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Updated: 10/25/07 11:31 AM |
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| HOME | HEAL | EDUCATE | RESEARCH | DIRECTORY | OUTREACH |
Authors: W. Volwiler, R.A. Willson, A.M. Larson, and J.D. Ostrow
Download Chapter ♦ Download Lecture Slides & Notes
Download Chapter ♦ Download Lecture Slides & Notes
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W. Exercises
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Case I
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A 22-year old male University student developed malaise, anorexia, nausea, and right upper abdominal discomfort followed by dark urine, pale stools, and jaundice. He had no pruritus or shaking chills. Six weeks prior to his illness, he had been reunited with his girlfriend who had recently developed jaundice while on holiday in Egypt. He drank four or five beers a day, but he denied abusing intravenous drugs or having receptive anal intercourse.
On examination, he was markedly jaundiced, although he had no cutaneous stigmata of chronic liver disease (e.g., spider angiomata). His liver was enlarged to 4 cm below his right costal margin (17 cm total span), and his spleen was palpable 2 cm below the left costal margin. There was no evidence of ascites or hepatic encephalopathy. His bilirubin was 10 mg/dL, alkaline phosphatase three times normal, AST 30 times normal, serum albumin normal, and prothrombin time 11 seconds prolonged.
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Case II
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A 32-year-old female nurse developed malaise, fatigue, anorexia, nausea, and intermittent fever of 38 degrees centigrade. Two days later, she complained of right upper quadrant pain, jaundice, pale stools, dark urine, and pruritus. One week previously, she had been diagnosed as having bronchitis. Five days before admission, she was given a course of erythromycin with resolution of her wheezes and coughs. She had received this antibiotic once previously without any adverse reactions. There was no other past history. She denied blood transfusions, sexual activity or contact with jaundiced patients.
On examination: Fever and jaundice were confirmed, but there were no stigmata of chronic liver disease. She was tender in the right upper quadrant, but the liver was not palpable. The bilirubin was 5 mg/dL, alkaline phosphatase twice normal, AST 4 times normal, serum albumin normal. Her total white cell count was elevated with atypical lymphocytes on the blood smear.
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Case III
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A 43-year old female housewife had a prolonged, increasingly severe episode of right epigastric and right upper quadrant discomfort, with fever, severe nausea, and some vomiting. After four days, she sought medical attention. 20 years ago, after her first child, she began to have periodic, late evening short (1-4 hours) attacks of sudden onset of mid-or-right epigastric pain, sometimes fluctuating in intensity, often very severe, with vomiting, but without fever. Sometimes the morning after, she had mild right upper quadrant tenderness. She was told that she had gallstones, based on an oral cholecystogram.
During the past eight years, she also experienced attacks which were of somewhat different character. Although starting in the same manner, the pain was more constant, more intense, more prolonged, and accompanied by rather severe penetrating pain in the back just below the right scapula. There was marked deep tenderness over the entire right upper quadrant of the abdomen, and also soreness and sensitivity of the thoracic wall posteriorly just below the right scapula. The upper abdominal tenderness lingered much longer (1-4 days) after each of these attacks. On examination, she was uncomfortable and sweating. Oral temperature was 38.5, pulse 100. There was marked tenderness to slight pressure over the entire right upper abdomen, with splinting. Icterus was noted in the eyes. Her gallbladder failed to fill during a radionuclide (PIPIDA) scan. The abdominal pain became much worse, extending higher anteriorly (over the lower chest) and also over the top of the right shoulder, with some exaggeration on deep breathing.
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Case IV
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A 60-year old apple farmer presented to his rural physician with jaundice. He denied abusing alcohol, but stated that he had sprayed his orchard for many years with insecticides. He had not had any contact with jaundiced people or blood transfusions. The physical exam indicated a firm, but smooth liver edge, which was palpable 2 cm below the right costal margin. The tip of the spleen was just palpable. Serum chemistries revealed an alkaline phosphatase four times normal with ALT of 1½ times normal. The prothrombin time was 3 seconds prolonged, but it was corrected by giving subcutaneous vitamin K. The patient was told that he had a viral hepatitis and was followed for another month while his jaundice deepened. He began to experience itching of the skin and was referred to the University Hospital. An ultrasound examination showed a normal common bile duct, but dilated intrahepatic ducts.
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Case V
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A 46-year old single woman fell down the stairs and fractured three ribs. Three weeks later, she developed nausea, anorexia, right upper quadrant pain, jaundice, dark urine, and pale stools, but no pruritus or chills. She denied taking drugs and claimed to drink alcohol on social occasions only.
On examination, she was obese and had a fever of 38º C with a tachycardia of 100 beats per minute. There was marked jaundice, tenderness in the right upper quadrant, and a positive Murphy’s sign. The liver was palpable 6 cm below the right costal margin. There was no splenomegaly or ascites. Serum bilirubin was 8 mg/dl, alkaline phosphatase three times normal, AST 80 IU per liter, ALT 50 IU per liter, serum albumin 2.9 g/dl. Her white cell count was elevated at 16,000. Her red cells were described as larger than normal in diameter. Her platelet count was reduced. The prothrombin time was prolonged by 7 seconds. An ultrasound scan identified an enlarged liver with a gallstone in the gallbladder, but a normal biliary tree.
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Case VI
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A 53-year old man was admitted with hematemesis and melena. He had not experienced abdominal pain or indigestion, and he had taken no drugs. He drank two to three pints of beer per week and four years previously had undergone a cholecystectomy with removal of calculi from the common bile duct. During this operation, the bile duct was accidentally cut and postoperatively he developed septicemia and peritonitis secondary to the leakage of bile.
On examination, he was pale, but there was no jaundice or stigmata of chronic liver disease. His liver was not palpable, but the spleen was detected 4 cm below the left costal margin. No ascites or hepatic encephalopathy were present. He was anemic, and the platelet count was half normal. The remainder of the blood examination, including liver tests, were normal. Upper gastrointestinal endoscopy confirmed bleeding esophageal varices.
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Case VII
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A 50-year old “bon-vivant” who abused alcohol for thirty years presents with bright red hematemesis. After two unsuccessful attempts to staunch esophageal variceal bleeding with sclerotherapy, a transvenous intrahepatic portosystemic shunt (TIPS) was performed. Post-TIPS, he became more encephalopathic and died.
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Case VIII
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A 60-year-old housewife complains of nagging right upper quadrant discomfort of one month's duration, but otherwise claims good health. The only remarkable finding on exam is an enlarged liver (total span of 17 cm) whose lower edge is 3+ firm. The liver function tests: normal albumin; normal prothrombin time; AST twice normal; alkaline phosphatase four-times normal.
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Extra Question
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You are challenged to distinguish between the abrupt onset of jaundice caused by hemolysis versus extrahepatic obstruction.
Which of these diagnostic tests would help to distinguish between these two entities?
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Extra Question
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A patient undergoes a prolonged surgery to correct injuries sustained during an automobile accident. Jaundice is obvious on the second postoperative day. The conjugated hyperbilirubinemia rises to 30 mg/dL.
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