Morning Rounds 1

One of my concerns when I decided to take a year off from medical school was that I would forget all my clinical knowledge. After just two days of rounds on the pediatric service at Korle-Bu, I am now assured that I will forget very little and learn a lot.

Pediatric rounds at Korle-Bu differ in several ways from UMDNJ:

1. Since the ward is one giant room, all rounds are bedside. No chance of hallway rounds here (phew)!
2. Since the ward is one giant room, privacy is a concern. The doctors and students talk in hushed voices and I have to crowd in tightly to hear everything!
3. Rounds are quick! No extended conversations, too many patients!

Korle-Bu is a regional referral center for almost all of Sub-Saharan West Africa, so every child on the ward is very very sick, generally with diseases I wasn’t able to see during my pediatric rotation at home. I could go on for hours (or pages) on all the patients I’m seeing. So as part of this blog, I’ll post a case with discussion every few days.

(Disclosure: I’m not directly involved in patient care here, and so the information I post here will be limited. It will also spare identifying details. And I’m a medical student, not a doctor, so please, don’t be too hard on me! If the details are a bit vague, it’s because I wasn’t able to get them. I’m posting random tidbits at the end for any med students reading. See? My blog is like studying!)

CASE 1: Hepatocellular Carcinoma

The patient is a 6-year old boy who was referred for weight loss and yellowing of the eyes. Lab tests showed elevated liver enzymes, and he was diagnosed with hepatocellular carcinoma before I first saw him. He received his first round of (cisplatin/5-flourouracil/doxorubicin) chemotherapy this week.

The boy is emaciated, with temporal wasting and abdominal distension. His eyes are not currently icteric (yellow). He is weak, and still on the inpatient service for febrile neutropenia. It is decided that his next course of chemotherapy will be delayed from 2weeks to 3weeks from now. Blood cultures and a white count are pending.

Hepatocellular carcinoma is a primary malignancy of the liver. It’s usually secondary to either Hepatitis (B or C) or Cirrhosis (usually due to alcohol abuse). It is relatively rare in developed Western countries, and is found more commonly in China and Western Africa. In these regions, chronic hepatitis is usually the culprit.

Hepatitis B is more common in West Africa than in the United States because routine childhood vaccination for the virus did not begin until 2002. This means that our 6-year old patient slipped through the cracks in 2003 as the vaccination was being established. Hepatitis B, when transmitted perinatally, increases the risk of hepatocellular carcinoma significantly, and is correlated with earlier disease onset.

The prognosis for Hepatocellular Carcinoma depends on tumor size/stage/ grade/vascularity, but is poor, estimated at approximately 3-6 months. Surgical resection and liver transplant have generally shown only 50-65% survival rates, and chemotherapy is considered palliative. Interventional radiology or Radiation oncology may offer potential treatments, but these are still in development, and definitely not available in resource-limited settings.

So, through my reading, I discovered that we’re essentially treating this boy palliatively, and he likely won’t survive my stay here in Ghana. This is my first taste of the difficulties of pediatric heme/onc….

Random tidbits from reading:

-In developed countries, patients with no other known risk factors for hepatocellular carcinoma should be screened for acute porphyries, which are risk factors for HCC.

-Aflatoxin infection is also associated with Cirrhosis-linked HCC

-All heme/onc patients at Korle-Bu are screened for HIV.