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Haematology. Group A. Patient X. A 61 year old male Presents with: generalised weakness & increasing dyspnoea on exertion for 3/52. Medical History: Alcoholism Social History Divorced for 2 years Lives Alone Retrenched 6 years ago; has not worked since. Mr X cont…. On Examination:

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Haematology l.jpg

Haematology

Group A


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Patient X

  • A 61 year old male

  • Presents with:

    • generalised weakness & increasing dyspnoea on exertion for 3/52.

  • Medical History:

    • Alcoholism

  • Social History

    • Divorced for 2 years

    • Lives Alone

    • Retrenched 6 years ago; has not worked since


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Mr X cont…

  • On Examination:

    • Pallor and scleral icterus were noted

    • Clinical evidence of chronic alcoholic liver disease with portal hypertension

    • Spleen was palpable (2cm).


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Mr X’s Biochemistry - FBC

  • Initial biochemistry:

  • Blood flim:

    • Marked anisocytosis (oval macrocytes +++)

    • Poikilocytes (tear drop & fragmented cells ++)

    • Red cells normochromatic

    • Neutropenia with marked neutrophil hypersegmentation

    • Thrombocytopenia.



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Portal Hypertension

  • Pressure in the hepatic portal vein is increased

  • Most common cause is cirrhosis, but any liver disease can cause it

  • In cirrhosis, hepatocytes regenerate more slowly than scar-tissue forms

    • As the scar tissue shrinks, it obstructs blood flow through the hepatic portal system


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Symptoms of Portal Hypertension

  • Common portal hypertensive complications include:

    • Hepatic encephalopathy

    • Bleeding esophageal varices

    • Ascites & spontaneous bacterial peritonitis

    • Hepatorenal syndrome


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Alcoholic Liver Disease

  • A spectrum of clinical syndromes & pathologic changes in the liver caused by alcohol. The spectrum includes fatty liver, alcoholic hepatitis & alcoholic cirrohsis.

  • Approximately 15% to 20% of those who abuse alcohol develop alcoholic hepatitis and/or cirrhosis, which may develop in succession or exist concomitantly

  • The level of alcohol consumption necessary for the development of these advanced forms of alcoholic liver disease is probably 80 g of alcohol per day, the equivalent to 6 to 8 drinks daily for several years

  • BUT, the threshold of alcohol necessary for the development of advanced alcoholic liver disease varies substantially among individuals


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Alcoholic Fatty Liver

  • Also called steatosis

  • Predominantly an asymptomatic condition that develops in response to a short duration (a few days) of alcohol abuse

  • Up to 15 drinks a day for 10 days

  • Entirely reversible with abstinence


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Alcoholic Hepatitis

  • Prolonged alcohol abuse results in alcoholic hepatitis.

  • Patients with this condition have various constitutional symptoms, such as fatigue, anorexia, weight loss, nausea and vomiting.

  • Severe alcoholic hepatitis may be evident by advanced symptoms due to portal hypertension, including gastrointestinal (GI) bleeding, ascites, and hepatic encephalopathy.

  • Other findings depend on the severity of liver insult and may include jaundice, splenomegaly, hepatic bruits, collateral vessels, and ascites.

  • Reversible if patients stop drinking


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Alcoholic Cirrhosis

  • Alcoholic cirrhosis may occur before, concomitant with, after, or independent of a bout of alcoholic hepatitis

  • Characterized anatomically by widespread nodules in the liver combined with fibrosis

  • Most common of specific organ damage in alcoholics

  • The clinical history is similar to that of alcoholic hepatitis, & symptoms are similar to those observed with other forms of end-stage liver disease


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Bilirubin

  • Bilirubin: A break-down product of haemoglobin

  • Dying RBCs are engulfed & destroyed by macrophages

  • Heme is split from globin & the iron core is salvaged

  • The remaining heme molecule is degraded to bilirubin


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Bilirubin

  • Unconjugated bilirubin is transported in the plasma bound to albumin

  • This free bilirubin is conjugated with glucuronic acid in the liver.

