Kingdom of Saudi Kingdom of SaudiArabiaArabia

King Fahd HospitalKing Fahd Hospital

JeddahJeddah

Internal MedicalInternal Medical DepartmentDepartment

Mortality MeetingMortality Meeting

:By:By

Gastro. teamGastro. team

Dr. Wail Ali BajhmoomDr. Wail Ali Bajhmoom

A.D 23.4.1426 A.H 31.5.2005A.D 23.4.1426 A.H 31.5.2005

History.History.Physical examination. Physical examination. DDx.DDx.Investigations. Investigations.

Diagnosis .Diagnosis .Treatment.Treatment.Hospital Course.Hospital Course .Discussion.Discussion.

:History:History

25-year-old , Lady, 25-year-old , Lady,

.Somalia.Somalia E.RE.R 16.2.1426 A.H (9:10 a.m). 16.2.1426 A.H (9:10 a.m).

C/O : yellow discoloration of her C/O : yellow discoloration of her

eyes 1/12 eyes 1/12

She was not known to have any She was not known to have any Medical ilness .Medical ilness . 1 mth prior to admission she had1 mth prior to admission she had jaundice associated fever & rigor . jaundice associated fever & rigor . No clear localizing symptomsNo clear localizing symptoms

for the fever.for the fever.

Just 2 wk prior to the episode of Just 2 wk prior to the episode of

jaundice she went to a polyclinic jaundice she went to a polyclinic

& was given drugs ? for neck& was given drugs ? for neck

problem ??problem ??

“ “ not a swelling “ not a swelling “

She also had a mild epigastric She also had a mild epigastric

abdominal pain for which sheabdominal pain for which she

had a cautery.had a cautery. Loss of appetite but no loss Wt. Loss of appetite but no loss Wt. She had been in KSA for 4 y She had been in KSA for 4 y

& never traveled anywhere& never traveled anywhere . .

Se denied any drugs use or abuse.Se denied any drugs use or abuse.

including herbals .including herbals . No Hx contact w/ No Hx contact w/

- jaundice pt.- jaundice pt.

-T.B pt .-T.B pt .

-animals. -animals. No family Hx of T.BNo family Hx of T.B

She had benign past HxShe had benign past Hx

-no blood transfusion.-no blood transfusion.

-no hospital admission.-no hospital admission.

-Hx malaria treated in-Hx malaria treated in

Somalia >5ySomalia >5y

-not D.M , HTN -not D.M , HTN

-not asthmatic -not asthmatic

No Hx allergy.No Hx allergy. Non smoker or alcohol drinker .Non smoker or alcohol drinker . She was divorced , came to KSA She was divorced , came to KSA

for Omrah 4 years ago .for Omrah 4 years ago . Socioeconomic life. Socioeconomic life.

:Summary:Summary

25 years Somali lady w/ benign 25 years Somali lady w/ benign

past Hx presented w/ past Hx presented w/

11stst episode of jaundice for 1 mth episode of jaundice for 1 mth

ass. wl fever & rigor w/ no Hx of ass. wl fever & rigor w/ no Hx of

T.B ;travel ;blood Tx ;herbal or T.B ;travel ;blood Tx ;herbal or

drugs use …drugs use …

General appearance: General appearance:

-well looking.-well looking.

-deeply jaundiced.-deeply jaundiced.

-not pale.-not pale.

-no L.N enlargement.-no L.N enlargement.

-no L.L edema. -no L.L edema.

Physical ExaminationPhysical Examination::

-No stigmata of C.L.D .-No stigmata of C.L.D .

- conscious & oriented.- conscious & oriented.

Vitals: Vitals:

B.P 103/55 R.R 18B.P 103/55 R.R 18

Temp. 36.6 P.R 65 reg.Temp. 36.6 P.R 65 reg.

Abdomen : Abdomen :

-no distention. -no distention.

-soft &lax.-soft &lax.

- no tenderness. - no tenderness.

-hepatomegaly of 4cm b.c.m. -hepatomegaly of 4cm b.c.m.

-tip of spleen was palpable. -tip of spleen was palpable.

Chest : clear Chest : clear

C.V.S : normalC.V.S : normal

C.N.S : intact C.N.S : intact

Acute hepatitis “ viral “ Acute hepatitis “ viral “ Exacerbation of ch. hepatitis.Exacerbation of ch. hepatitis. Drug or herbal meds. Induced .Drug or herbal meds. Induced . Autoimmune .Autoimmune . Or Budd-Chiari.Or Budd-Chiari.

:DDx:DDx

Investigations :Investigations : C.B.C : Hb 15.2C.B.C : Hb 15.2

WBC 11.8WBC 11.8

Plt 172Plt 172 BUN 8 ; Cr. 0.6BUN 8 ; Cr. 0.6

Na 139 ; K 3.2Na 139 ; K 3.2

glucose 200 ; Alb 2.4glucose 200 ; Alb 2.4

AST 413 ; ALT 1256AST 413 ; ALT 1256

LDH 620 ; AlP 148LDH 620 ; AlP 148

T.bili 32.1 ; D.bili 22.9T.bili 32.1 ; D.bili 22.9

PT 39.4/12 ; PTT 82.5/35.6PT 39.4/12 ; PTT 82.5/35.6

E.C.G : Sinus bradycardia.E.C.G : Sinus bradycardia.

