IMS Group A Sem 5 Abnormal Liver Function.pptx

7/25/2019 IMS Group A Sem 5 Abnormal Liver Function.pptx

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Integrated MedicalSeminar Phase 1 :Abnormal Liver Function

Oct 2015

International Medicalniversit!


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"ase #1


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$0#!ear#old la%!er %ithtiredness and &ruritus

M W, a 40-year-old lawyer presents to herGP with a progressive history of tirednessand pruritus. She has vitiligo and a past

history of rheumatoid arthritis that is inremission.

Physical eamination reveals a wellloo!ing woman with palmar erythema "ut

no other signs of chronic liver disease. Shehas "ilateral anthelasma. #"dominaleamination is normal. $er "lood tests arenormal apart from a raised al!aline

phosphatase of %&' i()* +normal % &0


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$er '-G/ is elevated at & ()*+normal &&0 ()*. 1urther2uestioning reveals that she does not

consume any alcohol. She is referredto the hepatology clinic.

/he hepatologist organised for her to

have a liver ultrasound. /hisdemonstrates that her liver isenlarged "ut with a normal

echoteture. /here is no "iliary duct


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$er antimitochondrial anti"ody is positive. # liver"iopsy demonstrates necrotic "ile ductssurrounded with early 3"rosis.

Mrs Wilco is started on cholestyramine andursodeoycholic acid which control hersymptoms.

She defaults from regular clinic follow - up. ightyears later she re-presents with 5aundice, ascites

and a "iliru"in of &0 6 mol)*. She placed on thewaiting list for liver transplantation and a suita"ledonor is found months later. /he transplant isuncomplicated and she is alive and well % years

later.


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"ase 2


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1(#!ear#old bo! %ithdeteriorating academic and

s&orting &er)ormance 7 M, a &8-year-old "oy, is "rought to his generalpractitioner "y his mother who is concerneda"out deterioration in his school performance.

# year ago he was one of the "est students in theschool "ut since then he has had pro"lemsconcentrating and his eamination mar!s havedeteriorated.

$is mother initially thought his change of

"ehaviour was a feature of adolescence "ut she"ecame more worried when his &0-year-old"rother "egan to "eat him at tennis and he hadto leave his local foot"all clu" as he was 3nding it

increasingly di9cult to run and control the "all.


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$e has a low serum caeruloplasmin,positive penicillamine challenge and thepresence of =ayser1leischer rings on slit-

lamp eamination. $e is started on penicillamine which he

tolerates without signi3cant side e>ects.$is liver function tests improve and 8

months later he has a normal #*/. $isconcentration improves a little "ut hecontinues to have a tremor and remainsuncoordinated.


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"ase #*


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19-year-old female with jaundiceand depression

M S is "rought into the emergency department "yher friend as she has "een vomiting andcomplaining of epigastric pain. $er friend reportsthat she "ro!e up with her "oyfriend a month ago

and she has "ecome depressed and increasinglywithdrawn. :n eamination she has "ilateralsu"con5unctival haemorrhages and is 5aundiced withtenderness on palpation of her a"domen. *iverfunction tests reveal?

7iliru"in &< 6 mol)*

#*/ 8%8' i()*

#*P ''0 i()*

#l"umin %' g)*


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M S is reluctant to give a history "ut herfriend reports that she hadn@t seen her for' days. When she entered her Aat therewere empty "ottles of paracetamol "y the

side of the "ed. /he clinical suspicion is that she has ta!en

a signi3 cant paracetamol overdose and B- acetyl cysteine is started immediately. #

few hours later she "ecomes increasinglyrestless wandering around the ward and

pulling out her intravenous infusion.


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1urther "lood tests are ta!en and theresults are as follows? Serum 7iliru"in '&< 6mol)*

Serum #*/ 4%&8 i()*

Serum #*P & i()*

CBD 4.%

;reatinine '8 6 mol)*

She "ecomes drowsy and re2uiresadmission to the intensive care for

intu"ation and ventilation.


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She is su"se2uently transferred to aspecialist liver unit. :ver the net '4hours she "ecomes anuric and

re2uires renal support withcontinuous venovenoushaemodia3ltration.

:ver the net few days her CBD"egins to improve and the rest of herliver function tests slowly recover.

She re2uires renal support for a


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"ase #$


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34-year-old pregnant lady withjaundice and abdominaldiscomfort Mrs E.:. is a %4-year-old female teacher. She

presents to her midwife with symptoms ofnausea and right upper 2uadrant discomfort.

