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Man with Abdominal Pain and Jaundice

Tuesday, March 16, 2010

32 Years old man was admitted to the medicine ward complaining of feeling tired for last 3weeks associated with yellowish discoloration of eyes.And he also complained that he had on and off abdominal pain for about 1week duration.There  is no history of fever,nausea,vomiting,loss of weight or loss of appetite.He has undergone appendectomy when he was 5 years.There was no significant past medical history or drug history.

On General Examination he looked well but mildly icteric.
Abdominal Examination - Mild tenderness in the upper quadrant of the Abdomen and there was a palpable mass in the upper left quadrant felt 3cm below the costal margin. 

  • What  are the differential diagnosis???

FBC,Blood Picture,Biochemical tests  were done


Full blood Count
  • HB        11.8g/dl
  • MCV     103fl
  • MCH     30pg/cell
  • MCHC   36g/dl
  • RBC      6x1012/l
  • WBC     10.5x109/l
  • Reticulocyte count  130x109 /l

Biochemical Tests
  • Bilirubin 25umol/L (0-17umol/L)
  • LDH 680IU/L(220 - 450 IU/L)
  • Coombs' test was negative 

Blood Picture




  •  What are the abnormalities in this blood picture??
  •  What further tests that you would need to do for a defenitive diagnosis??
  •  What is your diagnosis??


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13 Responses to Man with Abdominal Pain and Jaundice

  1. Anonymous Says:
  2. Chronic hepatitis leading 2 portal hypertention leading 2 spleenomegaly...coupld with macrocytic anemia( MCV increasd n reticulocytosis)

     
  3. hereditary spherocytosis

    lab work indicates hemolysis
    splenomegaly indicated chronic hemolytic diseases
    it is nonimmune, since coomb's is negative
    peripheral smear seems like spherocytes

     
  4. 32 M with Tender Hepatosplenomegaly, Mild Jaundice, mild anemia, macrocytosis in per.Blood with raised LDH and a Rett. Index <2.5 suggests that there is hypoproliferation of marrow. Everything can be explained by Megaloblastic Anemia. Other D/Ds are Alcoholic Hepatitis (CHeck AST/ALT and viral markers), MDS (marrow analysis), Infiltrative marrow disorders such as Amyloidosis, Glyc. Storage Dis etc.
    B12 estimation, Schilling's test and Marrow morphology is suggested.

     
  5. Anonymous Says:
  6. may be he has an autoimmune hepatitis associated with other autoimmune diseases as pernicious anaemia a;so associated with spleenomegally....

    dr.winzo

     
  7. Anonymous Says:
  8. arash from iran


    lets look out to positive points:

    1)jaundice
    2)reticulocytosis
    3)macrocytosis , MCV>100
    4)elevated LDH
    5)mild anemia
    6)splenomegaly
    7)MCHC>35

    jaundice can be explained by hemolysis, macrocytosis can be explained by hemolysis due to increasing in nucleated RBC and reitculocytes which have large cytoplasm ,hemolysis also increase LDH level ,so macrocytosis,elevated LDH and jaundice can be explained by hemolysis, so it is better to approach to hemolysis


    this list shows us DDx of hemolysis

    Extravascular destruction of red blood cells
    IExtravascular destruction of red blood cells
    Intrinsic red blood cell defects
    Enzyme deficiencies (eg, G6PD or pyruvate kinase deficiencies)
    Hemoglobinopathies (eg, sickle cell disease, thalassemias, unstable hemoglobins)
    Membrane defects (eg, hereditary spherocytosis, elliptocytosis)
    Extrinsic red blood cell defects
    Liver disease
    Hypersplenism
    Infections (eg, bartonella, babesia, malaria)
    Oxidant agents (eg, dapsone, nitrites, aniline dyes)
    Other agents (eg, lead, snake and spider bites)
    Microangiopathic (eg, DIC, TTP-HUS)
    Autoimmune hemolytic anemia (warm- or cold-reacting, drugs)
    Intravenous immune globulin infusion
    Large granular lymphocyte leukemia
    Intravascular destruction of red blood cells
    Microangiopathy (eg, aortic stenosis, prosthetic valve leak)
    Transfusion reactions (eg, ABO incompatibility)
    Infection (eg, clostridial sepsis, severe malaria)
    Paroxysmal cold hemoglobinuria
    Paroxysmal nocturnal hemoglobinuria
    Following intravenous infusion of Rho(D) immune globulin
    Following intravenous infusion with hypotonic solutions
    Snake bites

    remember coombs test just show us autoimmune causes of hemolysis , so autoimmune causes is excluded.

    now select from mentioned list, those which can cause splenomegaly

    G6PD def. and PK def.
    thalasemia
    spherocytosis
    liver dx
    hypersplenism
    infections
    paroxysmal nocturnal hemoglobinuria

    ok , our DDx is more narrow

    if we do not note to MCHC all above disease can explain jaundice , hemolysis , reticulocytosis , elevated LDH ,splenomegaly , macrocytosis and anemia BUT ONLY SPHEROCYTOSIS HAS ELEVATED LEVEL OF MCHC , IN SPHEROCYTOSIS MCHC IS MORE THAN 35 SO DIAGNOSIS IS SPHEROCYTOSIS

    remmeber in spherocytosis MCHC is more than 35 but MCV usually is NORMAL OR LOW

    in this case elevated MCV can be explained by hemolysis and release of young , large RBC or by mild megaloblastic anemia due to hemolysis , but typical case of spherocytosis has normal to low MCV

    film shows macrocytosis and decreased CENTRAL PALLOR OF RBC in favor of spherocytosis

    diagnosis can be made by osmotic fragility test and flow cytometery

     
  9. Anonymous Says:
  10. MCHC is increased in sperocytosis but MCV is normal , maybe the patient has co existing folate deficiency or parvo virus infection but again in that situation we usually see severe anemia and here the patient has mild anemia.

    I think liver function tests should be done cuz might be the patient has some liver disease that is causing portal hypertension and splenomegaly.

    Dr khan from Canada

     
  11. Anonymous Says:
  12. the Reticulocyte count is 130x109 /l but we should calculate RPI and RPI is less than 2.5 so it is hypoproliferative anemia and can R/O hemolytic anemia and spherocytosis and etc . . .
    in the hypoprolifrative macrocytic anemia category alcoholic hepatitis can cause splenomegaly
    I think alcoholic hepatitis is correct

     
  13. Anonymous Says:
  14. arash from iran ur amazn

     
  15. Admin Says:
  16. Ususally in spherocytosis MCV is low or normal and high MCHC.
    This patient has Reticulocytosis that means bone marrow is producing young red cells that are larger than normal RBC which will result in high MCV.
    In megaloblastic anamia there is an ineffective erythropoisis and blood counts will show pancytopenia and low reticulocyte count.Here WBC count is within normal range.

     
  17. Anonymous Says:
  18. Heriditory spherocytosis

     
  19. Anonymous Says:
  20. heriditary spherocytosis
    osmotic fragility test

     
  21. anak Says:
  22. Fever with mild jaundice and acute anemia --> acute hemolysis suspect hereditary spherocytosis

     
  23. kaney Says:
  24. Sickle cell anemia is an anemic condition which is genetically inherited and causes the red blood cells to form in an abnormal way. Normal red blood cells are round in shape and carry oxygen throughout the body, however, with sickle cell anemia the cells are more of a "C" shape or crescent moon which causes them to become lodged in blood vessels which slows down the flow of blood and oxygen throughout the body.

    Mag Glycinate D3 5000

     

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