Материал: 100_Cases_in_Clinical_Medicine
LIVER
CASE 7: NAUSEA AND WEIGHT LOSS
History
A man of 45 consults his general practitioner (GP) with a 6-month history of reduced appetite and weight loss, from 78 to 71 kg. During the last 3 months he has had intermittent nausea, especially in the mornings, and in the last 3 months the morning nausea has been accompanied by vomiting on several occasions. For 1 month he has noted swelling of his ankles. Despite his weight loss he has recently noticed his trousers getting tighter. He has had no abdominal pain. He has no relevant past history and knows no family history as he was adopted. He takes no medication. From the age of 18 he has smoked 5–6 cigarettes daily and drunk 15–20 units of alcohol per week. He has been a chef all his working life, without exception in fashionable restaurants. He now lives alone as his wife left him 1 year ago.
Examination
He has plethoric features. There is pitting oedema of his ankles. He appears to have lost weight from his limbs, but not his trunk. He has nine spider naevi on his upper trunk. His pulse is normal and the rate is 92/min. His jugular venous pressure (JVP) is not raised and his blood pressure is 146/84 mmHg. The cardiovascular and respiratory systems are normal. The abdomen is distended. He has no palpable masses but there is shifting dullness and a fluid thrill.
INVESTIGATIONS
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|
Normal |
Haemoglobin |
12.6 g/dL |
13.3–17.7 g/dL |
Mean corpuscular volume (MCV) |
107 fL |
80–99 fL |
White cell count |
10.2 % 109/L |
3.9–10.6 % 109/L |
Platelets |
321 % 109/L |
150–440 % 109/L |
Sodium |
131 mmol/L |
135–145 mmol/L |
Potassium |
4.2 mmol/L |
3.5–5.0 mmol/L |
Urea |
2.2 mmol/L |
2.5–6.7 mmol/L |
Creatinine |
101 &mol/L |
70–120 &mol/L |
Calcium |
2.44 mmol/L |
2.12–2.65 mmol/L |
Phosphate |
1.2 mmol/L |
0.8–1.45 mmol/L |
Total protein |
48 g/L |
60–80 g/L |
Albumin |
26 g/L |
35–50 g/L |
Bilirubin |
25 mmol/L |
3–17 mmol/L |
Alanine transaminase |
276 IU/L |
5–35 IU/L |
Gamma-glutamyl transaminase |
873 IU/L |
11–51 IU/L |
Alkaline phosphatase |
351 IU/L |
30–300 IU/L |
Urinalysis: no protein; no blood |
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|
Questions
•What is the diagnosis?
•How would you manage this patient?
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ANSWER 7
This man has abnormal liver function tests which indicate hepatic failure; the hypoproteinaemia has caused the ascites and ankle swelling. The number of spider naevi is more than the accepted normal of three. The cause is likely to be alcohol as it is a common cause of this problem, he is at increased risk through his work in the catering business. His symptoms of morning nausea and vomiting are typical, and this would account for his cushingoid appearance (alcohol increases adrenocorticotrophic hormone (ACTH) secretion) and the macrocytsis on the blood film (due to dietary folate deficiency and a direct toxic action on the bone marrow by alcohol). However his alcohol intake is too low to be consistent with the diagnosis of alcoholic liver disease. When the provisional diagnosis is discussed with him though, he eventually admits that his alcohol intake has been at least 40–50 units per week for the last 20 years and has increased further during the last year after his marriage had ended, the reason for this being his drinking.
The slight reductions in the sodium and urea reflect a chronic reduced intake of salt and protein; the rise in bilirubin is insufficient to cause jaundice.
Further investigations are the measurement of hepatitis viral serology, which was negative, and an ultrasound of the abdomen. This showed a slight reduction in liver size, and an increase in splenic length of 2–3 cm. There was no evidence of a hepatoma. These findings indicate that portal hypertension has developed. A liver biopsy, performed to confirm the diagnosis, assess the degree of histological damage and exclude other pathology, showed changes of cirrhosis.
The crucial aim in management is to impress upon the patient the necessity to stop drinking alcohol, in view of the degree of liver damage, the presumed portal hypertension and the risk of oesophageal varices and bleeding, and to effect this by his attending an alcohol addiction unit. In the short term he should also improve his diet to increase his protein intake. Diuretics could be used to reduce his oedema, but it should be remembered that they could cause postural hypotension more easily against this background.
His attendance at the addiction unit was fitful, he continued to drink heavily and he died 3 years later as a result of a second bleed from oesophageal varices.
KEY POINTS
•Patients who drink excessive amounts of alcohol will often disguise this fact in their history
•Alcoholic liver disease has a poor prognosis if the alcohol intake is not terminated.
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CASE 8: ANOREXIA AND FEVER
History
A 22-year-old man presented with malaise and anorexia for 1 week. He vomited on one occasion, with no blood. He has felt feverish but has not taken his temperature. For 2 weeks he has had aching pains in the knees, elbows and wrists without any obvious swelling of the joints. He has not noticed any change in his urine or bowels.
Five years ago he had glandular fever confirmed serologically. He smokes 25 cigarettes per day and drinks 20–40 units of alcohol per week. He has taken marijuana and ecstasy occasionally over the past 2 years and various tablets and mixtures at clubs without being sure of the constituents. He denies any intravenous drug use. He has had irregular homosexual contacts but says that he has always used protection. He claims to have had an HIV test which was negative 6 months earlier. He has not travelled outside Western Europe in the last 2 years.
He is unemployed and lives in a flat with three other people. There is no relevant family history.
