A 49 yr old male with cholelithiasis and HBeAg-negative chronic Hep B

August 18, 2022

NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

PATIENT HISTORY: Pt is a 49 yr old male, practicing as a rural physician in his village. He started practicing in 2001.

He suffered from infantile jaundice

Between ages 11 to 16 yrs, he used to c/o epigastric pain, vomiting, and bloatedness. It would resolve with medications. The symptoms would resolve for 15 days to 1 month and then again reappear, finally completely resolving at the age of 16 yrs with medications.

While preparing for his BA final exams, one day he c/o severe epigastric pain (pt claimed possible etiology can be due to him eating rice which was hard and not boiled properly and saag; his pain decreased after he vomited) along with light fever which resolved with medication. Dr. diagnosed his symptoms to be due to gastric issues. Prescribed him medications and also advised him to eat light food for 2-3 months, which resolved his symptoms.

In 2005, got married. For 3-4 yrs had no child even after having unprotected sex. In 2010, while doing various tests it was found that he is HbsAg reactive. Dr. suggested doing a retest from another diagnostic center to reconfirm it which he did not do, thinking he has no possibility of contracting HBV and the report is wrong. Sought no further treatment for the same.

[SIDE STORY: Later it was found that his wife is infertile so finally adopted a baby.]

In 2017, he donated blood to 2 of his relatives, but the hospital did not say to him whether his blood tested positive for HBsAg or not. In 2020, one of his relatives got pregnant. Her Hb was very low hence needed to transfuse blood. Pt. volunteered to donate blood. After donating blood, 15 days later he was called back by the hospital and told him his blood is HbsAg reactive. Dr. told him to routinely do HbsAg testing and report. No medicine was prescribed. In 2022 June, his report came to be -ve HBV DNA and HBeAg nonreactive. One month later, his report came to be negative for Hbe Ag and positive for anti-Hbe and HBV DNA was 48616 IU/mL. His ALT level was 56U/L. Dr. referred him to a Gastroenterologist, who told him to do USG, CT, CBP, and MRI. Detected Type 4a choledochal cyst with choledocholithiasis (incidental finding; he did not c/o any kind of pain or symptoms for the same) and F4 liver fibrosis. Sx was recommended and referred to Hyd. In Hyd. he was told since his HBV DNA lvl is 48616 IU/ml so Sx needs to be postponed. Pt. on medication for last 2 months: Tab. Durataf 25 mg (tenofovir alafenamide) and Usibon 300.(Ursodeoxycholic Acid) Pt. was referred to Hyd for further treatment.

On inquiry, pt claims that he does small operations and there had been occasions where he had done operations without gloves and there had been direct contact with body fluids. Also, there had been incidents of needle prick injury. Could explain possibly how he contracted HBV.

He started alcohol consumption in 1992 due to peer pressure while at work far away from home. Used to drink 300ml 2-3 times /wk and continued till 1999. After returning back to home, he consumes alcohol occasionally 200-300 ml 3-4 times/yr. After marriage in 2005, once in a yr and finally stopped in 2014 due to family pressure.

He started smoking cigarettes in 1992 due to peer pressure (4-5/day). Now, 1-2/day.

He started oral tobacco consumption in 1999, after returning home due to a new group of friends. Consumes 4-5 gms/day. He admits he is addicted to it.

His BP is normal and he is nondiabetic.

CURRENT CHIEF PROBLEMS AND PATIENT'S REQ.: Pt. wants further consultation to decide the best course of treatment and also explains his financial difficulties.

FAMILY HISTORY: No one in his family reported Hepatitis and his parents have no health issues as reported him.

REPORT:

13.6.22