Good service

I have been a bit rude in the past about the time it takes to get through to my hospital colleagues for advice, so I must tell this tale of excellent service which I received today. I was perhaps lucky that I got through immediately, but the advice was also first class.

I've been seeing a young woman who has had persistent watery diarrhoea (but no blood) since she went on holiday to India a month ago. Stool culture has been negative and she has remained very well, apart from the persistent diarrhoea. The other day she saw my colleague who requested some routine blood tests, since we still did not have a diagnosis. The blood was taken this morning, and when I arrived for evening surgery the lab had rung through the results urgently. One of her liver tests, the ALT, was eye-poppingly high at 2,150. (Technical stuff for medics: her other liver tests were pretty unremarkable, the GGT was slightly raised but her Alk Phos and bilirubin were normal.) I asked her to come and see me at the end of the surgery, and she still looked extremely well with no signs of any liver problem (no jaundice, liver not enlarged). I was a bit unsure about what to do. The very high ALT indicates that her liver cells are sustaining a lot of damage, releasing the ALT enzyme inside them. Yet she was clearly far too well to require hospital admission.

So I rang for advice, and luckily the Medical Registrar on call was a gastroenterology Registrar who knows a thing or two about liver problems. The diagnostic process began. He told me that only three things can cause such a high ALT level: a paracetamol overdose, ischaemic hepatitis, and viral hepatitis. My patient is cheerful and optimistic and certainly hasn't taken an overdose. Moreover she is young and healthy, and there is no reason why the blood supply to her liver should have been damaged to cause ischaemic hepatitis. So she must have viral hepatitis. She can't have Hepatitis B because she was immunised against it when she started working in a nursing home, and is known to be immune. She has no risk factors for Hepatitis C (anal sex, sharing needles). But she was in India a month ago where it is very easy to catch Hepatitis A from contaminated food or water, and the incubation period is up to six weeks. In Hepatitis A the ALT rises first, and the bilirubin rises later causing jaundice.

There is no doubt that she is in the early stages of Hepatitis A, and we made the diagnosis by inductive logic before the patient became jaundiced and without a serology result. I shall wait for serological confirmation before I notify the disease to the Proper Officer, but I was able to discuss the diagnosis and management confidently with my patient. I was really pleased with the diagnostic help and advice given by the Registrar, and I have written to his consultant to say so. One good turn deserves another.