Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.
A 57-year-old African American male (AAM) with a past medical history (PMH) of hepatitis C, alcohol (EtOH) abuse, and hypertension (HTN) is referred to the GI clinic because of elevated liver function tests (LFTs). He has no complaints.
Past medical history (PMH)
Intravenous drug abuse (IVDA) with heroin and cocaine abuse 3o years ago, hepatitis C, heavy alcohol abuse, HTN. Rectal bleeding for 2 months - a colonoscopy showed 9 benign polyps (one tubular adenoma and 8 hyperplastic polyps).
Tenormin (atenolol), lisinopril.
Social history (SH)
Drug abuse as described above. He told his PCP that he is "in remission" from alcohol. On closer questioning, the patient admitted to long term alcohol abuse in binging sprees, drinking 3-5 bottles of wine whenever he can afford it. The last binge was just 2 weeks ago. He finances his EtOH abuse with the money he is receives for disability because of his liver disease.
WD/WN in NAD.
No signs of chronic liver disease.
HEENT: no teeth (lost in brawls as per patient).
The rest of the examination was normal.
What is your diagnosis?
Hepatitis and alcohol abuse.
What laboratory work-up would you order?
CBC, CMP, AFP.
Liver ultrasound (U/S).
What about hepatitis C genotype?
The treatment response in hepatitis C depends on the genotype. The response in HCV type 1 is only 40% with interferon (INF) plus ribavirin for 12 months. HCV type 2 and 3 have a better response rate of 80% after 60 months.
Our patient's genotype was 1a.
CMP, hepatitis profile (left). Hepatitis C viral load and genotype (right) (click to enlarge the images).
The patient already had laboratory work several months ago that showed elevated LFTs. His HDL level it is high because of EtOH abuse. AFP is 6.2.
Would you recommend antiviral treatment with INF and ribavirin?
No. EtOH abuse is a contraindication to the antiviral treatment of hepatitis C.
The patient was referred to a drug abuse counseling center and a follow-up (F/U) appointment was made in 1 month to monitor the progress. Liver U/S and repeat LFT were ordered.
All patients with chronic hepatitis C need AFP and liver U/S every 6 months to screen for hepatocellular CA.
What did we learn from this case?
Take a careful history of drug abuse. You cannot treat hepatitis C patients if the patient is still drinking heavily. EtOH abuse has a detrimental effect on hepatitis C liver disease (interestingly, this is not typically the case with hepatitis B).
Even if you decide to treat this patient, his chance of response would be virtually zero because of the genotype and EtOH abuse. The studies show that African American patients also have a lower response rate. In conclusion, we should first help this patient stop drinking before treating his hepatitis C.
Management of Hepatitis C: Evaluating Suitability for Drug Therapy. AFP, 3/2004.