Thanks to David L Williams for suggesting this Case.
A 49 year old man, an inpatient on a medical ward. Clinical information is
'Jaundiced. Learning difficulty. Hep A and B negative'. Serum results were
Sodium: 149 mmol/L (135-145)
Potassium: 4.0 mmol/L
Urea: 17.6 mmol/L (2.8 - 7.0)
Creatinine: 106 umol/L (62 - 133)
Albumin: 30 g/L (35 - 48)
Globulins: 32 g/L (17 - 35)
Bilirubin: 482 umol/L (3 - 22)
Alkaline phosphatase: 151 IU/L (<126)
ALT: 116 IU/L (<56)
This Case attracted 38 participants, and as with previous cases involving
LFT abnormality, a very wide range of interpretational ideas.
4 would not usually comment on these results in the context of their own
hospital, [0.7]
and 3 would check previous results (including Haematology) before venturing
on a comment. [1.0]
5 would make an immediate 'phone call to the ward to discuss these results
with the clinicians.[0.0]
13 participants queried dehydration; [0.7]
8 queried a GI tract bleed; [1.3]
6 queried (alcohol-related) cirrhosis; [1.0]
5 queried hepatocellular damage; [0.3]
5 suggested intravascular haemolysis; [-0.7]
4 queried the recovery phase of a previous acute liver insult, possibly
involving paracetamol; [0.7]
4 mentioned the possibility of Wilson's disease. [-0.3]
2 each mentioned
renal failure/ renal impairment; [-0.7]
a drug-related cause, possibly phenothiazines; [-0.3]
an inherited hyperbilibinaemia; [-1.7]
post-hepatic cholestasis; [0.3]
acute hepatitis; [-0.7]
malnutrition causing the low albumin; [-0.7]
the possibility of leptospirosis. [-0.7]
1 queried ethnic origin and a possible Sickle cell crisis. [-0.3]
..
8 would measure conjugated bilirubin; [0.0]
5 would suggest Hepatitis-C serology; [1.0]
3 would measure gamma-GT; [-1.0]
3 would suggest measurement of ammonia; [-1.3]
2 would measure AST; [-1.3]
2 would suggest a liver scan/ liver biopsy; [-0.3]
1 each would measure/ suggest measurement of
Ethanol; [-1.3]
LDH; [-1.7]
serum protein electrophoresis; [0.0]
haemoglobin electrophoresis; [-0.3]
faecal occult blood. [-0.3]
Early last year, a complex pattern of liver function test abnormality
generated a very wide range of opinion, and one participant commented
'trying to interpret LFTs without seeing the patient is like trying to
interpret patterns of tea leaves in a tea cup, and best avoided'. The older
I get, the more I think he is right (at least, most of the time!).
In this Case, the combination of a raised urea and bilirubin obviously
suggested the possibility of a GI tract bleed. A sample for haematology
taken on the same day showed a high haematocrit, together with low
platelets. Three days, and seven days earlier, blood samples had been taken
for biochemistry, but both were haemolysed. On admission two weeks earlier,
haematology had shown a raised haematocrit and thrombocytopaenia. Liver
function tests were:
Albumin: 37 g/L
Bilirubin: 110 umol/L
Alkaline phosphatase: 100 IU/L
AST: 2205 IU/L (<41)
ALT: 1393 IU/L (<56)
So it looks as if there was an acute liver insult prior to admission. Our
local haematologists think the haematology picture was consistent with
liver damage and dehydration, rather than a GI tract bleed. The patient
appears to have died from liver failure two weeks later.
Best wishes
Gordon Challand
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