  • The conjugated bilirubin is then secreted in the bile as an orange-yellow pigment


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Bilirubin & Liver Disease

  • Generally, liver disease leads to mixed hyperbilirubinemia, i.e., high levels of both circulating (unconjugated) and conjugated bilirubin. (Total=84, range: 2-20) and conjugated 44 micro mol/L, range: 1-4

  • This is due to impaired liver uptake of unconjugated, and impaired excretion of conjugated bilirubin from bile duct perhaps due to gallstones, hepatitis, trauma or long term alcohol abuse

  • Also, an increase in bilirubin may mean too many RBC are getting destroyed


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Mr X – are his bilirubin results consistent with alcoholic liver disease?

  • Hyperbilirubinemia: excess of bilirubin in the blood

    • Visible jaundice occurs at ~20-30μmol/L

    • The patient has jaundice (scleral icterus)

  • History of alcoholism

  • Mr X has mixed hyperbilirubinemia


  • Lactate dehydrogenase ld l.jpg
    Lactate Dehydrogenase (LD) liver disease?

    • Cytoplasmic enzyme

    • Its function is to catalyze the oxidation of L-lactate to pyruvate

      • Assayed as a measure of anaerobic carbohydrate metabolism

    • Present in heart, liver, kindey, lungs, skeletal muscle and brains

    • Used as a diagnostic marker for MI, muscular disorders, malignancy and liver disease

    • Not a specific marker


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    Increased Levels Indicate: liver disease?

    • MI

    • Stroke

    • Anaemia

    • Hypotension

    • Liver disease

    • Megaloblastic anaemia

    • Perniciour anaemia


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    When is LD testing Performed liver disease?

    • Possible diagnosis:

      • Anaemia of Vitamin B12 deficiency

      • Megaloblastic anaemia

      • Perniciour anaemia

    • LD isoenzyme levels may be requested


    Lactate dehydrogenase liver disease l.jpg
    Lactate Dehydrogenase & Liver Disease liver disease?

    • LD has several isoenzymes (LD-1 to LD-5)

    • LD-1 and 2

      • MI, Renal infarction, megaloblastic anaemia

    • LD-2 and 3

      • Acute leukaemia

    • LD-5

      • Liver and skeletal muscle damage


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    What this tells us: liver disease?

    • Tissue damage

    • Possible liver disease

    • Possible anaemia

    • Muscle injury

    • MI


    Haptoglobins l.jpg
    Haptoglobins liver disease?

    • Plasma proteins that carry “free” haemoglobin (i.e., Hb NOT in RBCs)

    • Blood levels used to detect haemolysis (intravascular destruction of RBC)

      • Normally ~10% of haemolysis is handled by haptoglobins and haemopexin

      • Haemolysis > Haptoglobin synthesis  decrease in serum haptoglobin

    • Lower than normal levels may indicate chronic liver disease, haemolytic anaemia, primary liver disease, AMI and some cancers

    • Increased levels in certain chronic diseases and inflammatory disorders


    Mr x are his haptoglobin results consistent with alcoholic liver disease l.jpg

    Parameter liver disease?

    Value

    Reference Range

    Haptoglobin

    0.3g/L

    0.3-2.0g/L

    Mr X – are his haptoglobin results consistent with alcoholic liver disease?

    • 0.3g/L is boarder-line low for the normal range (0.3 – 2.0g/L)


    Ferritin l.jpg
    Ferritin liver disease?

    • An iron compound synthesised in response to erythrophagocytosis

    • Ferritin is stored in the liver, spleen & bone marrow for eventual encorporation into haemoglobin

    • Ferritin iron is the principle form of iron storage therefore serum ferritin levels indicate the body’s iron stores


    Ferritin24 l.jpg
    Ferritin liver disease?

    • Two main functions:

      • sequester potentially toxic iron into the apoferritin protein shell

      • provide a readily accessible store of iron

    • Can be used to diagnose iron deficiency anaemia

      • In combination with serum iron and total iron-binding capacity tests, it can differentiate and classify different types of anaemia's


    Mr x are his ferritin results consistent with alcoholic liver disease l.jpg

    Parameter liver disease?

