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Liver diseases are in several forms and from many causes as it performs hundreds of functionality. Liver disease is progressive and slow developing disease, in certain conditions the liver can become acutely ill as a result causes hepatic failure. Extensive liver damage can be irreversible depending on the pre-caser and even a surgical transplant may be necessary if the liver disease is long-term. The liver is quite resilient as it functions under the harshest stressors with few complaints, unless when it is acutely inflamed or seriously ill before clinical symptoms are manifested which may not be discernable as liver abnormality (alir 2009).
The diagram below shows an abnormal liver which seem to have been infected:
Case Presentation and Analysis
A 39 year old man who is a sailor visited the clinic to consult a GP about flu-like symptoms and mile fever, nausea and vomiting, slight pain in the upper right quadrant and dark coloured urine. Prior to the visit the patient has just finished a four months treat to South East Asia. His medical record shows that he has previously lived a promiscuous life during which he occasionally acquired common STD (sexual transmitted diseases) that were treated and cured with antibiotics.
Doctor's examination finds out that the patient have several tattoos some of which were attained at the time of his tour of duty. A mild yellowing of the sclera was detected. No palpable lymph nodes and his chest were clear. There was tenderness to his upper right quadrant and a palpable liver but not spleen.
The table summarises the results obtained from the patient's urine, blood and liver enzymes test conducted: 1:1
A urinalysis is a urine test performed to determine functional abnormality associated with the kidney or liver, such as an infection, chronic kidney disease, cystitis, cirrhosis hepatitis, diabetes or kidney stones. The urea level is high in the patient case, indicating an abnormal kidney, as it is responsible for the filtration of urea into urine so high level of urea implies an abnormality to the kidney. (Argent G, 1999) stated that as the body gets dehydrated, the kidneys will reabsorb more urea when (ADH) antidiuretic hormone, (a response from the brain to control further fluid loose), is produced to reduce additional loss of fluids. So as the patient vomit he loses a lot of fluids, which as a result increases the urea volume as to conserve fluids/water. Hence urea contains bilirubin the direct bilirubin (conjugated) appears in excess in the urine test of the patient (Chris Dr).
ESR (Erythrocyte sedimentation rate) blood tests are use to quantify the amount of inflammation that is present in the body. They are useful in detecting or monitoring abnormalities such as tuberculosis, autoimmune disorders, inflammatory diseases arthritis and necrosis, but they are not specific to diagnose a specific disorder. Increased ESR has many causes, including pregnancy, menstruation, infection or anemia and many more. Additionally, certain medications such as oral contraceptives, vitamin A, dextran and methyldopa (aldomet) can cause ESR elevation. In this patient's case the elevated ESR could be due to the inflammation caused by infection of hepatitis virus or following his antibiotic used to treat his previous sexual transmitted infection likely to be reason for the elevation (Wright E 1999).
ALT (Alanine aminotransferase) an enzyme located mainly in liver and kidney cells and quite identical quantity is found in the heart muscles. In a healthy person ALT levels are low. The test for this enzyme is of significant importance in determining liver damage due to hepatitis, drugs or toxic substances. Even though its elevation is not specific to the liver as it may show manifestation for other pathogenic conditions that may affect other organs of the body. It is due to the damage in the liver that ALT exceeds it minimal level as it is released into the bloodstream in hepatic damage. However in this patient's case the elevation of this enzyme is as a result of damaged inflated on the liver due to an infection he may have acquired through either the tattoos or through an un-eradicated virus he previously acquired, hence ALT elevation is the easiest symptoms that shows pathogenic liver disorder prior to the occurrences of more obvious symptoms such as jaundice. Several conditions can results in the damaging of the liver cells which in turns elevates ALT level (NIH- 2011).
ALP (Alkaline phosphatase) is an enzymes located in various tissues throughout the body, but most abundantly found in cells of the liver and bone. In the liver ALP is found at end of cells that conjoined in the formation of the bile ducts. An increased level of ALP is a clinical manifestation of liver disorder. However there are various pathological conditions that result to an increase of this enzyme such includes liver cancer and cirrhosis from drugs, and hepatitis (NIH- 2011). In this patient case pre-causer for the elevation is hepatitis virus, due to drug and infections.
Even though elevated bilirubin does not pathogenically manifest liver disease, it is a marker of hepatocellular injury, together with biliary obstruction, liver dysfunctions, haemolysis and glomerulonephritis. As a breakdown product of heam from haemoglobin, bilirubin is in two forms one of which is water-soluble and the other is insoluble in water (conjugated and un-conjugated respectively), (Underwood).
Total Bilirubin is the sum of direct and direct bilirubin in the blood stream. The total bilirubin level is high in this patient, due to disease of the liver, compromising it functionality in picking-up, processing and removal of excess bilirubin in a form of bile, hence the metabolic processing of indirect to direct bilirubin (i.e. un-conjugated bilirubin catalyzed by glucuronyl transferease) by binding with glucuronic acid. (Chris Dr 2006). When the liver is performing it functionality properly, conjugated bilirubin can flow freely as bile through the bile duct thus reaching the gut where it helps in the digestive process hence appearing in stool and urine. (Chris Dr 2006).
When there is excess direct bilirubin a condition known as conjugated hyperbilirubinemia is present, and excess indirect bilirubin signals an un-conjugated hyperbilirubinemia condition. In this patient's case conjugated hyperbilirubinemia is present within the liver as results of defect in excretion possibly due to hepatitis which are the causative for elevate biliburin in the patient. Although it is conjugated bilirubin that is excreted in stool and urine due to it water soluble characteristics, somehow in this patient's case the excretion process via bile is compromised as a result the total bilirubin appear high, hence the total bilirubin quantify direct and indirect bilirubin, the bilirubin level in the present's urine test also appears in excess (Chris Dr 2006).
