Transcript Paris Case Report - Blackwell Publishing

Progressive Liver Failure following
Gastric Bypass
History
Mrs S.T. is a 37 y/o markedly obese Hispanic
female.
She was hospitalized in 7/02 with the diagnosis
of liver failure for liver transplant evaluation
9/01 (10 months prior to transfer)
Open Roux-en-y gastric bypass operation
No mention of a cirrhotic appearing liver
Anesthetic agents: propofol and fentanyl
Patient lost over 200 lbs from a baseline of
600 lbs
5/02 (2 months prior to transfer)
Spinal fusion operation
Pre-operative anesthesia reports icteric sclera
Labs:
Albumin
Total bilirubin
Direct bilirubin
1.8 g/dl
6.5 g/dl
3.9 g/dl
Alk phos
AST
ALT
184 U/L
96 U/L
92 U/L
2 weeks prior to transfer
Nausea, vomiting, inability to tolerate p.o.’s and
increasing lower extremity edema
At a local hospital, she was treated with diuretics
and antibiotics for a UTI
Past Medical History:
SLE diagnosed at the age of 11
Social:
No history of alcohol abuse or
intravenous drug usage
Family History:
No history of end-stage liver disease
Medications at home:
None
Medications upon transfer:
Protonix 40 mg QD
Tequin 400 mg QD
Lasix 40 mg QD
Physical Examination
General appearance: Obese female
Ht: 5’4” , Wt: 407 lbs
BMI: 69.9
HEENT: Sclera icteric
ABD:
Hepatomegaly of 18 cm,
no shifting dullness
EXT:
1+ pitting edema of lower
extremities
Neuro: A,Ox3, no asterixis
Skin:
No spider angiomata
Laboratory Data
WBC
11.9/ul
Hb
9.4 g/dl
Platelets 157/ul
Creatinine 0.8 g/dl
MELD
20
Albumin
AST
ALT
INR
Total bili
1.4 g/dl
187 U/L
89 U/L
1.48
12.4 g/dl
Abdominal Ultrasound
Echogenic enlarged liver at 19 cm.
No focal masses.
Common bile duct diameter = 6 mm.
No intra-hepatic biliary dilation.
Free fluid around the liver.
Figure – 1 (CT scan of 7/16/02)
Special Laboratory Data
HAV IgM
HBsAg
HCV Ab
ANA
ASMA
Ceruloplasmin
Neg.
Neg.
Neg.
1:40.
Neg.
20 mg/dl.
Iron
TIBC
Ferritin
AMA
P-ANCA
39 ug/dl.
57 ug/dl.
1,536 ng/dl
Neg.
Neg.
The patient underwent transjugular liver biopsy
on July 22, 2002
Figure –2 (Liver biopsy of 7/22/02)