Conversation 1

A 28 year old man presented with recurrent abdominal pain on the right side for the past 6 weeks. The pain was worse with food and was relieved within one to two hours after antacids. He was admitted to the hospital because of increased severity of pain. He also reported one episode of non-bilious vomiting when the pain was intense the day before admission.

He had been diagnosed in the past to have non-alcoholic fatty liver disease as well as Gilbert’s syndrome.

On examination he was obese. He was jaundiced but without any stigmata of chronic liver disease. There was mild tenderness of the right upper and lower quadrants of the abdomen. There was no rebound tenderness. The spleen was enlarged.

His full blood count showed normal values for haemoglobin and platelets. The total white cell count was increased with predominant neutrophils. His glucose, urea and creatinine were normal. The total bilirubin was increased with increases in both direct and indirect bilirubin. The serum ALT was elevated almost 4 times the upper limit of normal (ULN) while serum AST was also elevated to approximately 3 times the ULN. The alkaline phosphatase value was normal. The serum albumin and INR were also both normal. Serum lipase was normal. A CT of the abdomen showed a normal size liver with infiltration of fat in the parenchyma. He had splenomegaly. No gall stones were seen and there was no dilatation of the biliary tract. No evidence of cholecystitis was seen.

He was treated with antibiotics. Soon the pain became less. But his serum bilirubin, ALT, AST and Alkaline phosphatase values increased further. His total serum bilirubin was now 334umol/L with direct bilirubin of 192umol/L (previously 44umol/L) and indirect bilirubin of 142umol/L (previously 115umol/L). He was negative for HBsAg but tested positive for antibodies to HBsAg. Antibodies to Hepatitis A, Hepatitis C and Hepatitis B core antigen were negative. Serum ceruloplasmin was normal. Antinuclear antibodies and anti-mitochondrial antibodies were negative. Ultrasound examination showed thickening of the gall bladder wall, sludge in the gall bladder and pericholecystic fluid.

He responded well to treatment with antibiotics and he improved clinically and his liver function test too showed improvement with decreases in bilirubin and transaminases and alkaline phosphatase.

After he was discharged, it was brought to record that, 2 years earlier, he had been documented to have elevated levels of indirect bilirubin and serum LDH. Also he had a low serum haptoglobin, normal haemoglobin and an increased mean cell haemoglobin concentration. At that time his ALT, AST and Alk phosphatase were all normal. The doctors also learnt that his father had undergone cholecystectomy for gall stones at a young age.

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