CASE

PROTOCOL: M&M
Charmaine A. Ballano, MD
March 22, 2024

Moderator: Ron Michael Castillo, MD, FPCP

Reactor: Dr. John Arnel Pangilinan MD FPCP FPSG FPSDE

Objectives:

• To review the pathophysiology of Hepatocellular Carcinoma

• To briefly discuss guidelines-based work up and management of Hepatocellular Carcinoma

• To discuss septic shock in a patient with probable Hepatocellular Carcinoma

General Data

This is a case of MP, 63-year old male, previous OFW currently working as a farmer, Filipino, residing at
Bignay, Valenzuela City, admitted for the first time at our institution.

Chief complaint: Epigastric Pain

History of Present Illness

1 week PTA, (+) on-off epigastric pain, non-radiating, PS 3/10, no aggravating/palliating factors elicited.
No other associated symptoms noted such as nausea/vomiting, fever, nor dob. There was no consult
done, no meds taken at this point.

During the interim, there was persistence of symptoms with noted increasing severity ranging from 5-
7/10 (from 3/10), still on and off/ colicky in character but now with noted radiation to the back,
associated with occasional dob brought about by worsening abdominal pain. Patient also had 3 episodes
of vomiting of previously ingested food, around half cup per bout with eventually loss of appetite
described as hesitant to eat for he might vomit thereafter. There were no loose bowel movement, no
fever noted. No other family members were experiencing the same symptoms. Still no consult done and
no meds taken.

Few hours PTA, there was further progression of epigastric pain, now with PS 10/10, radiating to the
back still episodes of vomiting of previously ingested food (2x), no fever, no cough, no loose bowel
movement noted. Patient then consulted at our institution and was subsequently admitted
Review of Systems

General : no weight gain/loss

HEENT: (-) headache, (-) icteric sclera, (-) naso-aural discharge

Mouth/Throat: (-) sore throat, (-) gum bleeding

Chest/Lungs: (-) cough, (-) hemoptysis, (-) difficulty of breathing

CVS: : (-) chest pain, (-) palpitations, (-) easy fatigability, (-) orthopnea

GI : (-) dysphagia, (-) reflux symptoms, (+) jaundice, (-) hematochezia/melena

GU: (-) dysuria, (+) hematuria

Neurologic: (-) seizures, (-) changes in sensorium

Past Medical History

He has Diabetes for 5 years and maintained on Metformin 50 mg tab with good compliance. No known
Hypertension, previous cerebrovascular disease, or exposure to TB or treatment. No history of trauma,
blood transfusion, previous hospitalization. No known allergy to food and medications.

Family History: Unremarkable

Personal and social history:

Previous OFW, currently a farmer with 10 pack years of smoking history. Patient denies alcohol and illicit
drug use. Patient prefers eating fish especially raw with vinegar.

Initial Physical Examination

Awake, Ambulatory, Conscious, coherent, oriented, in mild respiratory distress

BP: 90/60 HR: 98 bpm RR: 26 cpm Temp: 37.1⁰C O2 saturation: 98% at room air
Noticeable Jaundice with good skin turgor
Icteric sclerae, Slightly pale palpebral conjunctivae, no neck vein engorgement, no cervical
lymphadenopathy
Symmetrical chest expansion, vesicular breath sounds, no retractions
Adynamic precordium, normal rate, regular rhythm, Apex beat at 5th ICS MCL, no heaves no palpable
thrills
Soft, globular but not tense, the flanks were bulging, +spider nevi, NABS, slightly tender in palpation
Edema grade 1-2 and with full equal pulses
GCS15

Admitting Impression:
Acute Pancreatitis BISAP 1
t/c Obstructive Jaundice prob sec to choledocholithiasis
t/c CLD prob sec to ALD
Type 2 DM
Non-covid

Course in the Wards:

Patient was admitted under Gastroenterology service. On 1 st hospital day, diagnostics such as CBC, blood
chemistry (PT, PTT, INR, AST, ALT, ALP, BUN, Creatinine, TPAG, bilirubins), chest x-ray, and WAB ultrasound
were requested. Patient was started with Omeprazole 40mg IV OD, Tramadol 50mg IV q8 prn for pain,
Lactulose 30cc ODHS, started with Aminoleban 500cc to run for 8 hrs. Patient was put NPO, hydrated at
120cc/hr for 2 hrs then decreased to 80cc/hr.

