Morning Unknown

1
Morning Unknown 49
2

• A 38 year old woman presents with a 2-year
  history of rectal bleeding, abdominal pain and
  weight loss. Colonoscopy with biopsy is
  performed histology shows acute and chronic
  mucosal inflammation, crypt distortion with
  forked glands and crypt atrophy. You begin
  sulfasalazine, 4g daily.

3

• Three weeks later, she feels much better and
  bleeding has stopped. However, on routine follow
  up labs, the following is noted
• WBC 11.5, normal differential
• ALT 70 AST 65 Alk Phos 428 bili 1.4
• Albumin 3.1 TP 6.0 Chem-7 normal
• UA negative

4

• RUQ ultrasound is performed no stones or CBD
  dilatation are seen. What findings are most
  likely to be seen on further testing?
• Multifocal stricturing and dilation of
  intrahepatic bile ducts on cholangiography
• Elevated antimitochondrial antibodies and ANA,
  bridging fibrosis on liver biopsy
• HBsAg positive, anti-HBe positive, eventual
  resolution of liver enzymes
• Multiple areas of increased uptake on three-phase
  bone scan
• A large, heterogeneous hepatic mass on contrast
  CT of the liver

5

• RUQ ultrasound is performed no stones or CBD
  dilatation are seen. What findings are most
  likely to be seen on further testing?
• Multifocal stricturing and dilation of
  intrahepatic bile ducts on cholangiography
• Elevated antimitochondrial antibodies and ANA,
  bridging fibrosis on liver biopsy
• HBsAg positive, anti-HBe positive, eventual
  resolution of liver enzymes
• Multiple areas of increased uptake on three-phase
  bone scan
• A large, heterogeneous hepatic mass on contrast
  CT of the liver

6
Primary sclerosing cholangitis

• 90 have ulcerative colitis (5 of UC patients
  have PSC)
• Typically asymptomatic
• Presents with elevated liver biochemical tests
  (mainly Alk Phos)
• diagnosis is established by the demonstration of
  characteristic multifocal stricturing and
  dilation of intrahepatic and/or extrahepatic bile
  ducts on cholangiography
• Autoantibodies may be present but are of unknown
  signifigance
• AMA usually negative ( in PBC)

7
PSC - cholangiography
OBJECTIVE recognize the clinical presentation
and recall the diagnostic studies for a patient
with sclerosing cholangitis