Urinalysis: Bile pigment ,few cast ,Urinalysis: Bile pigment ,few cast ,

WBC 3-5 ,RBC 1-2 HPFWBC 3-5 ,RBC 1-2 HPF

Upper GI endoscopy : Normal Upper GI endoscopy : Normal

Abdominal US: Abdominal US:

- Thick wall G.B- Thick wall G.B

- C.B.D 6 mm- C.B.D 6 mm

- portal vein 11.3 mm- portal vein 11.3 mm

- Homogeneous liver wl- Homogeneous liver wl

hepatomegaly 15.4 cmhepatomegaly 15.4 cm

- no focal lesion - no focal lesion

- normal pancreas - normal pancreas

- mild spleenomegaly 13.8 cm- mild spleenomegaly 13.8 cm C.T scan of Abdomen :C.T scan of Abdomen :

- hepatomegaly, intrahepatic biliary - hepatomegaly, intrahepatic biliary duct dilatation, course texture of the liver duct dilatation, course texture of the liver finding suggest of CLD.finding suggest of CLD.

- otherwise normal . - otherwise normal .

Treatment & Hospital Treatment & Hospital:Course:Course

Patient spent about 12 daysPatient spent about 12 days

at hospital .at hospital .

IVF D5NS 2 L / day .IVF D5NS 2 L / day . Serology tests were requested.Serology tests were requested. Metoclpramide , Ranitidine . Metoclpramide , Ranitidine .

Pat. Was clinically showing some Pat. Was clinically showing some improvement.improvement.

Serology were neg. : Serology were neg. :

- HIV- HIV

- HBsAg- HBsAg

- HCV- HCV Hepatitis markers were requested. Hepatitis markers were requested.

HA IgM , HBcIgM , HCV-RNA were all HA IgM , HBcIgM , HCV-RNA were all requested. “20.2.1426 AH”.requested. “20.2.1426 AH”.

ANA , AMA & immunoglobulin level ANA , AMA & immunoglobulin level as well at 23.2.1426 AH.as well at 23.2.1426 AH.

Meanwhile patient was managed Meanwhile patient was managed as sever acute hepatitis as sever acute hepatitis “ “ ? Etiology “ ? Etiology “

Day 9 : - awake & a wearDay 9 : - awake & a wear Vitals - BP 123/82 RR 24Vitals - BP 123/82 RR 24

- PR 95 Temp. 37- PR 95 Temp. 37 c/o eigastric pain & vomiting c/o eigastric pain & vomiting CBC -WBC 19CBC -WBC 19

-Hb 14.2-Hb 14.2

-Plt 300-Plt 300

AST 1126 ALT 1336AST 1126 ALT 1336 PT 40.6/12.5 PTT 106/35PT 40.6/12.5 PTT 106/35 INR 3.3 ALP 1000INR 3.3 ALP 1000

F/U of all requested Investigations F/U of all requested Investigations Still NO RESULT ?? “ ~7 days” Still NO RESULT ?? “ ~7 days”

Day 10 - Normal vitals Day 10 - Normal vitals

- drowsy & confused - drowsy & confused

- H. Encephalopathy II.- H. Encephalopathy II. Ammonia 153Ammonia 153 ICU consultation “ NO BED “ICU consultation “ NO BED “ VARBALLY VARBALLY : high IgG >34.73: high IgG >34.73 Other result ((NOT YET)) .Other result ((NOT YET)) .

Pat. Was started on :Pat. Was started on :

-Prednisolone 30 mg orally-Prednisolone 30 mg orally

-Azathioprne 50 mg orally -Azathioprne 50 mg orally

- lactulose - lactulose

- zero protein , 2gm salt diet.- zero protein , 2gm salt diet.

- IVF D5NS Q6h.- IVF D5NS Q6h.

DAY 11 : -DAY 11 : - Still encephalopathy. Still encephalopathy. Clinically deteriorating .Clinically deteriorating . Responding to painful stimuli. Responding to painful stimuli. Late night – low BP.Late night – low BP. 22ndnd ICU consultation ICU consultation

-“ same answer ??”-“ same answer ??”

HBcIgM negative. 28.2.1426 AHHBcIgM negative. 28.2.1426 AH HAIgM negative. “ 10 days “ HAIgM negative. “ 10 days “ Other results “ NOT YET ??? ”Other results “ NOT YET ??? ” CBC WBC 15CBC WBC 15

Hb 14.5Hb 14.5

Plt 240 Plt 240

Na 134 , K 2.8 Na 134 , K 2.8 AST 800 , ALT 807AST 800 , ALT 807 Alb 2.4 , T.bili 45.2Alb 2.4 , T.bili 45.2 Cr 1.1 , BUN 23Cr 1.1 , BUN 23 Glucose 226 Glucose 226

Day 12 “ Day 12 “ last daylast day “ : - “ : -

- early morning 7:00 a.m she - early morning 7:00 a.m she

became irrecordable BP despite became irrecordable BP despite

all Rx “ fluid, dopamine ,…”all Rx “ fluid, dopamine ,…”

At 11:55 a.m 29.2.1426 AH She At 11:55 a.m 29.2.1426 AH She

had cardiorespiratory arrest .had cardiorespiratory arrest .

Code blue @ 12:00 p.mCode blue @ 12:00 p.m

Active CPR was initiated .Active CPR was initiated .

She was announced dead @ 12:15 p.mShe was announced dead @ 12:15 p.m Investigation results :Investigation results :

“ “ after patient expired ?? “ after patient expired ?? “ ANA –positive ANA –positive AMA –no reagent AMA –no reagent HCV-RNA “PCR” negative.HCV-RNA “PCR” negative.

THANK YOUTHANK YOU

Dr.Wail Bajhmoom Dr.Wail Bajhmoom