Examination
He has a temperature of 38.6°C and looks unwell. He looks as if he may be a little jaundiced. He is a little tender in the right upper quadrant of the abdomen. There are no abnormalities to find on examination of the joints or in any other system.
INVESTIGATIONS
|
|
Normal |
Haemoglobin |
14.1 g/dL |
13.3–17.7 g/dL |
Mean corpuscular volume (MCV) |
85 fL |
80–99 fL |
White cell count |
11.5 % 109/L |
3.9–10.6 % 109/L |
Platelets |
286 % 109/L |
150–440 % 109/L |
Prothrombin time |
17 s |
10–14 s |
Sodium |
135 mmol/L |
135–145 mmol/L |
Potassium |
3.5 mmol/L |
3.5–5.0 mmol/L |
Urea |
3.2 mmol/L |
2.5–6.7 mmol/L |
Creatinine |
64 &mol/L |
70–120 &mol/L |
Bilirubin |
50 mmol/L |
3–17 mmol/L |
Alkaline phosphatase |
376 IU/L |
30–300 IU/L |
Alanine aminotransferase |
570 IU/L |
5–35 IU/L |
Fasting glucose |
4.1 mmol/L |
4.0–6.0 mmol/L |
Questions
•What is your interpretation of the findings?
•What is the likely diagnosis?
•What treatment is required?
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ANSWER 8
The diagnosis is likely to be acute viral hepatitis. The biochemical results show abnormal liver function tests with a predominant change in the transaminases, indicating a hepatocellular rather than an obstructive problem in the liver. This might be caused by hepatitis A, B or C. The raised white count is compatible with acute hepatitis. Homosexuality and intravenous drug abuse are risk factors for hepatitis B and C. Other viral infections such as cytomegalovirus and herpes simplex virus are possible.
Since the drug ingestion history is unclear, there is a possibility of a drug-induced hepatitis. The prodromal joint symptoms suggest a viral infection as the cause, and this is more common with hepatitis B. Serological tests can be used to see whether there are immunoglobulin M (IgM) antibodies indicating acute infection with one of these viruses, to confirm the diagnosis. The reported negative HIV test 6 months earlier makes an HIV-associated condition unlikely although patients are not always reliable in their accounts of HIV tests, and HIV seroconversion should also be considered.
Treatment is basically supportive in the acute phase. The prothrombin time in this patient is raised slightly but not enough to be an anxiety or an indicator of very severe disease. Liver function will need to be measured to monitor enzyme levels as a guide to progress. Alcohol and any other hepatotoxic drug intake should be avoided until liver function tests are back to normal. If hepatitis B or C is confirmed by serology then liver function tests and serological tests should be monitored for chronic disease, and antiviral therapy then considered. Rare complications of the acute illness are fulminant hepatic failure, aplastic anaemia, myocarditis and vasculitis. The opportunity should be taken to advise him about the potential dangers of his intake of cigarettes, drugs and alcohol, and to offer him appropriate support in these areas.
KEY POINTS
•Viral hepatitis is often associated with a prodrome of arthralgia and flu-like symptoms.
•Confirmatory evidence should be sought for patients’ reports of HIV test results.
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RENAL
CASE 9: TIREDNESS
History
An 85-year-old woman is investigated by her general practitioner (GP) for increasing tiredness which has developed over the past 6 months. She has lost her appetite and feels constantly nauseated. She has lost about 8 kg in weight over the past 6 months. For the last 4 weeks she has also complained of generalized itching and cramps. She has been hypertensive for 20 years and has been on antihypertensive medication for that time. She has had two cerebrovascular accidents which have limited her mobility. She is an AfricanCaribbean, having emigrated to the UK in the 1960s. She lives alone but uses a ‘meals on wheels’ service and goes to a day hospital twice a week. She has two daughters.
Examination
Her conjunctivae are pale. Her pulse is 88/min regular, blood pressure 190/110 mmHg; mild pitting oedema of her ankles is present. Otherwise, examination of her cardiovascular and respiratory systems is normal. Neurological examination shows a left upper motor neurone facial palsy with mild weakness and increased reflexes in the left arm and leg. She is able to walk with a stick. Funduscopy shows arteriovenous nipping and increased tortuosity of the arteries.
INVESTIGATIONS
|
|
Normal |
Haemoglobin |
7.2 g/dL |
11.7–15.7 g/dL |
Mean corpuscular volume (MCV) |
84 fL |
80–99 fL |
White cell count |
6.3 % 109/L |
3.5–11.0 % 109/L |
Platelets |
294 % 109/L |
150–440 % 109/L |
Sodium |
136 mmol/L |
135–145 mmol/L |
Potassium |
4.8 mmol/L |
3.5–5.0 mmol/L |
Urea |
46.2 mmol/L |
2.5–6.7 mmol/L |
Creatinine |
769 &mol/L |
70–120 &mol/L |
Glucose |
4.1 mmol/L |
4.0–6.0 mmol/L |
Albumin |
37 g/L |
35–50 g/L |
Calcium |
1.94 mmol/L |
2.12–2.65 mmol/L |
Phosphate |
3.4 mmol/L |
0.8–1.45 mmol/L |
Bilirubin |
15 mmol/L |
3–17 mmol/L |
Alanine transaminase |
23 IU/L |
5–35 IU/L |
Alkaline phosphatase |
423 IU/L |
30–300 IU/L |
Urinalysis: ' protein; ' blood |
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Blood film: normochromic, normocytic anaemia
Questions
•What is the diagnosis?
•How would you investigate and manage this patient?
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