February 1, 2019 Quick Question Case
A 41-year-old man was admitted with severe gastrointestinal bleeding. He reported that he drinks an average of 15 ounces of whiskey per day, a habit of 15 years. Upon admission he was given Librium for withdrawal and parenteral nutrition with multivitamins. He was jaundiced and reported the jaundice had appeared 3 weeks before admission. His stools were black. Liver and spleen were enlarged and there was marked ascites and ankle edema. There were numerous ecchymoses over the arms and legs.
Initial Findings
- HGB: 7.8 g/dL, Reference interval 13.5–18.0 g/dL
- HCT: 23%, RI 40–54 %
- PT: 19 s, RI 10.7–13.9 s
- PTT: 52 s, RI 26.6–40.3 s
- PLT count: 51,000/uL RI 130,000-400,000/uL
- D-dimer: 850 ng/mL FEUs, RI 110–240 ng/mL FEUs
- BP: 110/50
Follow-up
From the history and initial laboratory results, what is the most likely possibility? Please suggest follow-up laboratory testing to confirm a diagnosis.
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High likelihood that his
High likelihood that his severe bleeding is due to varices or ulcer rather than coagulopathy. I would administer vitamin K regardless as it is inexpensive and has a low risk of adverse events and, given his alcohol intake, he very likely is vitamin K deficient. His abnormal labs are likely due to hypersplenism (thrombocytopenia) due to chronic liver disease as well as CLD itself leading to a decrease in liver dependent coagulation factors. However, he may also be at risk for thrombosis as is common in patients with severe chronic liver disease. Needs imaging/endoscopy to determine source of bleeding.
Tanja Antunovic suggests
Tanja Antunovic suggests liver cirrhosis.