Liver Disease

Case 1 Viral Hepatitis Mrs RK is a 65 year old woman admitted to hospital with upper right quadrant pain, having suffered bouts of vomiting and nausea over the last 5 days. In her history you note that Mrs RK had a serious motor vehicle accident in the late 1980’s where she suffered multiple injuries resulting in amputation of her lower right leg. At the time she had multiple blood transfusions. She is now a non-drinker but admits to being a heavy drinker in the past. She is a smoker (approx. 5 per day). Mrs RK also reveals that under no circumstances can she take codeine as it makes her violently ill. Mrs RK became HBC positive in the 1990’s. She qualified for a clinical trial with interferon alpha which she underwent for several months. At the conclusion of this she was largely HBCAg negative.

Current signs and symptoms: Temp (OC) 37.2, HR 92 bpm, Resps 20 bpm, BP 125/85. Weight 62kg, Height 1.65m

Ongoing medications: Moduretic (to control swelling in her stump) Salbutamol (for mild asthma) Recent medications: Tigecycline IV for an infected wound on her stump and paracetamol for pain management of the wound.
Blood samples are taken in the ER and their analysis is below: LFTs: Bilirubin 50µmol/L (3-20 mol/L) Alkaline Phosphatase 175 u/L (25 to 100u/L) Aspartate Aminotransferase (AST) 165u/L (5-45u/L) Alanine Aminotransferase (ALT) 105u/L (< 36 u/L)
Questions: 1. What is the significance of her HBCAg levels being “largely removed”? What does chronic infection with hepatitis C cause in patients?

2. Interferon alpha was the treatment of choice for clearing hepatitis C from patients with mixed success. Indicate a more current humanised antibody treatment that would be considered and its effectiveness.

3. Is tigecycline the best antibiotic of choice in this case? Explain in terms of her current condition and liver function tests. What else might be considered?
4. What would you recommend for pain management in this patient?

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