I have chronic hepatitis B - carried for 25 years or more. This means that my immune system and the HepB Virus (HBV) have fought to a standstill - the HBV does not make me seriously ill, and my immune systems keeps it in check but can’t kill it completely. Of course, this means I should not drink, and need to avoid irritating my liver with riotous living. So I am the worlds most boring person <sigh>.
But … for the last 18 months my Liver function has degraded to the point where I got to see a consultant (elevated AST). I saw the registrar - he took my history, poked and prodded my stomach, listened to my abdomen etc, then selected a full bloods workout and informed me that we needed a liver biopsy, but that he suspected I had a fatty liver - fois gras, indeed (well, fois Si - served on toast with a nice Chianti). I half expected this - I have had a weight issue, but am working on it and have lost 15kg so far this year. The registrar then went off to talk to the consultant.
He comes back, and says that another possibility is a mutant HBV strain. Yep - my liver could be a mutant virus factory. Cool. You see, my previous blood work showed no increase in HepB surface antigens, indicating that there was no increasing virus activity to cause the elevated AST. But, HBV is a very poor replicator, and mutates at 10 times the rate of most viruses. And a couple of specific mutations change the surface antigens and are still infectious and capable of replication. This is only an issue in people with chronic HepB - it takes a long time for enough of the mutant viruses to build up to a point where they cause a problem.
So mutant viruses could be in my liver, not showing on the blood test, but causing damage. Or I could be too fat. Or maybe something else - gall bladder problems, perhaps. Too many OTC painkillers. Or the big C - Hepatic cancer. That’s the killer (literally). I have to wait for the liver biopsy. Thats OK, I saw House get one, and it looked no big deal. But that was TV. The registrar points out the risks - punctured lung, punctured gallbladder, punctured artery (apparently they seem to be shooting blind), but the main risk - pain. It’s gonna hurt, and keep on hurting. Gee, thanks. And I have to lie on my side for four hours after the spike. Fun.
Anyhow, mundane and pointless except for Mutant Virii (dibs on the band name)
Wasn’t mentioned, but they added HepC to the panel.
Thanks for feedback - I was hoping for some practical info on biopsies. I’m not too worried, apart from the concern about missing work - I’m a contractor, so if I don’t show up I don’t get paid. And (go figure) the reason I don’t have suitable income insurance cover is the HepB makes me too much of a risk.
I don’t know - I can rewind House if I miss something, and my registrar was unfailing polite. Where’s the fun in that.
It was interesting, though, because I guess I am seeing differential diagnosis in progress. I have elevated AST, indicating liver damage. I have a pre-existing condition - chronic Hep B, with at least 25 years of history (maybe up to 42 years from birth), but low Hep-B antigens. I have a BMI over 30, so am clinically obese, and have been for some years. But I have never had significantly elevated cholesterol.
So the registrar chooses the obvious - fatty liver. The consultant picked on the long term consequences of Hep-B plus the low Hep-B antigens, and chooses HBV mutation (I am still unsure whether it was suggested as pre-core or core promoter - there is no rewind in real life).
Of course (unlike House where risky diagnostic choices are the norm to build dramatic tension) the diagnostic is the same in both cases - more bloods and a needle in the liver.
A different approach than we take here in the states, it seems.
In addition to Hep B antigen, I’d be wanting to know Hep Be antigen and antibody status, Hep B viral load, PT/INR, CBC, platelet counts, bilirubin counts, alphafetoprotein levels, Hepatitis Delta status, and also either an ultrasound or biphasic CT of the liver. Oh, and ALT levels of course. Then chat about biopsy.
But many paths eventually lead to the same (or at least similar) destinations.