39

Case 39


History



A 20-year-old lady presents with frequent urination. She has no abdominal pain, pruritis, fever or jaundice. There is no family history of diabetes.


Physical examination


Temperature 36.7°C, pulse 66 bpm, BP 100/53mmHg, SaO2 98-100% on RA.


Alert, no jaundice, no stigmata of chronic liver disease.


Examination of the hands reveals no clubbing and normal-appearing palmar creases.


Head and neck examination is unremarkable, with no lymph nodes palpable.


Cardiovascular: HS dual, no murmur.


Her chest is clear on auscultation.


Abdominal examination reveals a soft, non-tender abdomen, with no organomegaly.


No signs of oedema.


Investigations


CBC is normal.


Bilirubin 12μmol/L.


ALP 1375 IU/L (incidental finding).


ALT 115 IU/L (incidental finding).


Renal function is normal.


What is your differential diagnosis?


Biliary obstruction.


Hepatocellular disease, e.g. cirrhosis, alcoholic liver disease.


Drug-induced cholestasis.


Hepatocellular carcinoma.


Infiltrative disease, e.g. tuberculosis, sarcoidosis.


Primary biliary cirrhosis (PBC).


Primary sclerosing cholangitis (PSC).


What further history would you enquire?


Drinking history.


Drug history including herbs and over-the-counter medications.


She drinks 3-4 cans of beer per day. She is not taking any regular medications but she admits to using recreational drugs including ketamine.


What further blood tests would you order for the work-up of the underlying aetiology of deranged liver function?


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Oct 23, 2019 | Posted by in GASTROENTEROLOGY | Comments Off on 39
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