HEPATOMA

Definition Liver carcinoma is the malignancy of liver which formed a big, solitaier formation or multiple focus in the whole part of liver. It can be sourced from parenchyme, epithel of billiary duct and masenchyme tissues. Hepatoma is sourced from the liver tissue it self. . Etiology The caused of Hepatoma exactly was unknown, but there are predisposition factors that caused Hepatoma : Hepatitis virus type !irrhosis of the liver "flatoxin Infection of clonorchiasis and schistosomiasis Herediter

Clinical Feature Hepatoma sometimes could cause abdominal pain along with an abdominal mass fluid #called ascites$ and %aundice #yellow skin color$ are other sign of Hepatomas. "s the disease progresses , weakness, loss appetite, weight loss, and fati&ue can occur. 'nfortunately, many Hepatomas are detected late in the course. (arly detection provides the best hope for cure.
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Examination (nlargement of liver # hepatomegaly$. The consistent is firm, blunt edge, nodular surface and pain pressure. *clera is icteric "scitic fluid " fluid thrill, arterial murmur or hepatic bruit +yspnoe Looked kakhecties and weakness ,almar erytema 'rine is deeply pigmented #looks like dark tea$.

Diagnosis Hepatomas are difficult to diagnose because they don-t present with many symptoms early on.To diagnose Hepatoma can use invasive as well as non invasive diagnostic test. Invasive diagnostics are angiography, liver biopsy, laparascopy, and laparatomy. .on invasive diagnostics are physical examination, '*/, !T scan, and laboratory examination such as liver function test # */0T, */,T, alkali phospatase and certain blood test #"1,$.

Treatment If untreated, patient with Hepatoma have a rapid downhill course. *urgery offers the best chance for cure, but most patients are not surgical candidates because of underlying liver cirrhosis or because the tumor has spread to other
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parts of the body. If the tumor has not spread and the remaining liver has good function, the next most important predictor if the tumor will recur after surgery or not is the si3e of the tumor. Tumor greater than 4 cm in si3e have a higher rate of recurrence than those that are less than 4 cm. !hemotherapy and radiotherapy have small roles to play in the cure of Hepatoma. !hemotherapy drugs that can be used such as 4 1' and "driamicyn i.v. These drugs result in shrinkage of the cancer in up to 56 7 of patient and are associated with side effects, such as temporary hair loss, nausea and vomiting, lowering white blood counts, and lethargy. Hormonal treatment is an experimental option in certain centres.

Prognosis The extent of the Hepatoma presence of prior liver damage from hepatitis or alcohol exposure, and operability of the cancer determines survival of a patient with Hepatoma. If curative surgery is possible, the chance of surviving 4 years can be as high as 89 7.

CASE REPORT
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" 5) years old man was admitted to Internal :edicine +epartment of /eneral Hospital +r. "chmad :ochtar ukittinggi on .ovember 4th ,2662 with :

Main Complaint : ;aist pain since 2 months ago.

Present llness History ;aist pain since 2 months ago, pain has been felt uncontinue .ausea #<$, =omiting #>$, and felt abdomen was full reathlessness #<$ *wollen legs since 2 days ago "ppetite decreased since 2 month ago, body weight decrease progressivly since 2 month ago :ixturation : urine looks like dark tea since ) month ago, no history of bloody mixturatoin, no history of stony mixturation ody felt too tired and weakness +efecation : once in 2 days consistention firm, colour : yellow He was hospitali3e at surgery medicine departement for one month and refered to internal medicine departement

Pre!ious llness History .o history of yellow disease

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Family llness "istory .one of the family members had suffered from the yellow disease before

Social# Economic# an$ Occupational %ac&groun$ Truck driver

PH'S CA( E)AM *AT O* +ital Sign /eneral appearance !onciousness lood pressure ,ulse rate Bespiratory rate ody temperature .utritional : severe ill : composmentis cooperative : )56?@6 mmHg : A6x?min : 29x?min : 59,C6 ! : 'nderweight

Hea$ : (ye (ars and nose :outh : con%unctiva is anemic and sclera is icteric : normal : caries #<$
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*ec& : D=, Begional lymph node Thyroid gland : 4>2 cmH20 : no enlargement : no enlargement

C"est (ung : Heart : Inspection : ictus was not visible ,alpation : ictus was palpable at ) finger medial of the left Inspection ,alpation : simetric movement : fremitus on the right side E the left side

