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Presentation
A 54 year-old-women with recurrent
Jaundice

Dr. Makjana Alam Shaily

FCPS part 2 trainee
Unit-10
Department of Medicine
DMCH
PARTICULARS OF THE PATIENT

• Name : Shoriyat Begum

• Age : 54 years • Address : Matuail,
Badamtoli, Dhaka
• Sex : Female
• Date of admission :
• Occupation : House-wife
03/02/25
• Religion : Islam
• Date of examination :
• Marital status : Married
03/02/25
CHIEF COMPLAINTS
• Yellowish discoloration of urine and eyes for 20 days.
• Upper abdominal pain for same duration.
• Nausea and vomiting for same duration.
HISTORY OF PRESENT ILLNESS

According to the statement of the patient, she was

reasonably fine 20 days back. Then she noticed gradually
increasing yellowish discoloration of urine and eyes. Her
stool was yellowish, voluminous and she denied any pale,
greasy, foul smelling or blood mixed stools. There was no
history of itching. Bowel and bladder habit was normal.
Patient also complained of moderate pain and discomfort
in the right upper abdomen, dull aching in nature,
gradually increasing, not related with food intake,
movement or lying down and non radiating, did not
subside with medications and associated with nausea and
vomiting.
Vomitous consisted of partially digested food, bilious, has
no blood, nonprojectile, no relation with food intake,
preceded by nausea & there was no fever, diarrhea or
headache. She had suffered from loss of appetite but no
significant weight loss. She also complained of
generalized weakness for same duration.
There was no history of joint pain, skin rash, bodyache,
bleeding, recent travelling, abdominal distention,
injection, infusion, blood transfusion, IV drugs, food from
roadside or multiple sex partner.
Patient is nondiabetic, normotensive.
HISTORY OF PAST ILLNESS

As per query she stated that 5 months back she suffered

from similar symptoms and was admitted in a tertiary
medical college hospital and was diagnosed as a case of
HEV related acute viral hepatitis and received treatment
accordingly. She was recovered completely and was in a
good heath till 14 January, 2025.
No other significant past medical illness or surgical
intervention was present.
PERSONAL HISTORY
• Patient is nonalcoholic and nonsmoker.
• Denied history of any recreational or iv drug abuse or
having unprotected sexual exposure.
SOCIO-ECONOMIC HISTORY
• Patient’s husband is the only earning member of the
family and he earns around 15000 taka per month, lives
in a semi pakka house, drinks water from arsenic free
deep tubewell.
FAMILY HISTORY
• She is the third issue of non consanguineous parents.
• She lives with her husband and two children.
• All the family members are in good health & not
suffering from similar type of illness.
• No known disease runs in her family.
HISTORY OF IMMUNIZATION

Her immunization status is unknown, not vaccinated

against COVID -19.
DRUG AND TREATMENT HISTORY
• No significant history apart from taking antacid.
• No history of taking any antibiotics, blood transfusion or
herbal medications.
HISTORY OF ALLERGY
• No known allergy.
MENSTRUAL HISTORY

• Menarche at 12 years.
• Previously regular 28 day cycles, now irregular, ranging
from 21 to 60 days.
• Flow fluctuates between light to medium, lasting 2-10
days.
• LMP: December 14,2024.
• Reports hot flashes, night sweats and occasional vaginal
dryness.
• No history of hormonal therapy.
• No abnormal intermenstrual bleeding.
• No history of contraceptive use.
GENERAL EXAMINATION

• The patient is ill looking.

• Deep jaundice is present. • No leukonychia.
• No anemia. • No edema.
• No cyanosis. • No spider angioma or
• No clubbing. palmer erythema.

• No koilonychia. • No flapping tremor.

• No skin rash. • Temparature : 98 F
• Hair distribution is normal. • KF ring : Absent.
• Blood pressure 120/80 • Thyroid and parotid gland
mmHg with no postural are not enlarged.
drop.
• Bedside urine dipstick-test
• Pulse 80 b/m. negative for protein and
• Respiratory rate 20 b/m. sugar.
Systemic Examination
Gastrointestinal examination

• Lips, gums, teeth: normal.

• Under surface of tongue and oral cavity: Yellowish.
• ABDOMEN:
• INSPECTION: No abnormality detected.
• PALPATION : Abdomen is soft and tender in right
hypochondriac region.
• Murphy’s sign negative.
• Liver is not palpable. Upper boarder of liver dullness is in the
right 5th intercostal space.
• Spleen in not palpable.
• Kidneys are not ballotable.
• Para-aortic lymph nodes are not palpable.
• Ascites is absent.
• Auscultation :Bowel sound is present.
Nervous system examination
• Higher Psychic Function : Intact
• GCS: 15/15
• Cranial nerve :Intact
• Fundoscopy : Normal
Motor functions : Upper limbs :
Bulk : Normal
Tone : Normal (B/L)
Power: All (5/5)
Reflexes: Normal (B/L)
Hoffman sign : absent
Motor functions : Lower limbs:
Bulk : Normal
Tone : Normal (B/L)
Power: All (5/5)
Reflexes: Normal (B/L)
Planter : Flexor (B/L)
• Sensory modalities : Intact
• Coordination: Intact
• Signs of meningeal irritation : Absent
• Gait : Normal
• Examination of other system reveals no abnormality.
SALIENT FEATURES

