Liver Case - 2

Liver Case Haematemesis, ascites and jaundice

Case history: Initial presentation: A 58 year old female has experienced gradually increasing malaise, icterus, and loss of appetite for the last 6 months. She has a total bilirubin concentration of 7.8mg/dL, AST of 190U/L, ALT of 220 U/L and alkaline phosphatase of 26 U/L. A liver biopsy shows piecemeal necrosis of hepatocytes at the limiting plate with portal fibrosis and a mononuclear infiltrate in the portal tracts. A few years later: In spite of treatment her condition deteriorates over the following years and she presents to the accident and emergency department with haematemesis. She has a coarse flapping tremor. She is found to have ascites, mild jaundice and an enlarged spleen. Spider naevi are noted on her skin. Her haemoglobin is 9g/dl, and other investigations include an MCV of 102fl normal MCH, a prothrombin time of 20s, albumin 28g/l, and gamma-glutamyl transferase of 150IU/l. The patient is transfused and an upper G.I. endoscopy performed. Learning objectives: At the end of this case you will be able to: 1. Describe the clinicopathological features of chronic hepatitis and discuss the aetiology and histological classification 2. Define cirrhosis and discuss its aetiology. 3. Discuss the complications of cirrhosis and their pathogenesis. Questions: Q1: What is the initial diagnosis? Explain the laboratory findings in this patient. Q2: What are the possible causes of this condition? How would you confirm the cause? Q3: How does a liver biopsy help to predict the outcome of this liver disease? Q4: How is this liver disease classified histologically? Q5: What is the diagnosis a few years later? What is the underlying cause? How would you define this disease pathologically? Q6: What are other causes of this liver disease? Q7: What are the major complications of this liver disease? Which of the patients symptoms and signs can they explain?

Liver Case - 2

Liver Case - Pharmacology

Hepatic toxicology: Paracetamol Overdose
Case history: A 24-year-old woman presents with vomiting that has lasted several hours. The patient admits taking paracetamol but was evasive about the amount taken, and the time of ingestion. Her friend is concerned because the patient mentioned that she took a few extra headache tablets, and considering her recent depression, she suspects she may have taken an overdose. Blood was taken for measurement of plasma paracetamol concentration and a concentration of 170mg/kg was detected. The patient eventually informed a nurse that she began taking paracetamol just after lunch, approximately 10 hours before arrival in the emergency room. She has consumed at least 30 standard tablets (15g).
Learning objectives: Appreciate that paracetamol, a widely available over-the-counter medication for pain and fever relief, is toxic in overdose. Hepatocellular necrosis is the major toxic effect of paracetamol poisoning.

N-acetylcysteine is an antidote to paracetamol and is useful as long as it is administered up to 24 hrs following ingestion. Best results are achieved if administered within 8-10 hrs of overdose.

Questions:

Q1: What is the major toxic side effect of paracetamol overdose? Q2: What is the biochemical basis for the toxicity following paracetamol overdose? Q3: What is the toxic dose and how fast does paracetamol poisoning occur? Q4: What is the antidote for paracetamol poisoning?