,ercussion : Left and right is sonor "uscultation : vesiculer normal, rales #>$, whee3ing #>$

midclavicula line at = I!* ,ercussion : Left border at ) finger medial of the left midclavicula line at = I!* Bight border at right sternal line 'pper border at II I!* "uscultation: regular rhythm, :)F:2, ,2G"2

A%$omen Inspection : .o enlargment, !ollateral #>$. ,alpation :

Liver was palpable 8 fingers below costarum arch, the consistent was firm, nodular surface #>$ , blunt edge and pain pressure. *pleen was palpable *2, Hidney : was not palpable, allotement #>$. ,ac& : ,ressure pain :urphy angle #<$, hammer pain !=" #<$ ,ercussion : tympani, acites #>$ "uscultation : peristaltic sound was normal.

Anal an$ genitalia : It didn-t be examined. Extremity : 1lapping tremor #>$ ,almar erytema #>$ ,hysiological reflex <?< ,athological reflex >?>

(a%oratory Fin$ing ,loo$ : >Boutine : Hb *B +! : @,2 g7 : 22?hour : 6?2?)2?9)?2)?8

@

Leucocyte : 22.866?mm5

>*pecific : Total protein : 4,52 g?dl "lb : 2,6) /lob : 5,5) Total ilirubin : @,24 mg?dl +irect : 5,29 Indirect : 5,CC "lkali phospatase : 4)C '?I 'reum !reatinin */0T */,T -rine : !olor ,rotein Beduction ilirubin 'robilin >I=, > '*/ : dark tea : #>$ : #>$ : #<$ : #<$ : Left kidney is normal, right nephrolithiasis with disfunctional kidney. : "scites with hepatomegaly and noduler texture ++? cirrhosis hepatis, hepatoma, right nephrolithiasis with chronic process > !T>scan : Hepatoma, right nephrolithiasis : 45C mg 7 : ),C mg7 : 4C '?l : 86 '?l

.or&ing Diagnosis : Hepatoma, right nephrolithiasis Differential Diagnosis : !irrhosis of the liver post necrotic compesated stadium
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Treatment : / ed rest?liver diet II >+uphalac 5x ! > ) 5x) >1urosemid )x) Suggest Examination : > Boutine blood and urine test > Hepatitis marker > iopsy of the liver FO((O. -P *o! 0t" # 1221 S3 : waist pain #<$ 1elt tired and weakness felt abdomen was full urine like dark tea O3 : /" *evere L! cmc , )56?C6 ,B A6x?m BB 26x?m T 59,A6 >!urcuma 5x) > comp 5x) >*1 5x) >H!L 5x) >"moxicilin 5x)

Internal status same as before ;+? Hepatoma, right nephrolithiasis Thy? continued *uggest ,B! Tranfusion *o!4t"# 1221 S3 : waist pain #<$ felt tired and weakness felt abdomen was full urine like dark tea nausea and vomiting #<$ O3 : /" L! , ,B
C

BB

*evere

cmc

)26?C6

C9x?m 52x?m

59,A6

Internal status same as before ;+? Hepatoma, right nephrolithiasis Thy? continued

*o! 5t"# 1221 S3 O3 : no new complaint : /" *evere L! cmc , )56?96 ,B BB T 59,A6 C6x?m 56x?m

Internal status same as before ;+? Hepatoma, right nephrolithiasis Thy? continued *o! 6t"# 1221 S3 O3 : no new complaint : /" *evere L! cmc , ,B BB 28x?m T 59,96 ))6?A6 ACx?m

Internal status same as before ;+? Hepatoma, right nephrolithiasis Thy? continued *o! 77st# 1221 S3 O3 : no new complaint : /" *evere L! cmc , ))6?@6 ,B A8x?m BB T 28x?m 59,96

