An alcoholic presented with ascites, bloody tap and elevated alfa fetoprotien. The diagnosis is
Correct Answer: Hepatocellular Carcinoma
Description: (B) Hepatocellular Carcinoma # Hepatocellular carcinoma (HCC) is a primary malignancy of the hepatocyte, generally leading to death within 6-20 months. HCC frequently arises in the setting of cirrhosis, appearing 20-30 years following the initial insult to the liver.> 25% of patients have no history or risk factors for the development of cirrhosis.> Extent of hepatic dysfunction limits treatment options, and as many patients die of liver failure as from tumor progression.# Causes:> Cirrhosis: In general, cirrhosis of any etiology is the major risk factor for HCC.> Major causes of cirrhosis are attributed to alcohol, hepatitis C infection, and hepatitis B infection.# Alcohol> The risk of HCC is greater once the patient stops drinking alcohol, because heavy drinkers do not survive long enough to develop cancer.# Hepatitis B virus> Global incidence of chronic HBV infection is estimated to be 350 million persons; chronic HBV infection is the most common cause of HCC worldwide. In the United States, about 20% of HCC cases are thought to be related to chronic hepatitis B infection.> Chronic infection in the setting of cirrhosis increases the risk of HCC 1000-fold.> The mechanism by which the hepatitis B virus causes HCC is thought to be from a combination of chronic inflammation and integration of the viral genome into the host DNA.# Hepatitis C virus> HCV is a global pandemic affecting 170 million persons. HCV infection results in a higher rate of chronic infection compared to HBV infection (approximately 80% of infected subjects).> Co-infection with HBV further increases the risk; many patients are co-infected with both viruses. Alcohol use in the setting of chronic HCV doubles the risk of HCC compared with HCV infection alone.> Recent studies suggest that antiviral treatment of chronic HCV infections may reduce the risk of HCC significantly.# Hemochromatosis:> Patients with hemochromatosis, especially in the presence of cirrhosis, are at an increased risk of developing HCC. HCC accounts for about 30% of all iron-related deaths in hemochromatosis.# Aflatoxin:> This hepatic carcinogen is a by-product of fungal contamination of foodstuffs in sub-Saharan Africa and East and Southeast Asia. It causes DNA damage and mutations of the p53 gene. Humans are exposed to aflatoxin through the ingestion of moldy foods found in susceptible grains.# Lab Studies:> Expect total bilirubin, aspartate aminotransferase (AST), alkaline phosphatase, albumin, and prothrombin time to show results consistent with cirrhosis.# Alpha-fetoprotein (AFP) is elevated in 75% of cases.> The level of elevation correlates inversely with prognosis> An elevation of greater than 400 ng/mL predicts for HCC with specificity greater than 95%. In the setting of a growing mass, cirrhosis, and the absence of acute hepatitis, many centers use a level greater than 1000 ng/mL as presumptive evidence of HCC (without biopsy).
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