Gastroenterology studies

CONSULTATION

He received multiple transfusions for his multiple vascular surgeries.  There was no history of any jaundice following any of these transfusions, although he relates some jaundice many, many years ago with the etiology at that time being unclear.  He has manifested no symptoms referable to liver disease and generally remains asymptomatic in this regard.  There is no history of significant alcohol intake, recent travel, and the only drug one could implicate in his hepatitis is Aldomet, which he has been on for only 1 year.

His physical examination revealed that his liver extended 3 to
4 fingerbreadths below his right costal margin and was firm; however, no other signs of liver disease, namely, spider angiomata or palmar erythema were present.  We have found that his SGOT was elevated at least as far back as February.  Several repeat blood tests have shown varying degrees of elevation of the bilirubin and transaminases.  Additionally, his globulins have been elevated, and his prothrombin time has been mildly prolonged to approximately 50% of control.

It seems likely that Mr. (blank) has chronic liver disease from his transfusions in the 1970s, the etiology being non-A non-B.  It is unlikely that Aldomet is contributing to his elevated transaminases as the elevations have been documented prior to the Aldomet usage.  The possible chronic liver diseases include chronic persistent hepatitis, chronic active hepatitis, and the possible development of cirrhosis.  I am concerned about the development of cirrhosis in view of the prolonged prothrombin time and the elevated globulin level, although one cannot be sure regarding this diagnosis without a liver biopsy.  In view of his mild enzyme elevations, his asymptomatic state in regard to his liver disease, despite a liver biopsy showing chronic active hepatitis, I could not imagine treating him with immunosuppressive therapy in view of his age and general medical condition.  Additionally, it is still unknown at this time what the natural history of this disease is, as well as whether there is any significant response to steroid therapy in terms of prognosis.  As well, with his mildly prolonged prothrombin time, this would pose a slightly increased risk of the liver biopsy that at this time I do not feel is warranted in view of the unlikelihood of any treatment based on the liver biopsy findings.

We will simply watch him and have repeat liver tests in approximately 3 months.  Should the disease progress in any way or he become symptomatic or new data become available on the use of steroids in the treatment of non-A non-B chronic liver disease, then we may reassess the need for the liver biopsy at that time.

FOOTNOTE

Lines 17, 18 (Page 1).  Alternative:  3-4.

Line 18 (Page 1).  The comma dictated before the however clause was changed to a semicolon to correct the punctuation error.  To reduce the awkwardness of the sentence, the connector or was inserted between angiomata and palmar.

Lines 24, 34, 35, 44 (Page 1).  The brief form pro time (written as 2 words) was dictated and is expanded to prothrombin time.

Line 28 (Page 1).  The dictated period was changed to a comma for correct punctuation.

Line 37 (Page 1).  Regards (meaning sentiments) was changed to regard (meaning concerning).