Internal status same as before ;+? Hepatoma, right nephrolitiasis Thy? continued
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D SC-SS O* The diagnosis on this case based on anamnesis, physical examination, and laboratory findings. ;e diagnosis as a Hepatoma because from anamnesis we found that the patient complaint are felt abdomen was full, yellowish eyes followed by urine looks like dark tea, body felt tired and wekness, loss of appetite, loss of weight and fati&ue. 1rom physical examination, we found icteric sclera, enlargement of liver # hepatomegaly$ which palpable 8 fingers below costarum arch, the consistency was firm, blunt edge, pain pressure. ;hile from laboratory findings, we found that urine looks like dark tea, bilirubin #<$, total protein 4,52 gr?dl, albumin 2,6) gr?dl, globulin 5,5) gr?dl, total bilirubin @,24 mg?dl, direct bilirubin 5,29 mg?dl, indirect bilirubin 5,CC mg?dl, alkali phosphatase 4)C '?l, */0T 4C '?l, */,T 86 '?l. These facts support the diagnosis was hepatoma and it was strengthen by '*/, !T>scan examination that result the same. ;e diagnosis as a right nephrolithiasis from anamnesis we found that patient complaints are waist pain, pain has been felt uncontinue, nausea and vomiting, and he was hospitali3ed at surgery medicine department as right nephrolithiasis. 1rom physical examination , we found pressure pain :urphy angle #<$, hammer pain !=" #<$. ;hile from laboratory we found ureum 45C mg7, creatinin ),C mg7. 1rom I=,, '*/ and !T>scan we found that there is right nephrolithiasis.
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Ig cause of heart disease, but also the presipitating causes of it. !linical manifestation of heart failure appear of the first time in course of some acute disturbance that place additional load on myocardium that chronically is excessive burdened. The presipitating caused are: ). Infection 2. "nemia 5. Thyrotoxicosis and pregnancy 8. "rythmias 4. Bheumatic and other forms of myocarditis 9. Infective endocarditis @. ,hysical,dietary, fluid, environmental,and emotional excesses A. *istemic hypertension C. :yocardial infarction )6. ,ulmonary embolism
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Pat"op"ysiology (arly in the various heart diseases, the conpensatory mechanism are ade&uate to maintain a normal cardiac output and normal intracardiac pressure at rest and after exercise. Hypertrophy may be recogni3ed by physical examination ,electrocardiography, or echocardiography, and when ventricular dilatation occurs, cardiac enlargement can be seen on the plain chest film. !ompensated heart disease becomes JdecompensatedK as ventricular volume and filling pressures of the respective ventricle increases. This is known as diastolic dysfunction and can be the primary cause of increased left ventricular filling pressure and pulmonary congestive heart failure. +iastolic dysfunction is particularly common in elderly patients with hypertention and in patients with myocardial ischaemia due to the coronary heart disease. "s the filling pressure increases, hydrostatic pressure exceeds colloid osmotic pressure at the capillary level, and pulmonary venous congestion occurs. ;hen the limphatics can no longer ade&uately remove the excess fluid, interstitial and then alveolar edema of the lung occurs, resulting in symptoms nocturnal dyspnea, and ventricle. Clinical Fin$ings a. Left sided heart failure +yspnea 0rthopnea ,aroxysmal nocturnal dyspnea "cute pulmonary edema 1atigue, weakness, faintness .octuria
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of left

ventricular failure with dyspnea, exertional cough, orthopnea, paroxysmal pulmonary edema,. Baised venous pressure, hepatomegaly, dependent edema, and ascites occur when failure involves the right

!ough ,alpitation (nlargement of heart Bales or crackles !heyne>*toke respiration Tachycardia

b. Bight sided heart failure 1atigue Liver enlargement "norexia and bloating Bight ventricular hypertrophy !hronic pulmonary sign +istended neck veins ,itting edema "scites *igns of pleural effusion

Diagnosis : +iagnosis is made based on 8 main components : ). 1unctional diagnosis based on .ew Lork Heart "ssociation !lassification of +ysfunctional and +eficite Tolerance in ,hysical "ctivity. /rade I /rade II /rade III /rade I= L=H B=H
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: 'nlimited physical activity daily without cmplaints. : :inimally limited physical activity?light activity : =ery limited physical activity?light activity : "t rest with daily complaints.

2. "natomical diagnosis -

5. (tiological diagnosis "rteriosclerotic heart disease Bheumatic disease Hypertension "nemia *inus rhytm Tacycardy radycardy

8. +ysrytmic diagnosis Treatment The principle of heart treatment can be state as follow ). removal of the precipitating causes 2. correction of the underlying causes 5. control of congestion heart failure reduction of cardiac burden by reducing physical activity and after loads control of excessive salt and water retention by diet, diuretics, and vasodilator theraphy. (nhancement of cardia contractility.

