I have just come off the phone after a rather acrimonious
discussion with one of our paediatric intensivists. He had been
upset at the laboratories unwillingness to sanction a repeat gamma
GT on one of his patients. After the discussion I agreed to do the
test under protest but was I right to question the request? As we
get few requests for this test they are sent to our neighbouring
adult hospital and take 24 hours.
The patient is a 7 month male infant admitted with meningococcal
sepsis. He was severely ill with multiple organ failure. His ALT
rose from 16iu/L to 820 at 24 hours and 2200 at 72 hours. It fell
rapidly at first and then more slowly over the next 6 days to
167iu/l.and then rose slightly to 215 over the next three days. At
the same time bilirubin rose from 5 micromol/l to 250(60%
conjugated) but the alkaline phosphatase remained essentially the
same with minor fluctuation about the middle of our normal range
for his age. Albumin was also normal but the child has been
receiving 100ml packed RBCs per day and is on TPN.
The first gamma GT was asked for when the ALT was 175 (day 11
0f his admission) The result was 77iu/l (upper adult limit 70). A
repeat was requested the next day which the lab queried on the
ground of the previous result.
The refusal was not noticed for nearly 24 hours when I was
telephoned. The intensivist stated that repeat gamma GT was
required to establish a differential diagnosis of the continuing liver
disorder and that they would need to monitor it on a daily basis.
The value of gamma GT in children is fairly limited despite the
problems with alkaline phosphatase and age related reference
ranges. I know of only one indication for daily gamma GT, in liver
transplants. So what are the others either in children or adults?
How can a marginally raised gamma GT be interpreted in a child
with multi-organ disease on many drugs including antibiotics?
I asked my 'colleague' for his evidence but he said it was up to me
to show that gamma GT would not help him. He could not give me
a differential diagnosis over the phone which made much clinical
sense in a child with a known disorder.
All advice gratefully received even if it proves me wrong. Other
information can be provided if necessary but I am too frightened to
go onto PICU to get his notes at the moment!!
Mike Addison
Dr G.Michael Addison
Royal Manchester Children's Hospital
Pendlebury
Manchester M27 4HA
United Kingdom
Tel 0161-727-2250(AM)or 0161-220-5342(PM)
FAX 0161-727-2249
Email [log in to unmask]
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