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 No mention of a cirrhotic appearing liver Anesthetic agents: propofol and fentanyl Patient lost over 200 lbs from a baseline of 600 lbs

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

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

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

Medications at home: None Medications upon transfer: Protonix 40 mg QD Tequin 400 mg QD Lasix 40 mg QD

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

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

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.

Figure – 1 (CT scan of 7/16/02)

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

The patient underwent transjugular liver biopsy on July 22, 2002

Figure –2 (Liver biopsy of 7/22/02)