Prognosis : +epens primarily on the nature of the underlying cause, presence or absence of precipitating factors, which can be treated. In the later situation, survival rate usually ranges between 9 mounths to 4 years depending on the severity of the heart failure. CASE REPORT " male patient aged @4 years old was admitted to Internal :edicine +epartment of /eneral Hospital +r. "hmad :uchtar 2662 with:
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ukittinggi on Dune 69 th,

C"ief complain: reathless since 2 month ago. Present illness "istory: reathless since 2 month ago, increased since 2 day before admitted. reathless increased while he lied on the back, was walking and doing some daily activity, and decreased when he got rest, not influenced by wheather and food. He likes to sleep with 2 or 5 pillows under the head. He suffered pain knee and swollen since A month ago. ,ainless is continous. ,ale, tired, weak, and di33iness since ) years ago, and admitted at B*": ukittinggi twice and he got blood transfusion 8 bags amounth. > His extrimity was swollen since 2 week ago. .o blood out from mounth and nose. "ppetite decrease since illness. .ause is negative and vomit is negative. :ixturation and defecation were normal

Pre!ious illness "istory: / Familial llness History: .one of the family members had disease like this. P"ysical Examination : +ital Sign: > /eneral appearance > level of consciousness > blood pressure > pulse rate > respiratory > temperature S&in: > cyanotsis : #>$
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: severe illness : composmentis cooperative : 226?)86 mmHg : A6 x?menit : 94 x?menit : 5@ 6!

> pale > icteric Hea$: *ec&: -

: #<$ : #>$

> palpable temperature: afebris (ymp" no$e : no enlargement (ye: con%ungtiva anemic, non icteric sclera (ars, nose, and teeth : no disturbance, mouth : pale ,harinx: no disturbance D=, : 4 < 8 cmH20

.o enlargement of lymph nodes and thyroid gland Tonsil : no enlargement *hape: .ormochest : symmetric movement and rapid breathing 1re&uency 94 x?minute

C"est : (ungs: Inspection thoracoabdominal ,alpation ,ercussion "uscultation Heart: Inspection ,alpation : ictus was visible one finger lateral of the left midclavicula line of the =I Inter !ostal *pace, : ictus was palpable one finger lateral of the left midclavicula line of the =I Inter !ostal *pace, with strong pulsation and 2 fingers wide. ,ercussion : left border was one finger medial of the left midclavicula line of the =I Inter !ostal *pace. Bight border was L*+.
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: fremitus right and left were the same : sonor right and left : normal vesiculer, ronkhi #>$, whee3ing #>$

'pper border was Inter !ostal *pace II. "uscultation A%$omen: Inspection ,alpation : undistended abdomen : liver and *pleen was not palpable. allotement #>$ ,ercussion "uscultation ,ac&: Inspection simetric, no decubitus, and no pressure pain and hammer pain. Extrimity: > physiological reflex : <?< normal > patologycal reflex > swollen extrimity > tremor > sianotic fingers (a%oratory Fin$ing 8(F9 lood : Hb Leucocyte 'reum Hreatinin : A,9 gr7 : )6.C66?mm5 : )5C,@ mg?dl : C8 mg?dl : >?> normal : #<$ : #>$ : #>$ : timpany, shifting dullness #>$ : peristaltic sound was normal : Beguller rhythm, 1re&uency A6x?minute, :)F:2, ,2F"2, sistolic and diastolic murmur#>$, gallop #>$.

'rine : Himia : Hwalitatif : ,rotein #<<$ Beduksi #>$ *edimen : *ilinder : Hialin #>$ /ranuler #>$ (ritrosit?leukosit #>$ (pitel #>$ !rystal #>$
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0val fat bodies #>$ .or&ing Diagnosis: Heart failure left and right, B=H > L=H, 1unctional class I= ec. "nemia and Hypertensi /rade I=. Differential Diagnosis : Heart failure left and right, B=H > L=H, 1unctional class I= ec. "*H+. T"erapy: edrest. Low salt II and Heart II diet I=1+ + 47 )2 hour ? klof Lasic )x ) amp. I= Tonar 5x) "sepres 2x) ,renomia )x) mexpharm )x)

Planning examination: blood, urine and feces rutine examination rontgen thorax, (!/ Lipid profile, ureum and kreatinin serum */0T, */,T !omplete blood investigation #.a, H, "lb, /lob $

FO((O. -P :une 24t" 1221 "?: > breathless #<$ > pale #<$ > swollen extrimity #<$
)C

,(?:>

/" *evere

L! !:!

