A 54 year old lady, seeing her Family Doctor. Clinical information is
'cholecystectomy 3 months ago'.
Urea, electrolytes, and creatinine were within reference limits. Liver
function tests were:
Albumin: 38 g/L (35 - 49)
Globulins: 29 g/L (17 - 35)
Bilirubin: 17 umol/L (3 - 22)
Alkaline phosphatase: 115 IU/L (<126)
ALT: 1215 IU/L (<56)
AST: 640 IU/L (<41)
On discharge from hospital 3 months previously, liver function tests were
within reference limits apart from a slightly elevated alkaline phosphatase
of 140 IU/L.
This case attracted 35 participants.
16 would 'phone the family doctor,
15 checking the drug history [1.3]
6 checking the clinical picture [1.4]
3 to suggest a discussion with the surgeons or the duty physician. [1.2]
18 queried hepatocellular damage [1.0, but two assessors pointing out that
this was obvious]
(10 of these 'due to a virus or a drug'), [1.7]
10 said a cholestatic problem was unlikely.[1.1]
14 queried a blood-borne infection, [1.1]
9 queried early viral hepatitis, [1.7]
2 mentioned the possibility of mononucleosis, [0.5]
3 queried paracetamol use, [0.4]
2 queried a toxic agent, [0.4]
2 queried alcohol use [0.4]
1 each mentioned the possibility of
acute cholangitis; [0.4]
post-anaesthetic complication; [-0.6]
heparin problem; [-0.6]
anoxia due to ischaemic complications. [-0.8]
a chronic liver problem, [-1.1]
18 suggested hepatitis serology on the patient's sample; [1.8]
2 suggested hepatitis serology on a sample from the surgeon; [0.0]
6 would check gamma GT [0.4]
5 would ask for repeat liver function tests [0.0*]
2 would check prothrombin time [0.7]
2 would suggest liver ultrasound; [0.0*]
1 each would check
FBC/ ESR [0.3]
lipids [-0.4]
thyroid function tests. [-0.8].
I 'phoned the family doctor about this case. The patient's visit had been a
'routine' 3-month post-operation check, and she had seemed well. However,
two weeks prior to this visit, she had been prescribed lamotrigine. I
suggested that this should be stopped while hepatitis serology was checked
(probably mistakenly, since I subsequently found out that lamotrigine
should be phased out rather than stopped abruptly). However, hepatitis
serology was negative, and enzymes rapidly returned to within reference
limits after lamotrigine was withdrawn.
Best wishes
Gordon Challand
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