Labs were followed up with:

CBC: normal wbc but with microcytic hypochromic anemia (Hgb 74)
Albumin was noted at 21.6
Total bilirubin of 368.11 (17x of upper limit)
Direct bilirubin of 273.30 (33x) and Indirect bilirubin or 94.81 (7x)
PT was at 29.60, % Activity 23, INR 2.56, aPTT of 38.20.
AST 281 (8x), ALT (3x), ALP (1.3x)
Amylase 968.2 (9.6x)
HbsAg Nonreactive

CXR:
Pneumonia both lower lobes
PTB densities
Correlate clinically

On 2nd Hospital Day, patient was still noted with abdominal pain, epigastric area with 2 episodes of
melena around ½ cup.Patient was maintained on NPO, Omeprazole 80mg IV bolus was given with
subsequent drip of 8cc/hr for 72 hrs. Repeat CBC was noted to have decreased Hemoglobin from 74 to
64, hence patient was transfused with 2u prbc and CBC was repeated. EGD was requested.

On the 3rd hospital day, still with epigastric pain and jaundice, with no episodes of melena but with
seemingly increasing abdominal girth and fluid wave. Patient was given Spironolactone 25mg OD and
was also started with Ciprofloxacin 500mg as SBP prophylaxis. He was then referred to GS for
comanagement of the seen hepatic mass on ultrasound.

WAB ultrasound was immediately facilitated which revealed:

Liver parenchymal disease with dilated intrahepatic ducts
Isoechoic solid mass, Right Lobe of Liver
Cholecystolithiases with bile sludge
Enlarged prostate gland Grade I
Moderate Ascites
On the 4th hospital day, GS notes were appreciated suggesting for WAB CT with triple contrast. Results of
PT, PTT INR were still deranged, hence FFP transfusion and Vitamin K IV were requested.

On the 6th hospital day, patient was slightly tachypneic at 22 with crackles on auscultation, no fever and
no desaturations, but with noted decreased breath sounds on the Right lower lung field, repeat CXR
revealed bilateral pneumonia with homogenous opacity obscuring the right middle to basal lobe
probably secondary to Pleural effusion. Patient was then given Cefepime 2g IV q8 and Azithromycin
500mg/tab od to cover for pneumonia.

On 7th hospital day, EGD was facilitated with noted: medium esophageal varices and portal hypertensive
gastropathy.

On 8th hospital day, day 3 of started antibiotics, there were still crackles on both lung fields, repeat CXR
was requested at this point. Patient is still the same level of jaundice, icterisia, no abdominal pain.

On 9th hospital day, repeat CXR revealed progression of densities, and pleural effusion on Right lung. CT
scan was also facilitated revealing:
 Liver parenchymal disease with cirrhotic features and mass lesion in segments VII and VIII
exhibiting features of arterioportal shunting and possible right portal thrombosis that suggests
the possibility of hepatocellular carcinoma. Associated mass effects include intrahepatic ductal
ectasia
 Intraabdominal and retroperitoneal lymphadenopathy, worrisome for metastasis
 Gallbladder sludge formation
 Anasarca
 Fecal retention
 Spondylosis

At this point patient’s relative was primed of patient’s probable diagnosis and its prognosis.

On 11th hospital day patient was referred due respiratory distress advised intubation but refused, waiver
was secured. Patient was then hooked to BIPAP. Fe hours thereafter patient was noted with hypotension
started the patient on Norepinephrine 16mg in 250cc D5W to titrate until target Bp was achieved on
lowest possible dose.

On 12th hospital day, still on pressor, patient had decrease in sensorium GCS 8 (E2V1M5) from GCS15
appraised relative for necessity of intubation, consented but waived for CPR.
Patient was then intubated: AC mode, Fio2 100%, PEEP 5, BUR 16, TV 370.

Repeated laboratory work up: CBC, CXR post intubation, cultures, repeat RT PCR, ABG, electrolytes, Bun,
Creatinine

Antibiotics was shifted/stepped up to double negative coverage:

Meropenem 1g IV q8 and Levofloxacin 750mg IV q24
Patient was also started with Salbutamol + Ipratropium q8
Other medications were continued

On the 13th hospital day, patient was referred due to cessation of vital signs, noted DNR status.
Maximized medical management but still no spontaneous breathing, no heart rate and BP were
appreciated, pupils were fixed and dilated.

Sign out/Final Diagnosis:

Septic Schock sec to 1) SBP 2) HAP nonresolving
ARF Type 1 sec to HAP
Hepatocellular carcinoma with probable metastasis
CLD sec to ALD (Child Pugh C, MELD 19)
Gallstone pancreatitis, BISAP 1
Type 2 DM
Non covid