1. Haematology
Group A

2. Patient X A 61 year old male Presents with: Medical History:
generalised weakness & increasing dyspnoea on exertion for 3/52.
Medical History:
Alcoholism
Social History
Divorced for 2 years
Lives Alone
Retrenched 6 years ago; has not worked since

3. Mr X cont… On Examination: Pallor and scleral icterus were noted
Clinical evidence of chronic alcoholic liver disease with portal hypertension
Spleen was palpable (2cm).
Scleral icterus: yellowing of eyes

4. Mr X’s Biochemistry - FBC
Initial biochemistry:
PARAMETER
VALUE
REFERENCE RANGE Hb
33 g/L (L)
MCV
125 fL (H)
80-100
WCC
2.4 x109/L (L)
x109/L
Neutrophils
30% (L)
0.72 x109/L
x109/L
Monocytes
5% (L)
0.12 x109/L
x109/L
Lymphocytes
65%
1.56 x109/L
x109/L
Platelets
49 x109/L (L)
x109/L
Blood film
marked anisocytosis (marked variation in size between individual RBCs (oval macrocytes common in b12 & folate deficiencies)
poikilocytes (abnormally-shaped RBCs) (tear drop & fragmented cells ++).
Red cells normochromic
Neutropenia (decrease in number of neutophils) with marked neutrophil hypersegmentation.
Thrombocytopenia (low numbers of platelets).
Blood flim:
Marked anisocytosis (oval macrocytes +++)
Poikilocytes (tear drop & fragmented cells ++)
Red cells normochromatic
Neutropenia with marked neutrophil hypersegmentation
Thrombocytopenia.

5. Mr X’s Biochemistry - LFTs
PARAMETER
VALUE
REFERENCE RANGE
Serum bilirubin (total)
84 μmol/L (H)
2-20
Conjugated bilirubin
44 μmol/L (H)
1-4
AST
420 U/L (H)
10-45
GGT
640 U/L (H)
0-50 LD
3162 U/L (H)
Haptoglobins
0.3 g/L
Ferritin
442 μg/L (H)
33-330
Serum B12
138 pmol/L
Serum folate
0.7 nmol/L (L)
7-45
Red cell folate
125 nmol/L (L)

6. Portal Hypertension Pressure in the hepatic portal vein is increased
Most common cause is cirrhosis, but any liver disease can cause it
In cirrhosis, hepatocytes regenerate more slowly than scar-tissue forms
As the scar tissue shrinks, it obstructs blood flow through the hepatic portal system
Patients with alcoholic cirrhosis and those with isolated alcoholic hepatitis may develop complications of portal hypertension
Pressure in the hepatic portal vein is increased, causing enlargement of the spleen, oesophageal veins (which may rupture and bleed) & ascites (accumulation of fluid in the peritoneal cavity).
Commonest cause is cirrohsis, but most liver disease can cause it
In cirrohsis, the poisoned hepatocytes regenerate, however scar-tissue (i.e., connective tissue) forms more quickly  liver becomes fibrous
As the scar tissue shrinks, it obstructs blood flow through the hepatic portal system, leading to portal hypertension.

7. Symptoms of Portal Hypertension
Common portal hypertensive complications include:
Hepatic encephalopathy
Bleeding esophageal varices
Ascites & spontaneous bacterial peritonitis
Hepatorenal syndrome
Common portal hypertensive complications that require therapy include:
Hepatic encephalopathy (toxins normally removed by the liver  impair brain function)
Bleeding esophageal varices (dilated veins of the lower oesophagus due to portal hypertension)
Ascites and spontaneous bacterial peritonitis (Accumulation of fluid in the peritoneal cavity  bacterial infection)
Hepatorenal syndrome
all of which portend severe disease and a poor prognosis.

8. Alcoholic Liver Disease
A spectrum of clinical syndromes & pathologic changes in the liver caused by alcohol. The spectrum includes fatty liver, alcoholic hepatitis & alcoholic cirrohsis.
Approximately 15% to 20% of those who abuse alcohol develop alcoholic hepatitis and/or cirrhosis, which may develop in succession or exist concomitantly
The level of alcohol consumption necessary for the development of these advanced forms of alcoholic liver disease is probably 80 g of alcohol per day, the equivalent to 6 to 8 drinks daily for several years
BUT, the threshold of alcohol necessary for the development of advanced alcoholic liver disease varies substantially among individuals
A spectrum of clinical syndromes & pathologic changes in the liver, caused by alcohol. The spectrum includes fatty liver, alcoholic hepatitis & alcoholic cirrohsis.
Approximately 15% to 20% of those who abuse alcohol develop alcoholic hepatitis and/or cirrhosis, which may develop in succession or exist concomitantly
The level of alcohol consumption necessary for the development of these advanced forms of alcoholic liver disease is probably 80 g of alcohol per day, the equivalent to 6 to 8 drinks daily for several years [1]
However, the threshold of alcohol necessary for the development of advanced alcoholic liver disease varies substantially among individuals, and factors other than absolute alcohol consumption clearly have an important role in determining who will develop alcoholic liver disease and who will not.

