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 Best of Five 2.66



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BOF: 2.66

A 59-year-old male is admitted to your ward with a history of jaundice. The patient has had an aortic valve replacement with a metal valve and is on warfarin on account of this. He is also known to have alcoholic liver disease with cirrhosis of the liver, portal hypertension and oesophageal varices.  A transjugular intrahepatic portosystemic stent shunt (TIPSS) has been inserted to reduce portal pressure and decompress the varices.

He is on warfarin, allopurinol and propranolol

He admits to drinking 10 units of alcohol per week.

On examination, he was deeply jaundiced, afebrile and had a flapping tremor. Pulse 80 beats per minute regular, BP 110/70, JVP not raised, heart sounds native first heart sound, closing click heard instead of a second heart sound, soft systolic murmur at the aortic area, lungs clear abdomen was normal.

Investigations were as follows:


HGB     8.4 L g/dl      (13-18) 
RBC    2.36 L x10^12/l  (4.5-6.0)                       

HCT   0.251 L           (0.4-0.52)                         

 MCV   106.4 H fl        (80-96)                            

MCH    35.6 H pg        (27-32)                           

MCC    33.5    g/dl      (31.5-36.0)                        

WBC         4.3    x10^9/l   (4-11)      

NE       2.6    x10^9/l   (2.0-7.5)

LY        1.0 L x10^9/l   (1.5-4.0)

MO      0.6    x10^9/l   (0.2-0.8)

EO       0.16    x10^9/l   (0-0.4)

BA       0.0    x10^9/l   (0-0.1)                                                                

 PLT      46 L x10^9/l   (150-400)

Serum Folate             5.3       ug/l      (2.0-20.0)
B12                     1410 H    ng/l      (160-900)


ALT                             34       U/L           (13-43)
BILIRUBIN                     299  >> umol/L        (0-17)
ALKALINE PHOSPHATASE           129       U/L           (45-130)
ALBUMIN                         21  << g/L           (36-50)
CALCIUM                       2.00  < mmol/L        (2.10-2.55)


CALCIUM (CORRECTED) 2.45       mmol/L        (2.10-2.55)
C-REACTIVE PROTEIN               8  > mg/L          (up to 5)

Urinary Haemosiderin POS

Abdominal Ultrasound Scan

The liver is small in size.  The TIPSS appears patent with normal blood flow.  The IVC is also patent with normal blood flow.  The gallbladder is distended and contains thick bile sludge.  No gallstones identified.  The spleen is large in size measuring 14.5cm in maximum diameter.  Kidneys and pancreas are unremarkable.  The urinary bladder is distended to the level of the umbilicus.


In this patient the cause of the jaundice is most likely to be:

a) Haemolysis across the prosthetic aortic valve

b) Acute alcoholic hepatitis

c) Carcinoma head of pancreas

d) Infective endocarditis

e) Haemolysis across the TIPSS


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