أمراض الكبد

A 16-year-old girl in Macedonia presents to the local emergency department (ED) with a sudden onset of severe abdominal pain following what she describes as a "bear hug from a friend." The pain began a couple of hours before arrival to the ED. She describes the pain as sharp, constant, most intense in the right upper quadrant, and radiating to her right shoulder. The patient also reports having mild, dull abdominal discomfort and a feeling of progressive abdominal fullness for the past few months, but she has not sought medical attention for these symptoms. She also complains of having a diffuse, itchy rash that seems to have appeared around the same time as the onset of the abdominal discomfort. The patient has no history of food allergy and has not eaten any new foods before this episode. She denies having any fevers, nausea, or abnormal bowel movements. She has not had any changes in her skin coloration. She reports occasional use of acetaminophen in the last 2 weeks for the abdominal discomfort, but she is not otherwise taking any regular medications. She has no chronic medical conditions or past surgical history. She reports no significant family history. There are 2 dogs in her house which she cares for, but no other pets are present.

On physical examination, the patient is in obvious discomfort. Her body temperature is 99.1°F (37.3°C), she has a blood pressure of 110/70 mm Hg, and her pulse is 110 bpm. Her skin is pale and without jaundice, but she does have a diffuse urticarial rash that is most prominent on the trunk and proximal extremities. She appears well-nourished and well-developed. Her chest has symmetrical movements during respiration and clear breath sounds are noted on auscultation. Her heart sounds are normal, with a regular rhythm and no detectable murmurs. A firm mass overlying the liver edge in the right upper quadrant is noted on palpation. The entire upper abdomen is markedly tender and rigid, particularly in the right subcostal region.

The laboratory testing is remarkable for leukocytosis, with a white blood cell (WBC) count of 18.6 × 103/µL (18.6 × 109/L) and 40% neutrophils (0.40), 22% lymphocytes (0.22), 8% monocytes (0.08), and 21% eosinophils (0.21) (normal ranges: WBC, 4.5-11 × 103/µL; neutrophils, 40-70%; lymphocytes, 22-44%; monocytes, 4-11%; eosinophils, 0-8%). An elevated total bilirubin level of 1.98 mg/dL (33.8 μmol/L) was also noted (normal range, 0.3-1.0 mg/dL). Her aspartate aminotransferase (AST; also known as serum glutamic oxaloacetic transaminase [SGOT]) is 101 U/L and her alanine aminotransferase (ALT; also known as serum glutamic pyruvic transaminase [SGPT]) is 104.7 U/L. Her hematocrit and platelet counts are normal. An upright radiograph of the abdomen shows a nonspecific bowel gas pattern and no findings of pneumoperitoneum. An ultrasound is performed for a suspicion of possible gallbladder disease; it reveals a large hypoechogenic zone in the liver, with irregular margins and a small amount of free fluid around the liver. A computed tomography (CT) scan of the abdomen is subsequently performed (see Figures 1 and 2).