Abnormal liver function found after an unplanned consultation: case progression
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《英国医生杂志》
1 South View Lodge, South View, Bromley, Kent BR1 3DR james.heathcote@gp-G84001.nhs.uk
Last week (31 July, p 273) we presented the case of Mrs Prior, a 40 year old woman who mentioned to her general practitioner that she had cystitis, itching, and rash while attending her husband's consultation. The general practitioner examined her, prescribed treatment for the cystitis and rash, and ordered some blood tests, which showed raised liver enzyme activity and other abnormalities. As a result, he seeks the advice of the biochemistry department and is asked to order a further blood test for autoantibodies.
He telephones Mrs Prior and tells her that the tests have shown some abnormalities but that he needs more information and will see her one week later. At this consultation she is frankly jaundiced and admits to passing dark urine. The presenting symptoms of cystitis and rash are no longer an issue. Examination of her abdomen again shows no abnormality.
The local wait for an NHS ultrasound scan is 12 weeks and the wait for a gastroenterology outpatient clinic appointment is 21 weeks. Patients with suspected cancer will be seen within two weeks of referral. The general practitioner telephones the local consultant gastroenterologist and is advised to refer Mrs Prior routinely and, at the same time, to order an abdominal ultrasound scan, which her family offers to pay for privately.
The ultrasonogram (figure) comes back with the following report:
Mrs Prior's ultrasonogram
The bladder was empty. However, no ascites or enlarged nodes. Gall bladder wall thickened and there are stones in the bladder. There is intra and extrahepatic dilatation and there are stones in the lower half of the common bile duct. The common bile duct is 11mm wide. The pancreas is generally swollen but no focal pancreatic lesion or no pancreatic mass seen. Normal spleen. The liver is prominent and shows very abnormal pattern and presence of hepatic infiltration cannot be ruled out.
Questions
If you were the general practitioner, what would you do now?
What is the differential diagnosis?
Is it right to fast track this referral as a suspected cancer?
If you were the gastroenterologist, what urgency would you assign to this case and would you order further investigations before seeing the patient?
Please respond through bmj.com
Conclusion: There is no pancreatic mass. Stones in the gall bladder and common bile duct but I am quite worried about the liver pattern. The appearance is highly suggestive of hepatic infiltration.
Mrs Prior's sister had ovarian cancer and the couple are terrified that she too might have cancer diagnosed. They suggest selling their car to pay for an urgent specialist opinion.
This is the second of a three part case report where we invite readers to take part in considering the diagnosis and management of a case using the rapid response feature on bmj.com. In three weeks' time we will report the outcome and summarise the responses
Competing interests: None declared.
We welcome contributions of interactive case reports. Cases should raise interesting clinical, investigative, diagnostic, and management issues but not be so rare that they appeal to only a minority of readers.(James Heathcote, general )
Last week (31 July, p 273) we presented the case of Mrs Prior, a 40 year old woman who mentioned to her general practitioner that she had cystitis, itching, and rash while attending her husband's consultation. The general practitioner examined her, prescribed treatment for the cystitis and rash, and ordered some blood tests, which showed raised liver enzyme activity and other abnormalities. As a result, he seeks the advice of the biochemistry department and is asked to order a further blood test for autoantibodies.
He telephones Mrs Prior and tells her that the tests have shown some abnormalities but that he needs more information and will see her one week later. At this consultation she is frankly jaundiced and admits to passing dark urine. The presenting symptoms of cystitis and rash are no longer an issue. Examination of her abdomen again shows no abnormality.
The local wait for an NHS ultrasound scan is 12 weeks and the wait for a gastroenterology outpatient clinic appointment is 21 weeks. Patients with suspected cancer will be seen within two weeks of referral. The general practitioner telephones the local consultant gastroenterologist and is advised to refer Mrs Prior routinely and, at the same time, to order an abdominal ultrasound scan, which her family offers to pay for privately.
The ultrasonogram (figure) comes back with the following report:
Mrs Prior's ultrasonogram
The bladder was empty. However, no ascites or enlarged nodes. Gall bladder wall thickened and there are stones in the bladder. There is intra and extrahepatic dilatation and there are stones in the lower half of the common bile duct. The common bile duct is 11mm wide. The pancreas is generally swollen but no focal pancreatic lesion or no pancreatic mass seen. Normal spleen. The liver is prominent and shows very abnormal pattern and presence of hepatic infiltration cannot be ruled out.
Questions
If you were the general practitioner, what would you do now?
What is the differential diagnosis?
Is it right to fast track this referral as a suspected cancer?
If you were the gastroenterologist, what urgency would you assign to this case and would you order further investigations before seeing the patient?
Please respond through bmj.com
Conclusion: There is no pancreatic mass. Stones in the gall bladder and common bile duct but I am quite worried about the liver pattern. The appearance is highly suggestive of hepatic infiltration.
Mrs Prior's sister had ovarian cancer and the couple are terrified that she too might have cancer diagnosed. They suggest selling their car to pay for an urgent specialist opinion.
This is the second of a three part case report where we invite readers to take part in considering the diagnosis and management of a case using the rapid response feature on bmj.com. In three weeks' time we will report the outcome and summarise the responses
Competing interests: None declared.
We welcome contributions of interactive case reports. Cases should raise interesting clinical, investigative, diagnostic, and management issues but not be so rare that they appeal to only a minority of readers.(James Heathcote, general )