Great. Hi again. So the first part of our session this morning was all about transplant and aftercare of transplant and how to get to transplant. The second half of this course is now going to be more focused on general hepatology things. And so without really considering transplant for our general hepatology patients, what do we do and how can we best help them? So I'm going to lead you through three different case studies. And then the next three speakers will hone in deeper on each of those case studies and provide you with some real life scenario of how they would take care of that patient. So that is kind of the overview of our plan, how we planned for this to go. So only disclosure I have, I serve on an advisory board for Salinks. So this is our first case. So the topic is abnormal LFTs. So guess who is going to be giving more information about that in a little bit. You can look at your agenda and find that out really quick. So this is our female patient. She's 45 years old. She's of Hispanic ethnicity. She's 5' 5", 195 pounds with a BMI of 32.4. She's an insurance agent. She has past medical history of obesity, type 2 diabetes, and hypothyroidism. Current medications, she's on some thyroid medications and metformin for her diabetes. She doesn't have any allergies. She has a family history of diabetes, coronary artery disease, and her father had a myocardial infarction some years ago. So we know that she told us she had an emergency room visit about a week ago for itching and yellowing of skin. She had a recent diagnosis of acute bronchitis. She had gone to her PCP, and he gave her a 14-day course of an antibiotic. And she had only completed about seven days of it. On review of systems, we discover that she has some fatigue and nausea and some right upper quadrant pain. She denies any alcohol consumption. On physical exam, she has fairly normal vital signs with the exception of a temperature. She has febrile with a temperature of 38.2, respiration rate of 24, heart rate of 90, and a blood pressure of 120 over 75. She is visibly jaundiced. She has scleral icterus and severe itching, even areas of excoriations on her arms from scratching so hard. Her skin shows a mild maculopapular rash to her chest and her back. Heart sounds are present. Regular rate and rhythm, S1, S2, no murmur. Lungs are clear. GI, no noted hepatomegaly or splenomegaly. She does have some bowel sounds and an obese abdomen. And she follows commands appropriately. There is no asterixis when we look for that on exam. So looking at some data that we drew, CBC is normal, her INR is 1.2. ALKFOS is 250, AST and ALT, numbers are there. ALT, 75, AST, 42, and a total bilirubin of 12. Her ultrasound shows liver shows fatty infiltrate consistent with fatty liver disease, patent vasculature, and presence of gallstones. So here are some questions just to kind of be pondering as we start going into some of these cases. So what do you think you should ask the patient next? What is your possible differential diagnosis that you can think about? What medication should be started or stopped, knowing what we know about what she's taken and where she is now? And are there any other considerations that we should think about at this point? So I'm gonna let you ponder on that. And we're gonna talk about case number two. Case number two, this is a hepatocellular carcinoma case. So this is a 59-year-old male. He is African American. His height is 6'2". His weight is 198 pounds. He is a financial analyst. Past medical history is significant for type 2 diabetes. He does have high cholesterol and high blood pressure. Current medications he's on is prevostatin and lisinopril. He doesn't have any allergies. Family medical history is significant for coronary artery disease and MI and diabetes in his father and breast cancer in his mother. So here is his story. He presents to the emergency room with a three-week history of abdominal swelling and worsening fatigue. Symptoms have worsened over the past two days. His wife reports that sometimes he says things that are a little off, don't really make sense. She's kind of just poo-pooed it and not really thought much of it. Happening off and on for the past two months or so. On the review of systems, we know that he has some fatigue, some worsening shortness of breath with activities of daily living, walking the dog or just going upstairs. No chest pain or dizziness. No change in his bowel habits. He denies any current alcohol consumption. Occasionally, he'll have a glass of wine. On our physical exam, vital signs show a blood pressure of 145 over 90, heart rate of 89, respiratory rate of 18, and a temperature of 37. General, he appears dyspneic with conversation. He's having a little difficulty in the conversation as you've been examining him. He is oriented to person and place, but he says the year is 2001. Heart, his S1, S2 is present. Regular rate and rhythm, lungs are clear. GI distended, non-tender to palpation, no hepatomegaly or splenomegaly. He does have good bowel sounds. Neurologically, he follows commands appropriately, and when you look for esterixis, you do see a mild flap, a mild esterixis present. So in looking at the laboratory data, the CBC hemoglobin shows a little anemia, 8.7. Platelet count of 45, WBC is normal. INR 1.3, glucose is high, 320. ALT, AST, and ALKFOS, all liver enzymes there are normal. Total direct bilirubin is two and 1.2. Renal profile shows pretty decent electrolytes there, creatinine of 1.1 and a BUN of 20. The ultrasound shows a liver that is cirrhotic with sequela of portal hypertension, patent vasculature, no portal vein thrombosis, moderate ascites, 2.5 centimeter hypoicotic mass in the right lobe with recommendation for further studies. So what's next? So we know some ascites is there. His abdomen is tense, he's uncomfortable, so we do do a paracentesis. 