Liver + friends presentations Flashcards
A 43-year-old man with a 9-year history of mild ulcerative colitis is noted to have an elevated serum alkaline phosphatase, slightly elevated aminotransferases, and normal bilirubin on routine laboratory testing. He complains of fatigue and upper abdominal pain. He denies pruritus or fevers. Physical examination is unremarkable.
Primary sclerosing cholangitis
A 48-year-old woman with a history of migraine headaches presents to the emergency department with altered mental status over the last several hours. She was found by her husband, earlier in the day, to be acutely disorientated and increasingly somnolent. On physical examination, she has scleral icterus, mild right upper quadrant tenderness, and asterixis. Preliminary laboratory studies are notable for a serum alanine aminotransferase of 6498 units/L, total bilirubin of 95.8 micromol/L (5.6 mg/dL), and INR of 6.8. Her husband reports that she has consistently been taking pain medications and started taking additional 500 mg paracetamol pills several days ago for lower back pain. Further history reveals a medication list with multiple paracetamol-containing preparations.
Acute liver failure
INR 6.8 - coagulopathy
A lot of hepatic encephalopathy symptoms
High ALT indicates liver pathology
38-year-old man presents to the emergency department for severe alcohol use with nausea and vomiting. He has a significant medical history of chronic heavy alcohol consumption of about one bottle of wine each day for about 5 years until 1 year ago; since then he has had severe intermittent binge alcohol intake. He reports no other significant medical problems. The patient is confused and slightly obtunded, and hepatomegaly is discovered on physical exam. His body mass index is 22. Pertinent positive laboratory values show low haemoglobin, AST elevation > ALT elevation,
Alcoholic liver disease
A 40-year-old man with a history of alcohol-misuse is brought to the emergency department by police, who found him lying down by the side of the street. On examination he is somnolent and confused. He has a horizontal gaze palsy with impaired vestibulo-ocular reflexes and severe truncal ataxia in the presence of normal motor strength and muscle stretch reflexes.
Wernicke’s encephalopathy (Wernicke korsakoff syndrome)
- Alcohol misuse history - alcohol excess leads to thiamine deficiency
- Somnolent and confused
- horizontal gaze palsy
- Ataxia
- normal motor strength indicates a CNS problem and not PNS
A 42-year-old man is referred to the liver clinic with mild elevation in aminotransferases for several years. He has a medical history significant for obesity, hypertension, and hypercholesterolaemia. He does not smoke or drink alcohol and there is no high-risk behaviour. He has a family history of premature cardiac disease. He is taking a diuretic and, because of his elevated liver tests, was recommended to discontinue his statin medication several months ago. Other than complaints of mild fatigue, the patient feels well. Examination is notable for a BMI of 37 kg/m², truncal obesity, and mild hepatomegaly.
Non alcoholic fatty liver disease
A 34-year-old man presents 2 weeks after returning from a month-long trip to India. He denies attending pre-travel vaccination clinic and did not take prophylaxis of any sort while in India. He reports a 6-day history of malaise, anorexia, abdominal pain, nausea with emesis, and dark urine. He consumed salad at a road-side vendor 3 weeks before onset of symptoms. On examination there is icterus. His alanine transaminase (ALT) is 5660 units/L, and total bilirubin 153.9 micromols/L (9 mg/dL).
Hepatitis A
A 49-year-old woman presents with several days of fatigue, loss of appetite, and abdominal pain. She recently returned from a month-long culinary tour of Europe where she visited multiple wineries and farms and tried various local dishes like chicken tenders and pork sausages. Examination shows normal vital signs, scleral icterus, and a soft abdomen. Laboratory studies show an alanine aminotransferase of 809 IU/L, a total bilirubin of 133.41 micromol/L (7.8 mg/dL), and an international normalised ratio (INR) of 1.1.
Hepatitis E
A 46-year-old obese woman presents with a 6-hour history of moderate steady pain in the right upper quadrant (RUQ) that radiates through to her back. This pain began after eating dinner, gradually increased, and has remained constant over the last few hours. She has experienced previous episodes of similar pain for which she did not seek medical advice. Her vital signs are normal.
Cholelithiasis (possible cholecystitis?)
A 20-year-old obese woman with a 2-year history of gallstones presents to the emergency department with severe, constant right upper quadrant (RUQ) pain, nausea, and vomiting after eating fried chicken for dinner. She denies any chest pain or diarrhoea. Three months ago she developed intermittent, sharp RUQ pains. On physical examination she has a temperature of 38°C (100.4°F), moderate RUQ tenderness on palpation, but no evidence of jaundice.
Cholecystitis (a complication of cholelithiasis)
A 65-year-old woman presents to the emergency department with a 2-day history of progressive right upper quadrant (RUQ) pain that she rates as 9/10 in severity. She reports experiencing fever, and being unable to eat or drink due to nausea and abdominal pain at baseline, exacerbated by food ingestion. Her bowel movements are less frequent and have become loose. Her pain is not relieved by bowel movement and is not related to food. She has not recently taken antibiotics, nor does she use non-steroidal anti-inflammatory drugs or drink alcohol. On examination, she is febrile at 39.4°C (102.9°F); supine BP is 97/58 mmHg; standing BP is 76/41 mmHg; HR is 127 bpm; and respiratory rate is 24 breaths per minute with normal oxygen saturation. Her examination is remarkable for scleral and sublingual icterus, tachycardia, RUQ pain with no rebound, and involuntary guarding on the right side.
Acute cholangitis
A 58-year-old man with pancreatic adenocarcinoma, who had a plastic stent placed in his common bile duct 6 weeks ago to relieve obstructive jaundice, presents to the emergency department with a 1-week history of progressive nausea and occasional vomiting after eating. He has generalised abdominal pain that is worse in the RUQ. He has experienced subjective fever/chills and states that his bowel movements are pale.
Acute cholangitis
ERCP procedure done (plastic stent)
plus Charcot’s triad
A 50-year-old woman undergoing health screening is found to have a cholestatic pattern on her liver function test results. Her alkaline phosphatase and gamma-GT concentrations are elevated, although transaminases, bilirubin, and albumin concentrations are normal. On questioning she mentions that she had been getting increasingly tired over the past few years but felt that this was simply a result of her age and work pattern. She also describes occasional itch that feels as if it is deep underneath the skin and that is not associated with a rash. She had no other past medical history but had a family member who had autoimmune thyroid disease.
Primary biliary cholangitis
A 53-year-old man presents to the emergency department with severe mid-epigastric abdominal pain that radiates to the back. The pain evolved over 1 hour. He also describes nausea, vomiting, and anorexia, and gives a history of heavy alcohol intake over many years, including this past week. He is tachycardic, tachypnoeic, and febrile with hypotension. He is slightly agitated and confused. He is diaphoretic and tender in the epigastric region with guarding and rebound tenderness.
Acute pancreatitis
A 50-year-old man presents to the emergency department with a history of black, tarry stools but denies haematemesis or abdominal pain. His family has noticed progressive confusion. He has alcohol-related liver disease with cirrhosis. His heart rate is 112 bpm and blood pressure is 105/66 mmHg. He is jaundiced and lethargic, is oriented to person and place but not date, and has moderate ascites. Neurological examination reveals asterixis, and stool is positive for occult blood.
Hepatic encephalopathy
A 53-year-old man with a history of hepatitis C presents with a complaint of abdominal distention, fever, vomiting, and blood in his stool. Paracentesis has improved symptoms on the numerous occasions that he has previously presented with abdominal distension.
Spontaneous bacterial peritonitis