    Value

    Reference Range

    Ferritin

    442μg/L (H)

    33-330μg/L

    Mr X – are his ferritin results consistent with alcoholic liver disease?

    • 442μg/L is significantly higher than the upper normal range (33-330μg/L)

    • This suggests a high level of erythrophagocytosis, most likely due to severe inflammatory liver disease


    Folate vitamin b 9 l.jpg
    Folate (Vitamin B liver disease? 9)

    • Obtained from green, leafy vegetables

    • Total body folate is ~70mg

      • 1/3 of this is stored in the liver

    • In folate deficiency anaemia, the red cells are abnormally large (“megalocytes”)

      • Precursors, in the bone marrow are “megaloblasts”

      • Thus, this anaemia is referred to as megaloblastic anemia


    Folate deficient anaemia l.jpg
    Folate–Deficient Anaemia liver disease?

    • Causes of the anaemia are poor dietary intake of folic acid as in chronic alcoholism

    • Causes of folic acid depletion include:

      • Poor intake (e.g., chronic alcoholism, diet lacking in fresh vegetables)

      • Inadequate absorption/malabsorption syndrome (e.g, drug-induced by phenytoin, primidone, barbiturates; celiac disease)

      • Inadequate utilisation via antagonists such as methotrexate and trimethoprim

    • Alcohol also interferes with its intestinal absorption, intermediate metabolism & entero-hepatic salvage


    Megaloblastic anemia l.jpg
    Megaloblastic Anemia liver disease?

    • Results from defective DNA synthesis. RNA synthesis continues  increased cytoplasmic mass & maturation

      • I.e., All cells have dyspoiesis: cytoplasmic maturity > nuclear maturity  production of megaloblasts

      • Dyspoiesis  increased intramedullary cell death  hyperbilirubinemia & hyperuricemia

      • All cell lines are affected, so leukopenia & thrombocytopenia may occur

    • Main causes: defective utilisation of folic acid or vitamin B12 deficiency; cytotoxic drugs; Di-Guliemo Syndrome


    Mr x are his results consistent with megaloblastic anaemia l.jpg

    Parameter liver disease?

    Value

    Reference Range

    Serum B12

    138 pmol/L

    120-680

    Serum folate

    0.7 nmol/L (L)

    7-45

    Red cell folate

    125 nmol/L (L)

    360-1400

    Mr X – are his results consistent with megaloblastic anaemia?

    • The patient’s Hb is low, indicating anaemia, while his elevated MCV indicates macrocytic anaemia.

    • The patient has a serum folate of 0.7nmol/L, & a RBC folate level of 125nmol/L which are well below the normal ranges. His serum B12 is within the normal range

      • Normal serum B12 assay with a low RBC folate level are consistent with alcoholism

    • Both of these results

      also support the diagnosis of

      megaloblastic anaemia due

      to folic acid deficiency.


    Mr x s biochemistry fbc30 l.jpg
    Mr X’s Biochemistry - FBC liver disease?

    • Initial biochemistry:

    • Blood flim:

      • Marked anisocytosis (oval macrocytes +++)

      • Poikilocytes (tear drop & fragmented cells ++)

      • Red cells normochromatic

      • Neutropenia with marked neutrophil hypersegmentation

      • Thrombocytopenia.


    Mr x are his results consistent with megaloblastic anaemia31 l.jpg
    Mr X – are his results consistent with megaloblastic anaemia?

    • Mr X’s neutrophils are below the normal range.

      • This tends to occur in chronic disease states and megaloblastic anaemias

    • Hypersegmentation of neutrophils occurs in 91% of cases megaloblastic anaemia


    Conclusions l.jpg
    Conclusions anaemia?

    • Mr X is experiencing multiple biochemical changes due to his chronic alcohol intake.

    • Treatment for him is primarily supportive. He needs to improve his diet, and ideally, should cease alcohol intake.

    • Corticosteroids may be indicated.


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