Detailed Treatment Process
Male, 27 years old, presented on June 20 due to nausea, aversion to greasy food, and poor appetite for over one week, accompanied by yellow urine and mid-upper abdominal pain, without fever. Outpatient labs showed total bilirubin = 255.8; admitted on the same day or the next day (June 21). The following is the discharge summary. Admission date June 20 Discharge date July 28 Hospital stay 38 days Outpatient/emergency diagnosis Liver injury to be investigated Admission diagnosis Liver injury, viral hepatitis, obstructive jaundice Discharge diagnosis Chronic severe hepatitis B, acute cholecystitis Main symptoms and signs on admission Admitted with “yellow urine and nausea for over two weeks.” Physical examination: Temperature 36.6°C, clear consciousness, fair spirit, severe jaundice of the whole-body skin, liver palms not obvious, no spider nevi, severe jaundice of bilateral sclera, supple neck, no resistance. Liver and spleen not palpably enlarged, no sternal tenderness, symmetric tactile fremitus on both sides, clear percussion note, coarse breath sounds in both lungs, no dry or moist rales heard. Heart rate 73 beats/min, regular rhythm, no pathological murmurs. Soft abdomen, no visible intestinal patterns or peristaltic waves, no tenderness. No palpable masses, liver upper border at the 5th intercostal space in the right midclavicular line, liver and spleen not palpable below the costal margin, Murphy’s sign negative, shifting dullness negative, no tenderness in bilateral kidney areas, bowel sounds 4 times/min. Anus and external genitalia normal. No spinal deformity, no redness, swelling or pain in limb joints, no edema in both lower limbs. Main laboratory results Routine urine (06/21): Bilirubin 3+. Stool routine negative. Blood routine (06/21): White blood cells 7.8×10⁹/L, red blood cells 3.58×10¹²/L, hemoglobin 115.0 g/L, platelets 166×10⁹/L, neutrophil ratio 54.5%. Biochemistry (06/21): Alanine aminotransferase 88 U/L↑, aspartate aminotransferase 123 U/L↑, aspartate aminotransferase isoenzyme 30 U/L↑, total bilirubin 255.8 μmol/L↑, albumin 21.3 g/L↓, glucose 1.76 mmol/L, urea 2.6 mmol/L, creatinine 57 μmol/L, cystatin C 0.85 mg/L, potassium 3.6 mmol/L, sodium 138 mmol/L, chloride 113 mmol/L, uric acid 105 μmol/L↑, total cholesterol 2.03 mmol/L↑, triglycerides 1.61 mmol/L↑, creatine kinase 65.00 U/L, lactate dehydrogenase 254 U/L↑, C-reactive protein 17 mg/L↑, procalcitonin 0.60 ng/ml↑, adenosine deaminase 30.9 U/L↑, amylase 55.6 U/L. Biochemistry (06/23): Free thyroxine 15.48 pmol/L, free triiodothyronine 2.39 pmol/L↑, thyroxine 4.5 μg/dl↓, triiodothyronine 1.61 ng/ml, thyroid-stimulating hormone 3.20 μIU/mL, anti-thyroid peroxidase antibody 46.58 IU/ml↑, anti-thyroglobulin antibody 103.21 IU/ml↑. Biochemistry (06/23): Hyaluronic acid 571.36↑, type III procollagen N-terminal peptide 16.71↑, laminin 1090.94↑; Biochemistry (06/23): AFP-L3 9.22%, alpha-fetoprotein heterosome 32.28 ng/ml, alpha-fetoprotein 61.82 ng/ml↑, carcinoembryonic antigen 3.39 ng/ml, carbohydrate antigen CA-125 23.93 U/ml, carbohydrate antigen CA15-3 15.71 U/ml, carbohydrate antigen 19-9 422.450 U/ml↑, carbohydrate antigen CA50 285.13 U/ml↑, carbohydrate antigen CA72-4 414.220 U/ml↑; D-dimer: 1.5 mg/L. HBV-DNA negative. IgE: 115.71 U/ml. Syphilis antibody and HIV antibody negative. Blood routine (06/26): White blood cells 10.0×10⁹/L, red blood cells 3.63×10¹²/L, hemoglobin 