The mild yellowing of the patient's sclera is caused by the accumulation of bilirubin (which has yellow color) as the liver is compromised; this substance is release back into the bloodstream and builds up in tissues before it is expressed as a yellow tint to the patient's eye also known as Jaundice (Lamb EJ 1999). Furthermore due to the disruption to the outflow of bile the patient's urine get stained with conjugated bilirubin resulting to darkened urine hence bilirubin have a yellowish colour, increase concentration yield a darker colour.
CRP (C-reactive protein refers to as a substance that elevates in the human body in occurrences of tissue damage, due to due to inflammation, traumatic injury, infection, cancer or immune diseases. Even though the CRP test is not specific marker of any one abnormality, it is useful in establishing the presence of infection or abnormality. Also an increased level above the reference range (see table-1) indicates that that there is inflammation present in the body. In this patient's case the elevation of CRP signify the presence of inflammation within his abdominal cavity which causes tenderness of the patient's upper right quadrant and palpable liver, as the liver is damage an inflammatory respond is produced by the liver to heal itself. This CRP elevation reveals the intensity of the damage (Pestka J 1999).
Hepatitis refers to abnormal conditions that cause inflammation of the liver, such as (drugs, alcohol, chemicals and autoimmune diseases. Viral hepatitis refers to as to hepatitis caused by a few specific viruses that mainly attacks the liver. There are several of these viruses which are categorised into types A, B, C, D, E, and F, of which the most common types are A, B, and C. Hepatitis caused by (hepatitis A-virus) is an acute illness that does not progress to chronic condition and it is spread via food or water ingestion in environment with poor sanitation, through oral secretion like intimate kissing and poor hand washing. Hepatitis B referred to as 'serum hepatitis,'' hence serum containing the virus was believed to be the only way the virus could be spread. Currently HBV is understood to have several means of transmission which includes sexual contact, blood transfusion, tattooing, body piercing and many more. This class of hepatitis can develop into chronic infection lasting lengthy period. Patients with chronic hepatitis B infection also are at risk of developing cirrhosis, liver failure and liver cancer. Viral hepatitis C (HCV) usually is spread by shared needles among drug abusers, blood transfusion, haemodialysis, and needle sticks. Most abundantly blood transfusion holds the highest spreading percentage. Though it been reported via sexual contact it in not commonly acquired through this mean. Viral hepatitis can progress in chronic stage which may result to cirrhosis, liver failure and liver cancer (Lee D).
The patient's case history revealed a great deal that he may have perhaps contacted an infection resulting to the symptoms and eventually leading a liver disease, possibly via body fluids or on sterilized needle previously used on an infected person. Hence the patient's case highlighted a previous promiscuous life resulting to his contact with Common Sexually Transmitted Disease (CSTD), and the multiple tattoos, some of which he attained while on tour of duty in South East Asia. This infections may either be an existing ones that may have not been completely eradicated by the antibiotics or perhaps through the tattoos he attained in South East Asia, as this developing continent is amongst list of continents believed to have increased viral hepatitis infections especially hepatitis B (according to the British liver trust 2007). Also the fever is due to the invasion of foreign invader such as a common virus, according to (Benjamin C. W). In nutshell the fact that fever is amongst listed of symptoms reviled in the patient case, in-accordance with certain symptoms clearly revealing hepatic liver which is caused by hepatitis virus.
In conclusion due to the revealing symptoms and signs, of the patient's medical history and physical examination hepatitis B virus could be suspected as the pre-causer of the liver disease. Also the abnormal blood test in the patient also raises suspicions. From the above hepatitis viral descriptions, the patient's could have acquired hepatitis B virus while tattooing at his tour of duty and his previous promiscuous history of acquiring (CSTD) that was perhaps not completely eradicated, gradually progressing into acute hepatitis B, hence liver disease is slow and progressive. Additionally the time spent by the patient at his tour of duty could be a contributing factor for the viral accumulation suddenly leading to the hepatic damage. Moreover other possible causative could be viral hepatitis C, hence this virus disease manifests similar symptoms to that of hepatitis B, and appraised similar methodology in acquiring the disease.
Hence a specific causative of the liver disease in this patient's case is not establish, as both hepatitis (B and C) fall under the parameter in accordance with the research on the causative of the hepatitis viral infection,
it is therefore suggested that the patient should be referred for further preferable biological analysis (including PCR and liver biopsy) which are more sensitive and reliable approaches for detecting and identifying causative virus of the abnormality as to appraising appropriate treatment actions, hence this will help to establish a precise diagnostic and clinical evaluation for the patient. Furthermore distinguishing the specific pre-causer virus the appropriate treatment for the aiming goal of eradicating the viral infection could be achieved, as to avoid additional liver injury and its adverse consequences such as hepatocellular carcinoma (HCC) that are fatal and irreversible (Lee D).
Alternatively, if it hepatitis B is the causative virus, a further diagnostic specifically for hepatitis B virus blood tests known as hepatitis ''markers'' (a productive substance of hepatitis B virus antigen) and antibodies, to acquire confirmation and distinguishing acute from chronic infection or serology can be conducted. From the three classes of hepatitis B (surface, core, and e antigen), an acute hepatitis can be distinguished from chronic (Nattleman M & Mortad M 1999).