(Disclaimer: This article is for scientific use only, and the information in the following content has been processed to protect patient privacy) Abstract: In outpatient clinics, we often see patients with slow hepatitis B cirrhosis who are directly diagnosed with hepatocellular carcinoma because of high alpha-fetoprotein and clear imaging support during regular review, but not all patients are so diagnosed with hepatocellular carcinoma during review in clinical practice. AFP) is normal, hepatobiliary and splenic ultrasound shows no occupancy in the liver, alkaline phosphatase (ALP) and glutamyl transpeptidase (GGT) are abnormally elevated, hepatitis B virus has been replicating at a low level and no antiviral treatment has been administered, so don’t ignore the possibility of hepatocellular carcinoma at this time. The patient has a history of hepatitis B for more than 10 years and is currently suffering from early stage cirrhosis, but has not been treated with antiviral therapy. She has not been treated with antiviral therapy. The liver ultrasound of December 2021 was included in her laboratory report, which showed that she had early cirrhosis with no intrahepatic occupancy, and her tumor index was completely normal. The liver function in January showed that alkaline phosphatase was 131U/L and glutamyl transpeptidase was 535U/L. II. Treatment history With such results, many people may think that it is not a big problem, because patients with slow hepatitis B, especially cirrhosis, often have elevated chronic indicators, and we see that the ultrasound is not occupied, but at that time, it still made me very puzzled, because the patient’s current state does not explain well, alkaline phosphatase and glutamyl transpeptidase Why are they significantly elevated? Besides considering tumor, other diseases such as autoimmune liver disease could not be ruled out, so I gave the patient further tests for liver function, immunoglobulin, liver autoantibody profile, and copper blue protein in the outpatient clinic. After the results came back this time, we saw that aspartate aminotransferase was 47 U/L, alkaline phosphatase had dropped from 535 U/L to 218 U/L, and glutamyl transpeptidase was still 131 U/L. This still gave me doubts, so I wanted the patient to have further enhanced imaging, but this patient had very severe skin allergies for the last month, and when he came in we were still able to I gave him a CT scan of the liver without contrast, and found a suspected occupancy on the right side of the diaphragm, 28mm x 35mm in size. The next step was to give him a relatively safe ultrasonography, and the results returned as I feared. The ultrasonography suspected hepatocellular carcinoma, and after consultation and discussion, although it tended to be malignant, it was still not definitive. Currently, all major guidelines point out that the diagnosis of hepatocellular carcinoma must be supported by 2 items of imaging before it can be diagnosed, and this patient’s methemoglobin was completely normal, which made our diagnosis more difficult. Based on the fact that the patient was not allergic to the ultrasonography, I further performed an enhanced MRI on him and finally determined that there was a 3 cm primary hepatocellular carcinoma occupying the S8 segment of the liver, and thus, the diagnosis of this patient was very clear and he was sent to general surgery for radical surgical resection. III. Treatment effect The patient recovered very well after one month of outpatient follow-up. However, since cancer cells have the characteristic of metastasis, regular comprehensive checkups are needed to screen for the occurrence of metastasis, and active interventions once detected can control the progression of the disease and also have a chance of cure. Anti-viral treatment for hepatitis is also needed to improve the body’s immunity and reduce the probability of recurrence. Precautions In clinical practice, most patients develop liver cancer through the three processes of hepatitis B, cirrhosis and liver cancer. If timely intervention can be made during this process, the development of liver cancer can be slowed down and the probability of occurrence of liver cancer can be reduced: 1. At the same time, take reasonable rest, avoid staying up late, straining, smoking, etc. Also need to pay attention to appropriate exercise to improve the body resistance. V. Personal insight This case is a reminder that when the patient has abnormally elevated alkaline phosphatase and glutamyl transpeptidase and there is no other reason to explain, even if the methemoglobin is completely normal, we should consider whether there is hepatocellular carcinoma. In this case, in fact, we should also see another issue of antiviral therapy, which is also very critical, that is, the patient’s viral level has been low-level replication and has not been on antiviral therapy, but current clinical studies and evidence-based medical data show that low-level hepatitis B viral replication increases the incidence of cirrhosis and hepatocellular carcinoma. From this, I would like to summarize three points for you here: 1. We should always be alert to the occurrence of hepatocellular carcinoma even in patients with normal methemoglobin, especially when alkaline phosphatase and glutamyl transpeptidase are abnormally elevated, and we should be more careful in screening; 2. Ultrasonography is also a very important and convenient diagnostic tool in clinical practice to determine the nature of liver occupancy. In clinical diagnosis, we should not forget this means; 3. For low-level replication of hepatitis B virus, we should actively let patients undergo antiviral treatment and explain the advantages and disadvantages to prevent the occurrence of cirrhosis and liver cancer.