116.0 g/L, platelets 163×10⁹/L, neutrophil ratio 57.8%. Biochemistry (06/26): Alanine aminotransferase 84 U/L↑, aspartate aminotransferase 136 U/L↑, aspartate aminotransferase isoenzyme 33 U/L↑, total bilirubin 261.4 μmol/L↑, total protein 53.2 g/L↓, albumin 20.3 g/L↓, alkaline phosphatase 290 U/L↑, gamma-glutamyl transpeptidase 74 U/L↑, glucose 3.90 mmol/L, urea 3.0 mmol/L, creatinine 59 μmol/L, potassium 3.8 mmol/L, sodium 138 mmol/L, total cholesterol 2.17 mmol/L↓, triglycerides 1.70 mmol/L, lactate dehydrogenase 278 U/L↑, C-reactive protein 8 mg/L. Immunology (06/26): Hepatitis A antibody negative, hepatitis B surface antigen 351.85 ng/ml↑, hepatitis B surface antibody 0.00 mIU/ml, hepatitis B e antigen 11.656 PEIU/ml↑, hepatitis B e antibody 0.00 PEIU/ml, hepatitis B core antibody 3.17 PEIU/ml↑, hepatitis B core antibody IgM 6.78 PEIU/L, hepatitis E IgM antibody negative, hepatitis C antibody [0.37] negative. Blood routine (07/05): White blood cells 10.0×10⁹/L, red blood cells 3.77×10¹²/L↑, hemoglobin 123.0 g/L, platelets 142×10⁹/L, neutrophil ratio 51.6%. Biochemistry (07/05): Alanine aminotransferase 69 U/L↑, aspartate aminotransferase 105 U/L↑, aspartate aminotransferase isoenzyme 240 U/L↑, total bilirubin 236.2 μmol/L↑, direct bilirubin 172.7 μmol/L↑, total protein 60.2 g/L, albumin 24.0 g/L↓, glucose 3.87 mmol/L, creatinine 60 μmol/L, potassium 4.1 mmol/L, sodium 138 mmol/L, chloride 106 mmol/L, urea 3.1 mmol/L, creatinine 2.73 mmol/L↑, triglycerides 1.67 mmol/L, creatine kinase 55.00 U/L, lactate dehydrogenase 336 U/L↑, fucosidase 71.9 U/L↑, serum cholinesterase 2095.0 U/L↓, procalcitonin 1.23 ng/ml↑, adenosine deaminase 35.3 U/L↑, amylase 51.8↑. Biochemistry (07/07): Hyaluronic acid 650.01↑, type III procollagen N-terminal peptide 27.16↑, laminin 338.55↑, type IV collagen 1240.65↑; Biochemistry (07/07): Free thyroxine 17.20 pmol/L, free triiodothyronine 3.56 μIU/mL, anti-thyroid peroxidase antibody 23.10 IU/ml, anti-thyroglobulin antibody 50.68 IU/ml; Prothrombin time: 15.4 S. Blood routine (07/11): White blood cells 9.3×10⁹/L, red blood cells 3.52×10¹²/L↑, hemoglobin 118.0 g/L↓, platelets 130×10⁹/L, neutrophil ratio 48.8%. Biochemistry (07/11): Alanine aminotransferase 60 U/L↑, aspartate aminotransferase 91 U/L↑, aspartate aminotransferase isoenzyme 220 U/L↑, total bilirubin 148.2 μmol/L↑, total protein 53.8 g/L↓, albumin 21.1 g/L↓, alkaline phosphatase 347 U/L↑, gamma-glutamyl transpeptidase 52 U/L↑, glucose 3.98 mmol/L, urea 3.5 mmol/L, creatinine 60 μmol/L, potassium 3.9 mmol/L, sodium 138 mmol/L, chloride 106 mmol/L, total cholesterol 3.04 mmol/L↑, triglycerides 1.41 mmol/L↑, creatine kinase 45.00 U/L, lactate dehydrogenase 297 U/L↑. Blood routine (07/26): White blood cells 10.4×10⁹/L↑, red blood cells 3.93×10¹²/L↑, hemoglobin 137.0 g/L, platelets 169×10⁹/L, neutrophil ratio 34.1%. Biochemistry (07/26): C-reactive protein 5 mg/L; Biochemistry (07/26): Alanine aminotransferase 51 U/L↑, aspartate aminotransferase 74 U/L↑, total bilirubin 103.3 μmol/L↑, total protein 67.5 g/L, albumin 26.0 g/L↓, glucose 3.93 mmol/L, urea 4.6 mmol/L, creatinine 65 μmol/L, cystatin C 1.01 mg/L, potassium 3.7 mmol/L, sodium 141 mmol/L, chloride 104 mmol/L, total cholesterol 51.20 mmol/L, creatine kinase 58.00 U/L, lactate dehydrogenase 351 U/L↑, procalcitonin 0.32 ng/ml↑, amylase 52.2↑. Special tests and important consultations Color ultrasound (06/21): Examination