More likely a pancreatitis than an acute alcoholic hepatitis, though both
possible, so worth seeing if the lab can do a Ca2+ and albumin on the
existing samples. I think the arthralgia is probably just due to NSAID
withdrawal, so not diagnostically significant. Assuming that the diclofenac
is longstanding, probably not involved in the initial presentation, although
it can give you a granulomatous hepatitis. USS pretty insensitive in minor
degrees of pancreatitis whre the pain can be disproportionate to lab
findings.
Bad long term outlook whichever it is.......
-----Original Message-----
From: GP-UK [mailto:[log in to unmask]] On Behalf Of Graham Balin
Sent: 29 November 2008 03:36
To: [log in to unmask]
Subject: Clinical conundrum
64-year-old male, ex smoker, heavy drinker (>50 units per week)
PMH: hypertension, osteoarthritis of knees (severe)
Medication: Natrilix, atenolol, diclofenac, allopurinol
Presented with a two-day history of severe abdominal pain, constant in
nature, no radiation. No vomiting all diarrhoea, bowels open regularly.
On examination, afebrile, 150/80, BMI 28. Abdominal examination only
showed marked tenderness on the left side of the abdomen upper and
middle, but the liver was palpable just below the costal margin.
Presumptive diagnosis: ?gastritis, ?pancreatitis.
diclofenac stopped, pantoprazole started.
Ultrasound showed a fatty liver only.
Bloods showed Hb 145, WBC 17.3 brackets (neutrophils 11.4) ESR 46 CRP
162, amylase 140 lipase 87
GGT 150, ALT 18 AST 21, urine NAD
A few days later he was in less pain from his abdomen, but complaining
bitterly of the pain in his knees and now in his neck as well.
Bloods now show Hb 139, W. C. C. 11.8, ESR 111, CRP 62 GGT 201, amylase
120, lipase 140 urine: leucocytes 20 RBC 30 no growth.
So what are we thinking of now?.. [Just looking for ideas - no answers
yet! ]
--
Cheerio,
Graham
|