She is %8 wee!s pregnant and this is her 3rstpregnancy. /here is no past medical historyof note. She is currently teetotal and wasdrin!ing less than &0 units of alcohol "efore

"ecoming pregnant. /he midwife documents her "lood pressure

to "e &&0)80 mm$g and pulse 0 "eats perminute.


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She has some "lood tests and sees you foradvice?

7iliru"in 0 6 mol)* #*/ &F i()*

#*P %F i()*

#l"umin ' g)*

(rea &.' mmol)*

;reatinine


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Investigations

Mrs : has no history of liver disease. She ishepatitis 7 surface antigen negative. /here is nohistory of foreign travel, recent anti"iotics orfamily history. # liver screen +including viral

serology is sent for. /here is very mildproteinuria, the haemolysis screen is negativeand the "lood 3lm shows a neutrophilia with giant

platelets. #n urgent a"dominal ultrasound reveals

steatosis and patency of the normal hepaticvasculature. 1ollowing discussion "etween theconsultant o"stetrician and consultanthepatologist, an urgent ;/ scan of the a"domenis arranged. /his reveals mar!ed steatosis and asmall su"capsular haemorrhage "ut no rupture of


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Mrs : has an emergency caesareansection. /he "a"y re2uires one nighton the special care "a"y unit and

then ma!es an ecellent recovery.1ollowing delivery, Mrs :@ s liverreturns to normal and follow-up

imaging shows resolution of thesteatosis and haemorrhage.


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"ase #5


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A 27 year old secretary withascites

H ; is a '


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7lood tests are as follows?

7iliru"in %0 6 mol)* #*/ F< i()*

#*P 4 i()*

#l"umin %8 g)*

CBD &. 1ull "lood count Bormal

(rea and creatinine Bormal

$er serum amylase was normal. (ltrasoundeamination con3rmed large volume ascites. /he

spleen siIe was normal. /he liver was enlarged"ut of normal echoteture with a smooth margin./he portal vein was patent with normal A ow "utthere was no Aow in the hepatic veins, which

appeared distended.


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$epatic venography was performed whichdemonstrated complete o"struction in the hepatic

veins. ;areful cannulation of the right hepatic veinrevealed an elevated venous pressure with

sluggish "lood Aow. /he o"struction was dilated

"y inAating a "alloon, with improvement in "lood

A ow and reduction in venous pressure. Bet the middle hepatic vein was cannulated and

a "alloon inAated, resulting in improved venous

Aow and a reduction in the venous pressuregradient. Ct was not possi"le to cannulate the left

hepatic vein. Juring the procedure a trans5ugular

liver "iopsy was o"tained that demonstrated

centrilo"ular congestion.


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1ollowing the procedure her ascites rapidlyimproved and her liver function tests returned tonormal. She was referred to a haematologist forfurther investigation. 7one marrow eamination

was normal with no evidence of amyeloproliferative disorder.

$er procoagulant screen revealed that she hasfactor K *eiden mutation.

She is started on lifelong warfarin anticoagulationand advised to stop smo!ing and to cease theoral contraceptive pill.


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,ormal values

Serum /otal 7iliru"in +.&-'0.6mol)*

#*/ +#lanine #minotransferase+0-% i()*

Serum #l"umin +%- g)*

;-Deactive Protein +L .0 g)* Serum al!aline phosphatase +normal

%-&0 i()*

Serum '-Glutamyl /ransferase


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Assignment )or Small -rou&.iscussion /5 min each

.iscuss each o) the cases identi)!ing

the &ossible diagnosisdiagnoses andbrie3! describing the disorder o)structure or )unction res&onsible )or

the clinical s!m&toms or signs /total25 min4


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Assignment )or Large -rou&Presentation /20 min

Follo%ing the small grou&&resentation to the grou&s)acilitators the grou& as a %hole %ill

discuss the )ollo%ing statement :

/he diagnosis of illnesses presentingwith a"normal liver function can "e

di9cult as diseases presenting in thisfashion can arise from disorders ofdi>erent aetiologies. #n approach to

addressing this clinical pro"lem is


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Assessment

6he small grou& assignment %ill carr! 708 o) thetotal mar9s and each student in the grou& %illreceive an individual mar9 based on the smallgrou& &resentation4 /Include re)erence better

6he large grou& &resentation %ill carr! *08 o) thetotal mar9s and there %ill be one common similarmar9 )or each member o) the grou& based on themerits o) the large grou& &resentation4

All &artici&ants should be &resent during thesmall and large grou& &resentations to be able toreceive )ull mar9s4

Please remember that students should &artici&ate

in both the small and large grou& &resentations4


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Contact details: 012 - 2985998

IMS Group A Sem 5 Abnormal Liver Function.pptx

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