Gastroenterology Expert Witness Discusses Hepatocellular Carcinoma

This case involves a forty-five-year-old female who was referred to a gastroenterologist with right upper quadrant abdominal pain and fatigue. Her past medical history included hepatitis B, diabetes mellitus, and twenty years of smoking. She could only speak Spanish and understood English poorly. She first contracted hepatitis fifteen years prior to the incident in question, but medical records did not show how she was treated. The physician believed that the woman’s hepatitis infection had reactivated and he treated her with an antiviral. Blood work was done, but the woman was never contacted with the results. She was given a sheet to have a CT scan but translation services were never used to communicate this information. Additionally, she was never scheduled for a follow-up appointment. Six months later, she went to the emergency room because she experienced bloating, diffuse bruising, weight loss, abdominal pain, and yellowing of her skin and eyes. A CT scan of the abdomen revealed a large mass on the liver. Laboratory testing showed that she had markedly elevated alpha-fetoprotein levels. The lesion was later biopsied and diagnosed to be stage III hepatocellular carcinoma, a form of liver cancer. She underwent a left hepatic lobectomy. She was placed on an organ transplant list but died before she received a liver.

Question(s) For Expert Witness

1. Did this physician practice the standard of care when caring for this patient, and, if not, what would be the proper measures to treat this woman?

Expert Witness Response

This physician did not further investigate the possibility of hepatocellular carcinoma in a patient with chronic hepatitis. Hepatitis (B and C) infection is a major risk factor for the development of hepatocellular carcinoma. Given her symptoms and past medical history of hepatitis, the gastroenterologist should have ruled out liver cancer. Symptoms of liver cancer include jaundice, bloating due to ascites, nausea, vomiting, loss of appetite, weight loss, fatigue, abdominal pain, and bruising due to clotting abnormalities. Additionally, this woman was a non-English speaking patient. The physician failed to ensure that his patient understood the information he presented to her. He never confirmed whether she scheduled a follow-up appointment or went for a CT scan. Other risk factors include alcoholism, exposure to aflatoxin, cirrhosis, hemochromatosis, and Wilson’s disease. The gastroenterologist should have also ordered an alpha fetoprotein level. Alpha fetoprotein is a tumor marker that is elevated in patients with hepatocellular carcinoma. The physician may have ordered this during lab work but he did not communicate the results to this woman. A combination of missing the diagnosis and poorly communicating in this case resulted in the rapid mortality of this patient.