, 256?)86mmHg

,B A6x?i

BB 96x?i

T 5@,86 !

.eck: D=, 4<8 cmH26 Heart: Inspection ,alpation : ictus was visible one finger lateral of the left midclavicula line of the =I Inter !ostal *pace, : ictus was palpable one finger lateral of the left midclavicula line of the =I Inter !ostal *pace, with strong pulsation and 2 fingers wide. ,ercussion : left border was one finger medial of the left midclavicula line of the =I Inter !ostal *pace. Bight border was L*+. 'pper border was Inter !ostal *pace II. "uscultation : Beguller rhythm, 1re&uency A6x?minute, :)F:2, ,2F"2, sistolic and diastolic murmur#>$, gallop #>$. Bight border was L*+. 'pper border was Inter !ostal *pace II. (xtremity : swollen #<$ ;orking +iagnosis: Heart failure left and right, B=H > L=H, 1unctional class I= ec. "nemia and Hypertensi /rade I=. +ifferential +iagnosis : Heart failure left and right, B=H > L=H, 1unctional class I= ec. "*H+. Therapy: continue :une 5t" 1221 "?: > breathless #<$ > pale #<$ > swollen extrimity #<$
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> sleepless ,(?:> /" *evere L! !:! , 246?)54mmHg ,B A8x?i BB 92x?i T 5@,26 !

.eck: D=, 4<8 cmH26 Heart: Inspection ,alpation : ictus was visible one finger lateral of the left midclavicula line of the =I Inter !ostal *pace, : ictus was palpable one finger lateral of the left midclavicula line of the =I Inter !ostal *pace, with strong pulsation and 2 fingers wide.

,ercussion

: left border was one finger medial of the left midclavicula line of the =I Inter !ostal *pace. Bight border was L*+. 'pper border was Inter !ostal *pace II.

"uscultation

: Beguller rhythm, 1re&uency A6x?minute, :)F:2, ,2F"2, sistolic and diastolic murmur#>$, gallop #>$. Bight border was L*+. 'pper border was Inter !ostal *pace II.

(xtremity : swollen #<$ ;orking +iagnosis: Heart failure left and right, B=H > L=H, 1unctional class I= ec. "nemia and Hypertensi /rade I=. Th?: continued

2)

D SC-SS O* ;e diagnosed this patient as Heart failure left and right, B=H > L=H, 1unctional class I= ec. "nemia and Hypertensi /rade I= : "namnesis : reathless since 2 month ago, increased since 2 day before admitted. reathless increased while he lied on the back, was walking and doing some daily activity, and decreased when he got rest, not influenced by wheather and food. He likes to sleep with 2 or 5 pillows under the head. He suffered pain knee and swollen since A month ago. ,ainless is continous. ,ale, tired, weak, and di33iness since ) years ago, and admitted at B*": ukittinggi twice and he got blood transfusion 8 bags amounth. His extrimity was swollen since 2 week ago. "ppetite decrease since illness.

,hysical examination: (ye : con%unctiva anemic, non sclera icteric D=, was 4<8 cmH20 respiratory rate 94x?menit, pulse rate A6 x?menit, blood presure 226?)86mmHg

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Heart: Inspection ,alpation : ictus was visible one finger lateral of the left midclavicula line of the =I Inter !ostal *pace, : ictus was palpable one finger lateral of the left midclavicula line of the =I Inter !ostal *pace, with strong pulsation and 2 fingers wide. ,ercussion : left border was one finger medial of the left midclavicula line of the =I Inter !ostal *pace. Bight border was L*+. 'pper border was Inter !ostal *pace II. "uscultation : Beguller rhythm, 1re&uency A6x?minute, :)F:2, ,2F"2, sistolic and diastolic murmur#>$, gallop #>$. Bight border was L*+. 'pper border was Inter !ostal *pace II. (xtremity : swollen #<$ Lab. 1inding : Hb Leucocyte 'reum Hreatinin : A,9 gr7 : )6.C66?mm5 : )5C,@ mg?dl : C8 mg?dl

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