1. Progressive Liver Failure following Gastric Bypass

2. 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

3. 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 lbs

4. 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

5. 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

6. 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

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

8. 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

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

10. 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.

11. Figure – 1 (CT scan of 7/16/02)

12. 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.

13. The patient underwent transjugular liver biopsy on July 22, 2002

14. Figure –2 (Liver biopsy of 7/22/02)