
Elevated, but usually
<300 IU
Normal to <3 times
normal elevation
Often
decreased
Often
prolonged
Alcoholic hepatitis
Both fractions
may be
elevated
AST:ALT > 2
Normal to <3 times
normal elevation
Often
decreased
Often
prolonged
Intra and Extrahepatic Cholestasis
Both fractions
may be
elevated
Normal to moderate
elevation
Elevated, often >4
times normal
elevation
Normal,
unless
chronic
Normal
Infiltrative diseases
(tumors)
Usually normal
Normal to slight
elevation
Elevated, often >4
times normal
elevation
Normal
Normal
Harrison's Internal Medicine . 17th ed. Chapter 296. Evaluation of Liver Function. Mcgraw Hill Copyright .
Assessment
7/2/10
S> (+) icteric sclerae, no fever, no edema, no abdominal
pain
O> HBsAg = NR
Anti HAV IgM = NR
AST = 129 (H)
ALT = 263 (H) > Alk.phosphatase = 217.16 (N)
HBeAg = NR
Anti HCV = Reactive
Albumin = 61 (L) Crea = 72.5 (N) BUN = 5.5 (N)
Potassium = 2.5 (L)
t/c Hepatitis C
Hypokalemia
Dx: HBT UTZ, Potassium
Tx: Kalium durule TID
Refer to IDS
Refer to GI
NP: Incorporate banana in the diet
Alcohol Avoidance
HBT Ultrasound
7/12/10
IDS Notes: (-) jaundice,
(-) abdominal pain
E/N PE
AST = 52 (from 129)
ALT = 83 (from 263)
Hepatitis C infection
Repeat AST, ALT in 6 months
TCB with HBT UTZ
“Kailangan ko ba uminom ng gamot doc?”
Standard Indications for therapy
 Elevated ALT Activity
 AST = 52 (from 129)
 ALT = 83 (from 263)
 Fibrosis or moderate to severe hepatitis on liver biopsy
 Detectable HCV RNA
Page 1749 Harrison’s Principles of Internal Medicine 17th
ed. Mcgraw Hill. 2001
Antiviral Therapy not recommended
 Decompensated Cirrhosis
 Normal ALT Activity
Page 1749 Harrison’s Principles of Internal Medicine 17th
ed. Mcgraw Hill. 2001
Pwede pa ba ako makipagtalik sa bf ko?
Recommendations:Persons infected with HCV should be
counseled on how to avoid HCV transmission (Class I, level C)
 HCV infected persons should be counseled to avoid toothbrush and
dental or shaving equipments
 Persons should be counseled to stop using illicit drugs
 HCV infected persons should be advised not to donate blood, blood
organs, other tissue or semen
 HCV – infected persons should be counseled that the risk for sexual
transmission is low, and the infection itself is not a reason to change
sexual practices (i.e. Long term relationships need not start using
barrier precautions but others should always practice “safer” sex.
Adapted from “Recommendations for prevention and control of hepatitis C Virus and HCV related
chronic disease” Centers for Disease Control and Prevention. MMWR Recomm Rep 1998;47
(RR-19):1-39
Approved by the American Association for the study of Liver Diseases (AASLD) and the American
Gastroenterological Association Policy Statement
Mamamatay na ba ako doc?
 After acute HCV infection, the likelihood of remaining
chronically infected approaches 85–90%. Although
many patients with chronic hepatitis C have no
symptoms, cirrhosis may develop in as many as 20%
within 10–20 years of acute illness; in some series of
cases reported by referral centers, cirrhosis has been
reported in as many as 50% of patients with chronic
hepatitis C.
Harrison's Internal Medicine 17th ed. Chapter 298. Acute Viral Hepatitis . Copyright © The
McGraw-Hill Companies.
Anu ang kailangan kong gawin doc?
1. Avoidance of alcohol
There is an association between the use of excessive
alcohol and the development and progression of liver
fibrosis and even the development of Hepatocellular
carcinoma
Bedossa et. al. Natural History of liver fibrosis progression in patients with chronic hepatitis C. The
OBSVRC, METAVIR, CLINIVIR and DOSVIRC groups. Lancet 1997: 349;825-832
Harris et.al. The relationship of hepatitis c to the development of cirrhosis in the presence of alcohol
abuse. Ann Intern Med 2001;134:120-124
2. Weight loss for Obese patients
 Obesity and its associated nonalcoholic fatty liver
disease are believed to play a role in the progression of
fibrosis in HCV-infected individuals.
 It is therefore appropriate to counsel those with BMI
>=25 kg/m2 to attempt to lose weight
Hourigan et.al. Fibrosis in Hepatitis C correlates significantly with Body Mass Index and steatosis.
HEPATOLOGY 1999; 29:1215-1219
Ortiz et.al. Contribution of Obesity to Hepatitis C-related fibrosis progression. Am J Gastroenterol
2002:97:2408-2414
3. Vaccination against Hep A and B
 A single report suggested that the superimposition of
hepatitis A virus in persons with chronic liver disease
particularly with hep c was associated with fulminant
hepatitis
 No specific recommendation against Hep B but
evidence against those co-infected with Hep B and C
have worse prognosis than Hep C alone hence Hep B
vaccination should be offered.
Vento et.al. Fulminant Hepatitis associated with Hepatitis A virus superinfection in patients with chronic
Hepatitis C. N Eng J Med 1998; 338; 286-290
Tsai et.al. Independent and additive effect modification of hepatitis C and B virus infection on the
development of Chronic Hepatitis. J Hepatol 1996; 24:271-276
4. Use of Silymarin (milk thistle extract)
 The benefit of Silymarin and or other herbal therapies
for Hepatitis C has not been established. Currently, the
NIH is conducting a well designed scientific study of a
standardized formulation of silymarin to determine its
effectiveness
 Of concern, Some herbal mixtures have been
associated with hepatotoxicity, fulminant hepatitis
and death.
Strader et.al. Use of complementary and alternative medicine in patients with liver disease. Am J
Gastroenterol 2002;97:2391-2397
Seef LB. Herbal Hepatotoxicity. Clin Liver Dis 2007; 577 – 596, vii.
Pwede pa ba ako makapagtrabaho doc?
Should there guidelines about Hepatitis C in the workplace?
Section 6. Code of Ethics in Medical Profession
 The medical practitioner should guard as a sacred
trust anything that is confidential in nature that he
may discover or be communicated to him, except when
it is in the interest of justice, public health, or public
safety.
Where do we draw the line between privacy and public
health?