Case Study 010

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You have completed Case Study 010. Your score is %%PERCENTAGE%%. %%RATING%%

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Question 1

Mr. B. is a 60-year-old man who came to see his family physician because of fatigue, weight loss, loss of appetite, and difficulty of sleeping. He has been experiencing these symptoms for about a month. He also noticed yellow discoloration of his eyes. His medical history includes systemic hypertension for 10 years for which the patient is taking ACE inhibitor. Mr. B. drinks more than 125 g alcohol and he is a heavy smoker for more than 25 years.

On examination:

Height: 182 cm, Weight: 95.3 Kg, BMI: 28.8
BP: 143/95 mmHg, Heart rate: 92/min, Respiratory rate: 18/min, Temperature: 36.8°C, O₂ SAT: 98%
Yellow discoloration of sclera and skin.
The liver is slightly enlarged and tender on palpation. The spleen can be palpated under his costal margin.

Which of the following lab findings explains the yellow discoloration of Mr. B’s sclera and skin?

A	Elevated serum bilirubin level
B	Marked elevation of serum albumin
C	Hypervitaminosis A
D	Elevated BUN and creatinine
E	Anemia caused by chronic alcoholism

Question 1 Explanation:

The yellowish discoloration of the sclera and skin is called jaundice or icterus. It is caused by hyperbilirubinemia. NOTE: In Canada, the maximum daily recommended amount of alcohol is 3 standard units or 40 gram for men and 3 units for women. Refer to Drinking Guidelines https://iard.org/science-resources/detail/Drinking-Guidelines-General-Population

Question 2

Mr. B’s laboratory investigation showed:

Blood analysis:
- CBC:
  - RBCs: 3.7 x 10¹²/ L, Hemoglobin: 136 g/L, Hematocrit: 0.39,
  - MCV: 104 fL, MCH: 35 pg, RDW: 13.7%, Reticulocytes: 0.9%, ESR: 7 mm/hour,
  - WBC: 9 x 10⁹/l, (Neutrophils: 6.4 x 10⁹/L, Lymphocytes: 1.4 x 10⁹/L, Basophils: 0.07. x 10⁹/L, Eosinophils: 0.34 x 10⁹/L, Monocytes: 0.8 x 10⁹/L),
  - Platelet counts: 197 x 10⁹/L
- Na: 144 mmol/L, K: 3.9 mmol/L,
- Glucose: 6.3 mmol/L, Creatinine: 102.2 umol/L, Uric Acid: 336 mmol/L
- Triglycerides: 3.2 mmol/L, Cholesterol: 6.4 mmol/L, LDL: 3.8 mmol/L, HDL: 1.2 mmol/L
- Total bilirubin: 102 umol/L, conjugated bilirubin: 58 umol/L
- AST: 243 U/L, ALT: 119 U/L, ALP: 223 IU/L, GGT: 743 IU/L, 5'-NT: 29 IU/L, Albumin: 40.21 g/L, LDH: 266 U/L
- INR: 1.5, Prothrombin time: 16 sec
- B₁: 6.4 umol/L, Folic acid: 4.31 nmol/ml
- Viral serology: HBsAg, HCV Ab, HAV IgG: negative

Stool analysis: color: slightly pale, urobilin: +

Based on the laboratory investigations, which of the following disturbances to bilirubin levels applies to Mr. B’s condition?

A	Marked elevation of conjugated bilirubin, but the unconjugated bilirubin level is normal.
B	Both conjugated and unconjugated bilirubin are elevated.
C	Hyperbilirubinemia is caused mainly by the accumulation of unconjugated bilirubin.
D	None of the above.

Question 2 Explanation:

Unconjugated bilirubin can be calculated as the difference between measured total bilirubin and conjugated bilirubin. In this case, the elevation of conjugated bilirubin is caused by hepatocellular damage and conjugated bilirubin leaking into the blood. The elevation of unconjugated bilirubin results from decreased conjugation by the hepatocytes.

Question 3

On performing urinalysis, which of the following findings are expected? (Select all that apply)

A	Dark color
B	High osmolarity
C	Glucosuria
D	Bilirubin is elevated
E	Bacteriuria
F	Hematuria
G	Ketones

Question 3 Explanation:

Since conjugated and unconjugated bilirubin are both elevated in the serum, the conjugated bilirubin will be detected in higher amount in the urine. This gives the urine a darker color. On the other hand, urobilinogen excretion in urine is diminished because urobilinogen would be produced by bowel bacteria from conjugated bilirubin and due to the hepatocellular dysfunction, less conjugated bilirubin is excreted into the small intestine. High osmolarity, glucosuria, bacteriuria and hematuria are not characteristic for jaundice.

Question 4

Have a look at the laboratory results again before you answer the next question.

Blood analysis:
- CBC:
  - RBCs: 3.7 x 10¹²/ L, Hemoglobin: 136 g/L, Hematocrit: 0.39,
  - MCV: 104 fL, MCH: 35 pg, RDW: 13.7%, Reticulocytes: 0.9%, ESR: 7 mm/hour,
  - WBC: 9 x 10⁹/l, (Neutrophils: 6.4 x 10⁹/L, Lymphocytes: 1.4 x 10⁹/L, Basophils: 0.07. x 10⁹/L, Eosinophils: 0.34 x 10⁹/L, Monocytes: 0.8 x 10⁹/L),
  - Platelet counts: 197 x 10⁹/L
- Na: 144 mmol/L, K: 3.9 mmol/L,
- Glucose: 6.3 mmol/L, Creatinine: 102.2 umol/L, Uric Acid: 336 mmol/L
- Triglycerides: 3.2 mmol/L, Cholesterol: 6.4 mmol/L, LDL: 3.8 mmol/L, HDL: 1.2 mmol/L
- Total bilirubin: 102 umol/L, conjugated bilirubin: 58 umol/L, unconjugated bilirubin: 44 umol/L,
- AST: 243 U/L, ALT: 119 U/L, ALP: 223 IU/L, GGT: 743 IU/L, 5'-NTD: 29 IU/L, Albumin: 40.21 g/L, LDH: 266 U/L
- INR: 1.5, Prothrombin time: 16 sec
- B₁: 6.4 umol/L, Folic acid: 4.31 nmol/ml
- Viral serology: HBsAg, HCV Ab, HAV IgG: negative

What is your probable diagnosis based on the liver enzyme elevation pattern?

A	Acute viral hepatitis
B	Chronic active hepatitis
C	Biliary obstruction
D	Alcoholic hepatitis

Question 4 Explanation:

The extremely elevated GGT and AST indicates hepatitis with alcoholic origin. In viral hepatitis, the GGT is only slightly elevated or normal. In biliary obstruction, the GGT and the ALP would be elevated, but the AST would be only slightly elevated or normal.

Question 5

How do you interpret the following results: INR= 1.5 and prothrombin= 16 sec?

A	Both are elevated
B	INR is normal but the prothrombin time is elevated
C	Both are lower than the normal range
D	INR is elevated, but the prothrombin time is normal

Question 5 Explanation:

Please, refer to the “Normal Values of Laboratory Tests” table under Resources. Remember that the liver has a major role to synthesize most coagulation factors, four of those require vitamin K (II, VII, IX, and X). The elevated INR and prothrombin time puts the patient at risk of bleeding.

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