Case Study – Overview of learning achieved through post graduate course: advanced assessment and clinical reasoning

Case Study

Overview of learning achieved through postgraduate course: advanced assessment and clinical reasoning

Becky KaKei Leong, Bachelor of Nursing, Community Hepatitis Nurse from The Hepatitis Foundation of New Zealand 12C Princess Street, Takanini, Auckland 2112 p: 021 103 7805 e: beckakei@gmail.com Conflict of interest and / or financial disclosure: no conflict of interest or any financial related matter

Introduction

Hepatitis B is a silent disease; it often does not present any significant disturbances or disabilities until the condition is advanced; often asymptomatic or mild symptoms.

There is no medical intervention to cure chronic hepatitis B (CHB) (Tu et al, 2018); it increases the risks of developing liver cirrhosis, hepatic failure, and hepatocellular carcinoma (HCC). People living with CHB are recommended to engage in lifelong liver surveillance (bpac, 2018) to monitor disease progression and provide timely treatment to reduce the risk of HCC and the development of cirrhosis (Terrault et al, 2018).

The role of community hepatitis nurse is expanding to meet the high demand from higher level of screening for positive CHB and the aging population increasing in the risk of developing hepatitis B related liver complications. Engaging with patients and developing a strong rapport is essential in a service that provides lifelong monitoring, patients are empowered to contact community nurses for advice when experiencing gastro symptoms that maybe related to hepatitis flare.

In the postgraduate course advanced assessment and clinical reasoning; I have learnt to utilize various structural frameworks to begin differential diagnostic assessment to explore the cause of presenting complaints. Yan is a pseudonym; she has consented to use her event for the case study with omission or alteration to any specific information that may identify her.

Case study

Health history collection using the OLDCART framework:

Yan is a 40-year-old Chinese female, afebrile, she was having moderate intermittent right upper quadrant (RUQ) abdominal pain over the past two months. Pain has worsened over time, aggravates after eating, and resolves spontaneously within 2 hours at its longest duration. Two weeks ago, she began having nausea and vomiting with epigastric pain. She feels fatigued, and her weight is down from 68kg to 65kg. She has also noticed her urine colour darkened but no obvious haematuria and dysuria.

Yan has presented with classic symptoms of gallstone disease; she also is living with CHB infection, which a hepatitis flare could also have similar presentations. When the hepatitis B virus (HBV) is active and is rapidly replicating, hepatitis B e-antigen (HBeAg) protein is secreted into the bloodstream (Liu et al, 2016). Her HBeAg is positive and she has been in immune-tolerant phase for at least ten years.

Physical exam and diagnostics

On examination, her vital signs are within normal parameters, minimal voluntary guarding. Normal JACCOL assessment. Reassuring physical examination, negative Murphy’s sign.

Yan’s presenting complaints are typical signs of cholelithiasis with biliary colic pain (Tanaja et al, 2020). Yan meets the risk profile of high-risk groups being a female, age between 30 to 75 (bpac, 2014), use of oral contraceptives, her recent dietary alteration (overall reduction of intake and dietary cholesterol), along with chronic liver disease with HBeAg positive could be contributing factors to developing gallstone disease (Li et al, 2016).

Her high viremia CHB in the past ten years with her alanine transaminase (ALT) gradually elevated; in the context of her previous blood test pattern in relations to her presenting symptoms, it is a possible indication of hepatitis flare related to HBeAg seroconversion or transitioning from immunetolerance CHB to becoming immune active CHB. Viral flare can be asymptomatic; however, fatigue, loss of appetite, weight loss, nausea and vomiting can be present (Li et al, 2016).

In the context of this case, HBV DNA Quantitation combining liver function test provides a high prediction of viral flare with a “sensitivity and a specificity both of 86%” (Chang & Liaw, 2014).

CHB is a dynamic disease; as the presentation of the complications of CHB is vastly different from one person to another, additionally the transition between inactive to active phases of the disease can be unpredictable (Terrault et al, 2018).

According to the international guidelines for CHB infection, normal ALT for healthy females is ranged between 19-25U/L. This value is lower than the normal enzyme reference range in New Zealand local laboratory for ALT of normal range <40 U/L. The fundamental determinant of the threshold for treatment is based on changes in ALT, with values more or equal to two times upper limit of normal (ULN) (Terrault et al, 2018).