5.5 liters is removed, shows some clear yellow fluid. White cell count on the fluid is 150 with 5% neutrophils, and we also sent it for gram stain total protein and cultures. We also were recommended to do more imaging studies, so we got an MRI of the abdomen with and without contrast, and the results are seen there. Cirrhosis with sequela of portal hypertension, including varices, splenomegaly, and small ascites. A 2.5 centimeter by 1.8 centimeter mass is seen in segment five with arterial phase hyperenhancement with washout and enhancing capsule, and we'll talk about all of that very soon with Dr. Harnoy and Caitlin. So what is your differential diagnosis for this patient? So I think we all can agree this patient is a decompensated cirrhotic. We definitely have presence of ascites, hepatic encephalopathy, all signs that he has definitely moved from a compensated state to decompensated state. And thinking about that uncontrolled diabetes, what can we do to help manage that a little bit better? And then we have this mass that is very consistent with a possible diagnosis of a pedicellular carcinoma, so we have to definitely think about next steps for that, for this patient. So at this point, we refer them to a liver transplant center for a full liver transplant evaluation, because he did definitely move from that compensated state to decompensated state. We have plans for a transplant hepatology consultation and interventional radiology consultation to see is this patient a candidate to have some local regional treatment of this possible tumor. Our third case is on hepatitis B, and this is a 42-year-old female, Caucasian. She is 5'7", and she weighs 135 pounds, and she's a grocery cashier. She, past medical history is significant for IV drug use. She had hepatitis C treated in 2018. She has some asthma and depression and anxiety. She says that she currently does not take any medications, and she has a penicillin allergy. Her father had cirrhosis, and her mother had ovarian cancer, which she passed away from at the age of 45. So what is her story at this point? So she arrives to you at your clinic for a new diagnosis of hepatitis B. She was seen at her primary care office two weeks ago after her new boyfriend told her that he was hepatitis B positive. Lab work was done by the PCP, and we're gonna go into that on the next slide. Review of systems showed that she has some fatigue, some anxiety, obviously, related to this new possible diagnosis, and some nausea. She denies current alcohol or any IV drug use consumption at this point. She does have a prior history of that, five years off and on, but completed a drug rehab program and has been clean for two years. So here's a look at her radiology and lab data that we received. CBC's normal, INR is one. You can see she definitely has some elevation of her ALT and AST, and she has a total bilirubin of 3.2. You can look at her viral serologies there, so we have some definite positives there. We have a HBV DNA of 365,000. Her HCV RNA is undetectable. Ultrasound was done, showed hepatomegaly, no splenomegaly, no ascites, and a thickened gallbladder wall and normal bile ducts. On physical exam, she has pretty normal vital signs. She appears thin, generally malnourished, and older than her stated age. She, heart and lung sounds are great. GI-wise, she does have some hepatomegaly that is noted, no splenomegaly, good bowel sounds, and a flat abdomen. Her neurological exam shows that she can follow commands appropriately and no atherosclerosis present. So what are some questions we can think about when we think about this patient? So as the liver specialist seeing this patient, what would you do next? What are some things, testing or other things that you should consider? Would you order any additional testing? What education would you provide the patient? What are some need-to-knows that she needs to know at this point, knowing that she definitely has a new diagnosis of hepatitis B? What considerations would you think about giving the patient has already had recent treatment for hepatitis C? And what is your treatment of choice for the hepatitis B? So as we go through some of our next talks, these are the three people that we're going to be thinking about as our experts come up and talk about their individual pieces. So our first talk's gonna be about abnormal LFTs, then we're gonna jump into hepatocellular carcinoma, and then we will jump into hepatitis B. Thank you. Thanks, Amanda.

hepatology

case studies

abnormal liver function tests

liver transplant evaluation

hepatitis B