conclusion: Liver parenchyma shows enhanced and coarse echoes in some areas, gallbladder wall edema and thickening, enlarged gallbladder; spleen, kidneys, ureters, bladder, and prostate show no obvious abnormalities. Electrocardiogram (06/21): Examination conclusion: Sinus rhythm, normal electrocardiogram. Color ultrasound (07/26): Examination conclusion: Liver parenchyma shows enhanced and coarse echoes, enlarged gallbladder, rough and thickened gallbladder wall, no obvious abnormality in pancreatic body, spleen slightly enlarged. Disease course and treatment After admission, relevant examinations were completed. Reduced glutathione, polyene phosphatidylcholine, hepatocyte growth-promoting factor, bitter yellow, and adenosylmethionine were given for liver protection, enzyme reduction, and jaundice relief. Alprostadil was used to improve systemic circulation. Amino acid injection and human albumin were administered to correct hypoalbuminemia. Cefmetazole was given for anti-infection treatment. The patient requested discharge; after consulting the superior physician, he was allowed to leave with signed consent. Complications None. Condition at discharge The patient had no nausea or vomiting. Abdominal distension and yellow urine had improved. He experienced general fatigue and weakness in the limbs, with no skin itching. Appetite was fair without obvious reduction. No clay-colored stools. No chest tightness or chest pain. Sleep was acceptable at night. Physical examination: Temperature 36.5°C, blood pressure 115/60 mmHg, clear consciousness, fair spirit, moderate jaundice of the whole-body skin, liver palms not obvious, no spider nevi, smooth skin with good elasticity. Moderate jaundice of bilateral sclera, supple neck, no resistance, trachea in midline, coarse breath sounds in both lungs, no dry or moist rales. Heart rate 75 beats/min, regular rhythm, no pathological murmurs. Soft abdomen, no visible intestinal patterns or peristaltic waves, no tenderness, no palpable masses, liver upper border at the 5th intercostal space in the right midclavicular line, liver and spleen not palpable below the costal margin, Murphy’s sign negative, shifting dullness negative, no tenderness in bilateral kidney areas, bowel sounds 4 times/min. No edema in both lower limbs. Post-discharge medications and advice Further treatment at a higher-level hospital, rest, take medications on time, and regularly recheck liver function, HBV-DNA, ultrasound, AFP, etc. Dispensed: Ursodeoxycholic acid soft capsules 30# × 3 boxes, 2# tid po; Compound glycyrrhizin capsules 40# × 3 boxes, 2# tid po. Treatment outcome Improved. The above is the content of the discharge summary. The day after discharge (July 29), the patient went to another hospital. Imaging (CT) at that hospital showed local subcutaneous soft tissue edema in the buttock-lumbar region (which had resolved) and no obvious abnormalities in the upper abdominal liver parenchyma. Considering persistent jaundice and incomplete recovery of liver function, steroid treatment was given (specific regimen unknown). Subsequent follow-up medical records show: Two years later (patient approximately 28–29 years old): Liver function returned to normal, but imaging suggested diffuse liver lesions. Four years later (patient approximately 30 years old): Liver function still normal, but imaging suggested diffuse liver lesions with features approaching cirrhosis.