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
Answer: e)
The scenario and the results would
suggest the patient has haemolytic jaundice. Haemolysis may occur across
prosthetic heart valves but this is usually a low-grade haemolysis and doses
not cause severe jaundice. There were no features to suggest endocarditis.
The fact that he has porto-systemic
encephalopathy indicates that the TIPSS is causing complications and the
jaundice is also likely to be a complication of the shunt.
Transjugular intrahepatic portosystemic
stent shunt (TIPSS) is a procedure in which a shunt is created between the
portal vein and the hepatic veins. It thus reduces portal pressure. It is
mainly used to treat variceal bleeding from oesophageal and gastric varices.
It is also used to treat resistant
ascites, hepatic hydrothorax, hepatorenal syndrome and Budd-Chiari syndrome.
The main complication that results from
a TIPSS is porto-systemic encephalopathy but haemolysis is also a recognised
complication.
