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A 60-year old, markedly emaciated white male was brought in by his sister who found him in his apartment in a state of confusion, completely disoriented and markedly agitated. He had lived alone, was eating poorly and drinking large amounts of hard liquor.
Upon physical examination, he was emaciated, with a distended, protruding abdomen and a postive fluid wave. The skin and mucous membranes were yellow. Mentally, he was slow and drowsy, with prominent slurred speech. A tremor of the hands was evident. Palmar erythema, gynecomastia, and spider nevi were also noted. The liver and spleen were both palpable.
| Serum chemistry values: | (Normal values) | |
|---|---|---|
| sodium (Na) | 135 mEq/L | (136 -146 mEq/L) |
| potassium (K) | 2.9 mEq/L | (3.5 - 5.1 mEq/L) |
| chloride (Cl) | 97 mEq/L | (98 - 106 mEq/L) |
| urea nitrogen | 28 mg/dl | (7 - 18 mg/dl) |
| AST | 274 U/L | (10 - 30 U/L) |
| ALT | 117 U/L | (5 - 30 U/L) |
| Alk. phosphatase | 325 U/L | (50 - 175 U/L) |
| GGT | 163 U/L | (8 - 50 U/L) |
| LD | 667 U/L | (210 - 420 U/L) |
| bilirubin | 5 mg/dL | (0.2 - 1.0 mg/dL) |
| albumin | 2.1 g/dL | (3.5 - 5.0 g/dL) |
| total protein | 5.8 g/dL | (6.4 - 8.3 g/dL) |
Shortly after admission the patient experienced massive hematemesis, which could not be controlled, and he died.
The patient was a 27-year old physician, who worked as a PGY-1 medicine resident in a University Hospital. His chief complaint was fatigue; this was manifested by weakness, flu-like symptoms, and mild fever. He had noticed dark urine and yellow discoloration of his sclera.
His past medical history was unremarkable. He did not remember having any contact with a jaundiced patient. He takes no medications. He has never received a blood transfusion.
Upon physical examination, there was slight enlargement of the liver, and it was tender. He was jaundiced.
| Serum chemistry values: | (normal values) | |
|---|---|---|
| Bilirubin | 15 mg/dL | 0.2-1.0 mg/dL |
| Albumin | 3.8 g/dL | 3.5-5.0 g/dL |
| AST | 1100 U/L | 10-30 U/L |
| ALT | 980 U/L | 5-30 U/L |
| Alk. phosphatase | 200 U/L | 50-175 U/L |
| Hepatitis virus B | Surface antigen positive | |
Clinical course:
The patient made a complete recovery, albeit over a period of 6 months.
This 50 year old man was admitted with the chief complaint of easy fatigability and swelling of legs. He noticed progressive pigmentation of his skin, and has an urge to urinate 5-8 times per day. He is always thirsty. Several of his uncles and his father died of cirrhosis.
Physical findings: Shortness of breath. Tachycardia. Rales over the basal portions of both lungs. Ascities. Pitting edema of lower extremities. The liver is enlarged 2 finger breadth below costal margin and sensitive to palpation.
| Serum chemistry values: | (normal values) | |
|---|---|---|
| Bilirubin | 2.5mg/dL | 0.2-1.0 mg/dL |
| Albumin | 3.1 g/dL | 3.5-5.0 g/dL |
| AST | 70 U/L | 10-30 U/L |
| ALTIron | 100 U/L360 mcg/dL | 5-30 U/L50-160mcg/dL |
| Transferrin | 8 g/L | 2-4 g/L |
| (Saturation)Glucose | 80% 180 mg/dL | 20-55% 70-115 mg/dL |
| Prothrombin time | 20 seconds | 11-13.5 seconds |
Liver biopsy was performed. It showed signs of cirrhosis and massive deposits of hemosiderin in liver cells, Kupffer cells and bile duct epithelium.
A 30 year old woman presents with jaundice and long-standing itch, mild upper abdominal quadrant pain, weight loss, anorexia. Xanthomas are present on the eyelids. She noticed that her stools were yellow.
| Serum chemistry values: | (normal values) | |
|---|---|---|
| Albumin | 3.0 | 3.5-5.0 g/dL |
| Bilirubin | 12 mg/dL | 0.2-1.0 mg/dL |
| Alkaline phosphatase | 480 U/L | 50-175 U/L |
| Cholesterol | 520 mg/dL | < 220 mg/dL (for her age) |
Antimitochondrial antibodies positive 1:520
66 year old man with past history of viral hepatitis 20 years ago. Since then he was more or less healthy until 2-3 months prior to admission.
Chief complaint:
Upper abdominal pain. Distended abdomen. Edema of legs.
Physical findings:
Weak, appears cachectic. Enlarged liver. Ascites. Splenomegaly.
Abdominal tap revealed blood in ascites.
Special Studies:
A CT scan shows a large mass in the liver.
| Serum chemistry values: | (Normal values) | Albumin | 2.1 g/dL | 3.5-5 g/dL |
|---|---|---|
| AFP | 4,000 mg/L | <40 mg/L |
| Prothrombin time | 18 seconds | 11-13.5 seconds |