If Alanine Aminotransferase (ALT) results, gamma-glutamyl trans peptidase (GGT), aspartate aminotransferase (AST), and HBV DNA are elevated, it could rule in hepatitis flare (ESAL, 2017). However, if the hypothesis of gallstone disease is also present, the ALT and GGT could also be raised. However, in a pure hepatitis flare, alkaline phosphatase (ALP) should not rise, which could rule in cholelithiasis (bpac, 2014).

The gold standard for diagnosing a liver injury and cholelithiasis is via ultrasound of the abdomen; it is an inexpensive, high specificity, and non-invasive procedure (Tazuma et al, 2016). It can identify any calcification and free-fluid in the abdomen.

Results

The blood test result with elevated ALT more than two times upper limit of normal, elevated AST, GGT and ALP, with high HBV viral load. Ultrasound identified uncomplicated cholelithiasis, partially distended gallbladder. No choledocholithiasis.

The degree of elevated ALT, AST, and GGT with a high level of HBV DNA cannot rule out hepatitis flare. In Yan’s condition, the acute phase of cholelithiasis can obscure the degree of hepatitis flare. A further blood test will be required to evaluate whether hepatitis flare has occurred or is continuing, and whether HBeAg seroconversion has been achieved.

Conclusion

Yan’s acute presentation occurred in a close time frame of a likely episode of a hepatitis flare, in which some of the symptoms overlapped, making differential diagnosis more difficult. It highlights the importance of having a good knowledge base of medical understanding, a thorough history taking, and physical examination skills to begin the differentiation process, and bearing in mind that more than one disorder could be happening simultaneously. This case study is not a straightforward investigation but a real-life example of more than one diagnosis co-exists.

References

Bpac. (2014). Biliary colic and complications from gallstones. Best Practice Journal, 61, 28-35. https://bpac.org.nz/BPJ/2014/june/docs/BPJ61-gallstones.pdf Bpac. (2018). Hepatitis B: treatments no available for primary care. Best Practice Journal, 1-10. https://bpac.org.nz/2018/docs/hepatitis-b.pdf

Chang, M., & Liaw, Y. (2014). Hepatitis B flares in chronic hepatitis B: pathogenesis, natural course, and management. Journal of Hepatology 61, 1407-1417. https://doi.org/10.1016/j.jhep.2014.08.033

European Association for the Study of the Liver. (2017). EASL 2017 clinical practice guidelines on the management of hepatitis B virus infection. Journal of Hepatology, 67, 370-398.

Li, X., Guo, X., Ji, H., Yu, G., & Gao, P. (2016). Gallstones in patients with chronic liver diseases. BioMed Research International. 2017.

https://doi.org/10.18632/oncotarget.15003

Liu, X., Chen, J.M., Lou, J.L., Huang, Y.X., Yan, Y., Sun, G.Z., & Li, N. (2016). Correlation between hepatitis B virus DNA levels and diagnostic tests for HBsAg, HBeAg, and PreS1-Ag in chronic hepatitis B. Genetics and Molecular Research. https://www. geneticsmr.com/articles/6675

Tanaja, J., Lopez, R., & Meer, J. (2020). Cholelithiasis. https://www.ncbi.nlm.nih.gov/books/NBK470440/

Tazuma, S., Unno, M., Igarashi, Y., Inui, K., Uchiyama, K., Kai, M., Tsuyuguchi, T., Maguchi, H., Mori, T., Yamaguchi, K., Ryozawa, S., Nimura, Y., Fujita, N., Kubota, K., Shoda, J., Tabata, M., Mine, T., sugano, K., Watanabe, M., Shimosegawa. (2016). Evidencebased clinical practice guidelines for cholelithiasis 2016. Journal of Gastroenterol. (2017)52, 276-300 https://link.springer.com/article/10.1007/s00535-016-1289-7

Terrault, N., Lok, A., McMahon, B., Chang, K., Hwang, J., Jonas, M., Brown, R., Bzowej, N., & Wong, J. (2018). Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Journal of Hepatology 67(4), 1560-1589.

Tu, T., Budzinska, M., Vondran, F., Shackel, N., & Urban, S. (2018). Hepatitis B virus DNA integration occurs early in the viral life cycle in an in vitro infection model via NTCP-dependent uptake of enveloped virus particles. Journal of Virology. https://www.10.1128/JVI.02007-17