Mrs. Soriyot begum, 54 years old, normotensive,

nondiabetic, nonalcoholic, muslim, married women hailing
from Matuail was admitted in MU 10 of DMCH on 3rd
February, 2025 with complains of gradually increasing
jaundice and fatigue for 20 days not associated with
pruritus and stool was yellowish in colour.
She also complained of moderate right hypochondriac
pain, dull aching not related with food intake, movement
or lying down, non radiating and associated with vomiting.
Vomiting was non projectile, 3-4 times a day, bilious,
containing partially digested food but there was no
hematemesis, melaena, fever, diarrhea or headache.
On query, she stated that 5 months back she suffered from
similar symptoms and was admitted in a tertiary medical
college hospital and was diagnosed as a case of HEV related
acute viral hepatitis and received treatment accordingly.
She recovered completely and was in a good heath till 14
January ,2025. She had no other significant medical
history or surgical intervention.
There was no history of joint pain, skin rash, contact with
jaundice patient, intake of any herbal or homiopathic
drug, bodyache, bleeding, abdominal distention, blood
transfusion, IV drugs, food from roadside, travelling
history or multiple sex partner and no history of
ammenorhea.
On general examination patient is ill looking and has deep
jaundice. On gastrointestinal examination, abdomen is
soft and tender in right hypochondriac region. Other
system examination reveals no abnormalities.
PROBLRM LIST

Recurrent jaundice

Upper abdominal pain

54 years old female

Nausea and vomiting

PROVISINAL DIAGNOSIS

?
Provisional diagnosis

My provisional diagnosis is Acute Viral Hepatitis.

DIFFERENTIAL DIAGNOSIS

• Acute on chronic viral hepatitis.

• Autoimmune hepatitis.
• Wilson disease.
Complete blood count
Result Normal
HB% 10.8 gm/dL 12.0-14.0 gm/dL
TC OF WBC 10,500 4000-11000/mm3
Platelets 395000 150000-400000/
mm
Neutrophil 70% 40-70%
Lymphocyte 28% 20-45%
MCV 70 83-101fL
ESR 25 mm 1st hour 0-10 mm 1st hr
Peripheral Blood Film
• RBC – Aniso-poikilocytosis with Microcytes with
occasional Target cells
• WBC – Mature with normal distribution
• Platelets –Normal
URINE R/M/E
• Protein : Trace
• Sugar : Nil
• Pus cell : 2-3/HPF
• RBC : Nil
• Cast : Absent
 Result Normal
S. Creatinine 0.66 0.7-1.3 mg/dL
RBS 6.7 <7.8mmol/L
S. Albumin 3.9 3.2-4.8 gm/dL
S. Electrolytes

Na 136 mmol/L
K 3.6 mmol/L
Cl 105 mmol/L
USG of whole abdomen

• Normal study
Thyroid Function Test
Result Normal
TSH 1.03 microU/L 0.35-5.5 microU/L
FT3 3.19 pmol/L 3.5-6.5 pmol/L
FT4 12.3 pmol/L 11.55-22.7 pmol/L
 Result Normal
S. Bilirubin 25.9 <1.2 mg/dl
Direct 17.5
Indirect 8.4
SGPT 388 <35 U/L
SGOT 280 <35 U/L
ALP 397 30-120 IU/L
Viral markers
result
HBsAg Negative
Anti HCV Negative
Anti HEV Positive on 20/01/25 = 2.85
IgM on 13/07/24 =4.42
Anti HBc Negative
total and
IgM
Anti HAV Negative
IgM
 Result Normal range
PT 20 seconds 14 seconds
APTT 33 seconds 30 seconds
 Result Ref value
ANA 100 AU/mL Negative < 40
Positive >=40
Anti-ds DNA 10 < 30
U/L=Negative
>75 U/L=Positive
 Normal value Reference value
Anti smooth 5 U/mL 0-19 U/mL
muscle antibody
Anti mitochondrial >400 U/mL 0-20 U/mL
antibody
IgG level 33 g/L 7-16 g/L
Liver biopsy
Liver biopsy

• Microscopic appearance:
• Sections shows liver tissue. This reveals parenchymal
destruction, interface hepatitis,hepatocyte rosettes
formation. Portal inflammation with infiltration of
lymphocytes, plasma cells extending into hepatocytes
are also seen. Masson trichome stain is done and it
reveals bridging fibrosis.
• MRCP report is pending.
FINAL DIAGNOSIS

Primary Biliary Cholangitis and

Autoimmune Hepatitis overlap syndrome
Current Treatment

• Prednisolone 30 mg/D
• Azathioprine 50mg/D
• Ursodeoxycholic acid 300mg/D
• Symptomatic management
Acknowledgment

• Department of gastroenterology ,DMCH

• Department of radiology & Imaging ,DMCH