Viral Hepatitis — Clinical Case

DCE Long Case

Patient brief (provided to trainee)

Patient: Mr Minh Nguyen, 54 years old.

Presenting complaint: Referred to hepatology clinic after a surveillance liver ultrasound showed a 2.2 cm nodule in the right hepatic lobe. He feels well. ^[2]

Past history:

• Chronic hepatitis B, diagnosed at age 25 on screening before migration. Never treated; he was told his liver tests were normal at the time and was lost to follow-up.
• Type 2 diabetes, obesity and hypertension. ^[1]

Current medications: Metformin and an ACE inhibitor. No antiviral therapy. ^[1]

Examination findings (trainee elicits):

• Thin and comfortable. Several spider naevi over the upper chest. Palmar erythema.
• Spleen palpable. Liver edge firm and irregular. No ascites. ^[4]

Investigations:

• HBsAg positive, anti-HBs negative, anti-HBc positive, HBeAg negative, anti-HBe positive, HBV DNA 45,000 IU/mL. Anti-HDV negative.
• ALT 118 U/L, platelets 110 ×10⁹/L, INR 1.2, albumin 36 g/L, bilirubin 22 micromol/L.
• Transient elastography 18 kPa.
• Multiphase CT: the 2.2 cm nodule shows arterial phase hyperenhancement and washout. ^{[1] [2]}

Candidate's structured presentation (model)

"Mr Nguyen is a 54-year-old Vietnamese-born man referred after a surveillance ultrasound found a liver nodule. He has untreated chronic hepatitis B, type 2 diabetes and obesity. My problems are a probable hepatocellular carcinoma, HBeAg-negative immune-active hepatitis B, and probable compensated cirrhosis."

Interpretation:

1. The nodule. AASLD supports LI-RADS, which grades nodules from LR-1 (benign) to LR-5 (HCC). For nodules of 2 cm or more, arterial phase hyperenhancement plus one additional feature (washout, enhancing capsule or threshold growth) is enough for an HCC diagnosis. For nodules of 10 to 19 mm, APHE plus either washout or threshold growth is required, or APHE plus two major criteria. ^[2]
2. The hepatitis B. ALT of 118 U/L is more than twice AASLD's 35 U/L upper limit for men, and HBV DNA of 45,000 IU/mL is above the 2,000 IU/mL HBeAg-negative threshold, so this is immune-active disease. ^[1]
3. The liver. AASLD-IDSA counts elastography above 12.5 kPa or a platelet count below 150,000 as evidence of cirrhosis. ^[6]

Management plan:

1. HCC: discuss at a multidisciplinary meeting. AASLD describes the Milan criteria (one lesion of 1 to 5 cm, or two to three lesions of 1 to 3 cm) as the standard for selecting transplant candidates. Liver transplantation cures both the HCC and the underlying liver disease, with a median survival of 10 years. Its 5-year recurrence is about 10 percent, against 50 to 60 percent after resection or ablation. ^[2]
2. Antiviral therapy: therapy is recommended for immune-active disease with cirrhosis if HBV DNA is above 2,000 IU/mL, regardless of ALT. Use a preferred agent (entecavir, TDF or TAF). ^[1]
3. Ongoing surveillance: antiviral therapy does not eliminate HCC risk. HBsAg-positive patients with cirrhosis need ultrasound, with or without AFP, every 6 months. ^[1]
4. Family: household members and sexual partners should be vaccinated if they test negative for HBV serologic markers. ^[1]

Examiner discussion questions

Q: "Do you need a biopsy?"

"AASLD supports the LI-RADS algorithm, and arterial phase hyperenhancement with delayed washout are the features most strongly associated with HCC. For a nodule of 2 cm or more, APHE plus washout meets the LI-RADS criteria for an HCC diagnosis." ^[2]

Q: "Where do the Milan criteria come from?"

"Mazzaferro transplanted 48 patients with cirrhosis and small unresectable HCC. The eligibility criteria were a single tumour of 5 cm or less, or no more than three nodules each 3 cm or less. In the 35 patients whose explants met these criteria, overall and recurrence-free survival at four years were 85 and 92 percent, against 50 and 59 percent in the 13 whose tumours exceeded them." ^[3]

Q: "He was never treated. Was that right at the time?"

"If he was immune-tolerant then, AASLD recommends against treatment but suggests ALT testing at least every 6 months to detect transition to immune-active or inactive disease. Being lost to follow-up meant that transition went unmonitored. He now meets the immune-active definition." ^[1]

Q: "Does his diabetes and obesity matter?"

"AASLD warns that ALT elevation may come from causes other than hepatitis B, including fatty liver, drug-induced liver injury and alcohol-associated liver disease, so these need assessment alongside the HBV." ^[1]