QUIZ: Enlarged liver *solved*

Sunday, 13 December 2009 01:54

45-years old male is worried about a quick enlargement of his abdomen circumference
The physician recognizes ascites.
Physical examination: liver enlarged (3cm under costal arcus)

Additionally patient complains about permanent sleepiness, arthralgia and gastrointestinal dysfunctions.
In basic laboratory tests: high AspAT and AlAT, fasting glycaemia - 150

The patient claims, he is an abstinent
Professional history - irrelevant
Family history - his father died in age 60 for heart infarct, mother lives - she has diabetes mellitus type II.
Sibling: older sister with dermatitis athopica, twin-brother - healthy, plays sports and he's blood donor.

QUIZ questions: We are looking for as the cause of that condition.
Which tests we will order for confirmation?

Comments

0 #1 mariusz02042 2009-12-13 12:33

The cause of the affliction could be one of the following:
congestive heart failure, non alcoholic fatty liver, viral hepatitis (types a, b, c) or a neoplasm

For lab tests I would suggest: sugar, cholesterol and liver enzymes levels, mark antigens and antibodies, make a CT scan or a biopsy of the liver

Cheers :-)))

-1 #2 MMader 2009-12-13 12:56

Does every patient with such symptoms receives such broad and expensive diagnostic point blank? It's not "dr.House", where there is a MRI done right away for a simple itch

Let's put ourselves in a place of the doctor receiving such patient.
Country hospital - decent enough, but nothing too flashy equipment wise.
The doctor should diagnose the patient but should also try to keep his job (because, for example liver biopsy without earlier tests for coagulation factors could have a miserable finale)

Cheers :-)

+1 #3 silver 2009-12-13 18:36

Let's measure the urea and creatinine levels and make a coagulogram. For a good start let's make an USG of the abdomen, it won't cost us a fortune :-) What are the results?

0 #4 Anna Kamińska 2009-12-13 19:36

I'd test the iron metabolism and do a liver biopsy. Throw in a whole liver panel to that as well, for full assessment - ALT ASP, bilirubin, albumins, PT and APTT. Anyways, I think the patient has hemochromatosis . His brother doesn't have the symptoms because he's a blood donor thus getting rid of the iron excess (if they're mono zygotic twins there's no point in diagnosing the brother, if not the he should also be diagnosed)

0 #5 mariusz02042 2009-12-13 20:02

I still don't have the results, without the biopsy :-)

0 #6 MMader 2009-12-15 00:58

Mariusz: the results from portion of the tests you asked about are in the case description:
- increased glicemia
- HBV and HCV negative
- There is no fatty liver, only cirrhosis
- The USG excluded any changes suggesting a neoplasm

dr.Fish found the answer. The patient has hemochromatosis , which can be suspected due to correlated presence of cirrhosis and diabetes.
If the two brothers were to be placed together side by side, we could observe a darker skin in the sick one. The brothers are mono zygotic twins. The sister also has hemochromatosis but women, because of the menstrual bleeding develop the symptoms much later.

It's a shame the case was solved so quickly, I guess I gave too many obvious clues in the case description, although about a year ago my friends were having quite a trouble solving this one.

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