NYU Medicine Grand Rounds Clinical Vignette

Jay Desai, MD

PGY3

January 19, 2011

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 66 year old African American man, who was referred to Gastroenterology Clinic for further work up of abnormal liver function testing

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•The patient was in his usual state of health of good health when he presented to his primary care physician _____ (when) for a routine health maintenance visit.

•On routine labs at that time, it was noted that his liver function tests were abnormal

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History•Past Medical History:

•Coronary artery disease, complicated by a myocardial infarction in 2001•Recurrent oral Herpes Simplex Virus infections

•Past Surgical History:•None

•Social History:•No tobacco or illicit drug use, minor alcohol intake (how much)•Sexually active with men and women, uses protection

•Family History:•Grandfather died of liver disease (patient unfamiliar with further details)•Father died of myocardial infarction in his 60s•Mother alive, healthy

•Allergies: •No Known Drug Allergies

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History•Medications:

•Aspirin 81mg daily •Atenolol 25mg daily •Simvastatin 20mg before bed •Ranitidine 150mg twice daily as needed for heart burn•Acyclovir 400mg four times daily as needed (requires it 3-4 times a year)•Ibuprofen 400mg as needed for pain•Levitra 20mg as needed

•Over the counter Medications:•Vitamin B12, B6, C, E, Calcium, Rosehip, selenium, alfalfa, kelp, lecithin, ginseng, cod liver oil, bee pollen complex, green tea extract, red rice extract, Gingko extracts, Lysine. (Dosages unknown)

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

•Vital Signs: T 98.6 BP: 140/70 HR: 80 RR: 15 and

O2 sat: 100% on Room Air.

•General: Overweight individual, resting comfortably on exam table, in no acute distress

•HEENT: anicteric sclera

•Abdomen: non tender, non distended, no fluid wave, positive bowel sounds, no hepatosplenomegaly.

•The remainder of the physical exam was normal

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

•CBC: within normal limits •Basic Metabolic panel: within normal limits•Hepatic panel:

•AST 100•ALT 124 •Alkaline Phosphatase 515•GGT 2030•Remainder of the hepatic panel was within normal limits

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hepatotoxicity secondary herbal medication intake

• Undisclosed excessive alcohol intake• Infectious hepatitis• Choledocolithiasis • Primary sclerosing cholangitis• Primary biliary cirrhosis • Cholangiocarcinoma

Differential Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Visit 1:– The patient was advised to discontinue all herbal

medications, and was advised to abstain from alcohol use.

– A right upper quadrant ultrasound was obtained, which showed a normal liver, and no biliary dilatation.

Clinic Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Visit 2:– AST/ALT remained stable, but the patient’s alkaline

phosphatase and GGT continued to rise.– Hepatitis serologies were sent and returned negativel– Magnetic Resonance Cholangiopancreatography

(MRCP) was ordered.

Clinic Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•The liver is normal in size, contour, and signal intensity.•No focal hepatic lesion is identified. •No enhancing mass or choledocholithiasis is identified. •Mild prominence of portions of the intrahepatic biliary tree. •Some of these dilated biliary ducts demonstrate subtle beading. •Findings are suggestive of primary sclerosing cholangitis

Magnetic Resonance Cholangiopancreatography

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Primary Sclerosing Cholangitis, causing asymptomatic elevations in liver function tests.

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS