Are you Really Fat?

health, libido, body

Persistent Pain After Cholecystectomy

Case 1: 25 yr. old male was admitted with a weeks history of malaise, fatigue, anorexia, nausea and vomiting. He was treated symptomatically by his family physician for "flu". The patient was previously healthy. About 2 weeks ago his girl friend had complained of "flu" like symptoms which subsided on its own. On further questioning he admitted epigastric discomfort. He had lost taste for cigarettes and noticed that his urine had gone very dark like "curry sauce ". He had loose motions once or twice a day and his stools were pale. He denied any arthralgia, skin rashes or pruritus. His alcohol intake was about 8 pints of beer per week. He was not using any drugs. He had no homosexual relationship. He had not travelled outside the U.K. Physical examination revealed mild icterus and mild hepatomegaly. Spleen was just palpable. Rest of the examination was normal.

Investigations were : Hb : 12.4 Bilirubin : 2.4 mg % WCC : 7.8 ALT : 942 I.U/ Plt : 180,000 Gamma GT : 678 I.U. Alk. phos. : 153 I.U. Prothombine time : !7 /14 sec. Peripheral smear : few atypical lymphocytes < 10 %

Q: What is your likely diagnosis ? What other tests you would carry out ? What is the prognosis ?

A: This patient clearly has hepatitis. Judging from his history and lifestyle it is unlikely that he has alcoholic or drug induced hepatitis or even hepatitis B. He is likely to have hepatitis A or infectious mononucleosis. Atypical lymphocytes are seen in both but generally less than 10 % in HAV infection. Further tests would be for these only. Monospot or Ig M against Epstein- Barr virus would confirm infectious mononucleosis. IgM against HAV would confirm Hep. A. This patient had Hepatitis A infection. Prognosis is excellent in this group however there is a chance of prolonged jaundice if it is acquired at an older age. Upto 15 % relapse before ALT has returned to baseline , between 30 to 70 days. Relapse also settles down although it may take time. Another complication of hepatitis A is cholestasis marked by usually deep jaundice and intense itching. This too settles down with time, however short course of steroid or ursodeoxycholic acid may be tried with good results.

Case 2: 30 yr. old man was admitted with jaundice. Admitting house officer elicited following history. The patient was married and had no homosexual relationship. He drank ocassional alcohol and did not smoke. There was no history of blood transfusion, illicit drugs or any operation. There was no arthralgia, skin rash or pruritus.. He had obvious jaundice and tender hepatomegaly about 4 cms. in midclavicular line. Spleen was not palpable. Rest of the examination was normal. Hb :14 Urea & electrolytes : normal WCC : 9.6 Glucose : 96 mg. Plt :234,000 Ultrasound scan : Normal liver and spleen PT : 13/13 sec. Urine : urobilinogen +

Q: Would you have made any further inquiry ?

A: The registrar saw the patient and found that the patient was working as a rodent controller and thus prone to leptospirosis. He was also handling dogs and one of his friend's dog had developed jaundice a few days ago though the patient himself had never come in contact with the dog. The patient had developed slightly sore eye 10 days ago. About a month ago patient's wife had developed jaundice.

Q: How will you manage further ?

A: Our main concern was leptospirosis although the patient did not look particularly ill. Blood was obtained for culture and serology. Counter immunoelectrophoresis and microscopic agglutination are two very sensitive and specific tests. Urine was also obtained for dark ground illumination. This is not a very sensitive test. Blood could be examined in the same way. All these tests were negative in this patient. Ultimately he was found to have hepatitis A as confirmed by IgM-HAV. Pointers towards the diagnosis of leptospirosis are conjuctival haemorrhages, haematuria, very high grade fever and leucocytosis with low platelets. Penicillin given in good time could reduce the morbidity and mortality.

Case 3: 69 yr. old bank executive was admitted for investigation of weight loss and jaundice. Her husband had died 6 months ago and since then she lived alone. She smoked about 5 cigarettes / day and drank socially. she reported weight loss of about 14 kg in six months. Examination revealed moderate icterus and moderately enlarged tender liver. Liver surface was smooth and the edge was rounded. Spleen was not palpable and rest of the examination was normal. Hb : 12.4 Bilirubin : 7.0 mg WCC : 17,600 ALT : 247 i.u. Plt : 110,000 AST : 491 i.u. MCV : 104 fl GGT : 543 i.u. Na : 140 mmol / l alk. phos. : 360 i.u. K : 3.3 mmol /l Albumin : 37 gms. urea : 56 mg T-3., T-4., TSH : normal creatinine : 1.3 mg HBsAg : non reactive, HAV : nonreactive., HCV : nonreactive PT :23 / 15 sec. ANF : negative, Antimitochondrial antibodies : negative. Ultrasound liver : Enlarged liver, fatty infiltration +., spleen - not enlarged. Gallbladder and common bile duct showed no stones and not dilated. Intrahepatic biliary radicles normal.

Q: What do you suspect ?

A: The patients social background, biochemical and haematological profile almost certainly meant that she had alcoholic liver disease. She maintained her story and after correcting her coagulation profile she had live biopsy which showed centrilobular, large droplet type fatty infiltration, hepatocellular necrosis mainly centrilobular type, with polymorphonuclear infiltration. There was mild cholestasis. Mellory hyaline was present which is of course is not diagnostic of alcoholic liver damage. While on the ward she started putting on weight and started improving. Psychiatrist's help was taken for her depression where she confided that she was taking about 1/2 bottle of whisky everyday for past 4 months. This type of patients need close follow-up and counseling as they have a tendency to revert to their habit. Thrombocytopaenia seen in this case could be because of binge drinking or hyperspleenism.