A 49-year old male complaints of digestive tract disorders. He reports to experience loss of appetite (Jarvis, p.21-2), a rather non-specific complaint. Loss of appetite, however, in combination with other complaints and data from his history point to possible liver disorders. Loss of appetite also suggests malnutrition. Thus, his next complaint of fatigue is not unexpected. Nutrition is a typical subjective pattern in abdominal management (Jarvis, p.21-2).
The patient’s history includes multiple sexual encounters with different partners, the fact that may suggest a high risk of sexually transmitted diseases. Among the latter hepatitis B and C are enlisted. For example, as Buggs et al., (2012) state, hepatitis B virus is sexually transmitted more easily than human immunodeficiency virus. The authors report that “Sexual activity is estimated to account for as many as 50% of HBV cases in the US”. The epidemiology of hepatitis C virus is somewhat different. The same group of authors wrote that 20% of cases of hepatitis C were due to sexual contacts. Nevertheless, it is evident that the patient’s history is strongly supportive towards the suspicion of diseased liver. The complaints of joint pains agree with assumption of viral hepatitis infection. Arthritis is especially specific in hepatitis B infection (Buggs et al., 2012). Multiple blood transfusion that this man had nine years ago point to another possible mechanism of parenteral transmission. Hepatitis B virus is the most important causative agent of blood borne hepatitis in humans (Arora et al., 2005). Historically, hepatitis B used to be a common complication of blood transfusions. The introduction of test systems into blood donors screening approach dramatically reduced the incidence of hepatitis B as compared to the 1970’s (Buggs et al., 2012). Nevertheless, 1 in 250,000 transfusions is thought to transmit the hepatitis B virus. Today, hepatitis C virus is estimated to contaminate 0.01-0.001% of units of transfused blood. The possible infection of hepatitis B often accompanies hepatitis D virus, another infection commonly appearing after blood transfusions (Arora et al., 2005).
The patient mentioned that he loves to eat oysters. Improperly cooked oysters are a known source of foodborne infection, such as hepatitis A. Untreated sewage had been described to be the cause of hepatitis A outbreaks in the US (Fiore, 2004).
This patient’s complaints are suggestive of a disorder of the digestive system. Albeit, non-specific, loss of appetite and fatigue are common in liver diseases. History data, obtained from him strongly suggest a possible infection with hepatitis. The whole history pattern of this man indicates a poor behaviors that increase the risk of hepatitis A, hepatitis B, and hepatitis C infections (Jarvis, p.21-3). However, because the man had risk factors for both foodborne and parenteral infection, it cannot be estimated which kind of infection he actually gained. Moreover, because there were several risk factors for parenteral contamination (multiple sexual partners and history of blood transfusions), it cannot be ruled out at this stage which type of possible bloodborne hepatitis is most possible. Apparently, the many-years history of behavior habits and transfusion relations nine years ago, this is a case of some chronic condition.
In this patient, one may search for other subjective data (Jarvis, p.21-2): food intolerances, a symptom indicating reduced liver capabilities to digest fats and other nutritional components, abdominal pain, especially in the right upper quadrant (Jarvis, p.21-1), which may suggest enlarged liver, past abdominal history, a noteworthy sign for chronic conditions.
This male patient appears to be cachectic. The nutrition state suggests he had been energetically and nutritionally depleted for a long time, the assumption already made on the basis of his history. To confirm the suspicion, it is recommended to calculate the body-mass index or upper arm circumference (Jarvis, Ch. 11). His abdomen is enlarged, a very important sign to be discussed in detail. Enlarged abdomen in liver disease may indicate the presence of excess fluid, called ascites. Ascites may develop in other states, such as cancer or renal failure, but should the hepatic dysfunction be the cause of ascites, it points to advanced stage of disease, again in agreement to the long-standing history of this case. Test for a fluid wave is an essential part of abdominal inspection if ascites is expected (Jarvis, p. 21-3).
Body piercings and tattoos are performed by skin damage, the mechanism that enables hepatitis viruses to enter the bloodstream. These objective findings support the possibility of viral hepatitis.
Physical examination of the abdomen is the mainstay in management a patient with suspected liver disorder. According to Jarvis (Ch. 21) attention should be paid to contour (probably round and enlarged due to ascites), skin (skin veins may be distended in hepatic cirrhosis). Percussion of the liver as soon as performed will reveal hepatomegaly. Spleen may be enlarged in advanced stage of liver diseases. Palpation for the liver supports liver enlargement. Here, the liver can be also characterized as stiff and painful. The left lobe may be noted. Spleen palpation is prominent in advanced stage of disease liver.
Pulmonary status: percussion may reveal pleural effusions, which are sympathetic to ascites.
Cardiac status may state a hyperdynamic state of circulation as seen in portal hypertension due to liver cirrhosis (Carale et al., 2012).
Neroulogical status is expected to be unremarkable. However, it is important to check his reports on alcohol consumption regiment and to check the information from his spouse.
The following investigations are helpful:
- abdominal US to obtain information about liver size, structure and gross abnormalities as well as abdominal fluid
- immunological markers of viral hepatitis to state the infection
- esophagostroduodenoscopy to search for varices
- liver biopsy for a more concrete differential
- liver tests to state the stage of liver dysfunction (Mayo, 2012).