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Progressive Liver Failure following Gastric Bypass

Progressive Liver Failure following Gastric Bypass. History. Mrs S.T. is a 37 y/o markedly obese Hispanic female. She was hospitalized in 7/02 with the diagnosis of liver failure for liver transplant evaluation. 9/01 (10 months prior to transfer). Open Roux-en-y gastric bypass operation

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Progressive Liver Failure following Gastric Bypass

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  1. Progressive Liver Failure following Gastric Bypass

  2. History • Mrs S.T. is a 37 y/o markedly obese Hispanic female. • She was hospitalized in 7/02 with the diagnosis of liver failure for liver transplant evaluation

  3. 9/01 (10 months prior to transfer) • Open Roux-en-y gastric bypass operation • No mention of a cirrhotic appearing liver • Anesthetic agents: propofol and fentanyl • Patient lost over 200 lbs from a baseline of 600 lbs

  4. 5/02 (2 months prior to transfer) • Spinal fusion operation • Pre-operative anesthesia reports icteric sclera • Labs:Albumin 1.8 g/dl Alk phos 184 U/L Total bilirubin 6.5 g/dl AST 96 U/L Direct bilirubin 3.9 g/dl ALT 92 U/L

  5. 2 weeks prior to transfer • Nausea, vomiting, inability to tolerate p.o.’s and increasing lower extremity edema • At a local hospital, she was treated with diuretics and antibiotics for a UTI

  6. Past Medical History:SLE diagnosed at the age of 11 • Social:No history of alcohol abuse or intravenous drug usage • Family History:No history of end-stage liver disease

  7. Medications at home:None • Medications upon transfer:Protonix 40 mg QDTequin 400 mg QDLasix 40 mg QD

  8. Physical Examination • General appearance: Obese female Ht: 5’4” , Wt: 407 lbs BMI: 69.9 • HEENT: Sclera icteric • ABD: Hepatomegaly of 18 cm, no shifting dullness • EXT: 1+ pitting edema of lower extremities • Neuro: A,Ox3, no asterixis • Skin: No spider angiomata

  9. Laboratory Data WBC 11.9/ul Albumin 1.4 g/dlHb 9.4 g/dl AST 187 U/L Platelets 157/ul ALT 89 U/LCreatinine 0.8 g/dl INR 1.48MELD 20 Total bili 12.4 g/dl

  10. Abdominal Ultrasound • Echogenic enlarged liver at 19 cm. • No focal masses. • Common bile duct diameter = 6 mm. • No intra-hepatic biliary dilation. • Free fluid around the liver.

  11. Figure – 1 (CT scan of 7/16/02)

  12. Special Laboratory Data HAV IgM Neg. Iron 39 ug/dl.HBsAg Neg. TIBC 57 ug/dl.HCV Ab Neg. Ferritin 1,536 ng/dlANA 1:40. AMA Neg.ASMA Neg. P-ANCA Neg.Ceruloplasmin 20 mg/dl.

  13. The patient underwent transjugular liver biopsy on July 22, 2002

  14. Figure –2 (Liver biopsy of 7/22/02)

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