ETD: Obstructive jaundice for investigation

I have completed 5 mandatory postings, currently tagging in final posting, which is the Emergency and Trauma posting. Day in day out I see a lot of interesting cases, I think it is worthwhile to share these interesting cases in this blog as the blog has been abandoned for a long time.

This case I saw few days ago was a 60 years old gentleman, came in complained of generalised body weakness and abdominal discomfort for 3 to 4 days. When we first saw this gentleman, he appeared to be restless and looked really yellow, and it was an obvious full blown jaundice.

At first we thought this is some kind of decompensated liver failure secondary to liver cirrhosis or hepatocellular carcinoma, but upon further questioning, the family member mentioned they only realised the jaundice in past few days and worsening on the day of visiting ETD.

He was previously NKMI, not known of any liver disease, hepatitis infection or malignancy, had a history of right bimalleolar fracture, done ORIF and plating 7-8 years back. Otherwise, no fever, no pale stool, no tea coloured urine, no altered bowel habit, no chest pain, no SOB. On top of that, patient wife claimed he has taken paracetamol and other painkiller daily for the past 7-8 years after the op done over his right leg due to pain.

On examination, abdomen slight guarding but otherwise bedside scan unremarkable. Our thinking that time were hepatitis vs obstructive jaundice vs infection. It could be also paracetamol toxocity causing liver failure, but unlikely acutely presented in this case as patient has been taking it for so many years. FBC showed TWC 22, platelet 87, so we also taken infective screening for dengue, malaria and lepto. It turned out all of them were negative.

The urgent LFT showed total bilirubin 752, direct bilirubin 612, AST and ALT just slightly raised, the ALP is 139. Our EP decided to label the case as obstructive jaundice but not hepatitis as the bilirubin is very high, ALP raised, whereas AST and ALT just slight raised. Because if it is a hepatitis, the AST and ALT should be sky high as well because the jaundice is very prominent. The case then referred to surgical side and their impression was obstructive jaundice secondary to ascending cholangitis. 

But when we traced other results, we realised that the kidney was in failure, the urea was 75, creatinine 655, urine output was also poor, only 250cc after around 7 hours in ETD. The VBG came back to be in severe acidosis, so we also referred the case to medical side for oliguric AKI with metabolic acidosis. Then they referred to nephro side, KIV for bedside urgent dialysis due to severe uremia. 

Personally I not sure how both kidney and liver link together in this case. It is unlikely to be a hepatorenal syndrome as the liver/gall bladder issue looks like an acute problem, or it could be an acute on chronic issue because of the PCM usage. For me, the kidney might be an undiagnosed chronic problem here, it could be due to chronic NSAIDs usage causing CKD. But nevertheless case is taken by surgical side, I think they have a lot to work on, especially the cause of obstructive jaundice, they should order an urgent CT abdomen.