9. Alcoholic Fatty Liver Also called steatosis
Predominantly an asymptomatic condition that develops in response to a short duration (a few days) of alcohol abuse
Up to 15 drinks a day for 10 days
Entirely reversible with abstinence

10. Alcoholic Hepatitis
Prolonged alcohol abuse results in alcoholic hepatitis.
Patients with this condition have various constitutional symptoms, such as fatigue, anorexia, weight loss, nausea and vomiting.
Severe alcoholic hepatitis may be evident by advanced symptoms due to portal hypertension, including gastrointestinal (GI) bleeding, ascites, and hepatic encephalopathy.
Other findings depend on the severity of liver insult and may include jaundice, splenomegaly, hepatic bruits, collateral vessels, and ascites.
Reversible if patients stop drinking
Prolonged alcohol abuse results in alcoholic hepatitis.
Diagnosed predominantly on clinical history, physical examination, and laboratory testing, although liver biopsy is often necessary to secure the diagnosis.
The history of patients with this condition is notable for various constitutional symptoms, such as fatigue, anorexia, and weight loss, and other nonspecific symptoms, such as nausea and vomiting.
Severe alcoholic hepatitis may be evident by advanced symptoms due to portal hypertension, including gastrointestinal (GI) bleeding, ascites, and hepatic encephalopathy.
Other findings depend on the severity of liver insult and may include jaundice, splenomegaly, hepatic bruits, collateral vessels, and ascites.

11. Alcoholic Cirrhosis
Alcoholic cirrhosis may occur before, concomitant with, after, or independent of a bout of alcoholic hepatitis
Characterized anatomically by widespread nodules in the liver combined with fibrosis
Most common of specific organ damage in alcoholics
The clinical history is similar to that of alcoholic hepatitis, & symptoms are similar to those observed with other forms of end-stage liver disease
Alcoholic cirrhosis may occur before, concomitant with, after, or independent of a bout of alcoholic hepatitis.
The clinical history is similar to that of alcoholic hepatitis, and symptoms are similar to those observed with other forms of end-stage liver disease.

12. Bilirubin Bilirubin: A break-down product of haemoglobin
Dying RBCs are engulfed & destroyed by macrophages
Heme is split from globin & the iron core is salvaged
The remaining heme molecule is degraded to bilirubin

13. Bilirubin
Unconjugated bilirubin is transported in the plasma bound to albumin
This free bilirubin is conjugated with glucuronic acid in the liver.
The conjugated bilirubin is then secreted in the bile as an orange-yellow pigment

14. Bilirubin & Liver Disease
Generally, liver disease leads to mixed hyperbilirubinemia, i.e., high levels of both circulating (unconjugated) and conjugated bilirubin. (Total=84, range: 2-20) and conjugated 44 micro mol/L, range: 1-4
This is due to impaired liver uptake of unconjugated, and impaired excretion of conjugated bilirubin from bile duct perhaps due to gallstones, hepatitis, trauma or long term alcohol abuse
Also, an increase in bilirubin may mean too many RBC are getting destroyed
Bilirubinemia: excess of bilirubin in the blood
Visible jaundice occurs in concentrations 20-30umol/L
i.e., patient has jaundice

15. Serum bilirubin (total)
Mr X – are his bilirubin results consistent with alcoholic liver disease?
Hyperbilirubinemia: excess of bilirubin in the blood
Visible jaundice occurs at ~20-30μmol/L
The patient has jaundice (scleral icterus)
History of alcoholism
Mr X has mixed hyperbilirubinemia
PARAMETER
VALUE
REFERENCE RANGE
Serum bilirubin (total)
84 μmol/L (H)
2-20
Conjugated bilirubin
44 μmol/L (H)
1-4

16. Lactate Dehydrogenase (LD)
Cytoplasmic enzyme
Its function is to catalyze the oxidation of L-lactate to pyruvate
Assayed as a measure of anaerobic carbohydrate metabolism
Present in heart, liver, kindey, lungs, skeletal muscle and brains
Used as a diagnostic marker for MI, muscular disorders, malignancy and liver disease
Not a specific marker

17. Increased Levels Indicate:MI
Stroke
Anaemia
Hypotension
Liver disease
Megaloblastic anaemia
Perniciour anaemia

18. When is LD testing Performed
Possible diagnosis:
Anaemia of Vitamin B12 deficiency
Megaloblastic anaemia
Perniciour anaemia
LD isoenzyme levels may be requested

19. Lactate Dehydrogenase & Liver Disease
LD has several isoenzymes (LD-1 to LD-5)
LD-1 and 2
MI, Renal infarction, megaloblastic anaemia
LD-2 and 3
Acute leukaemia
LD-5
Liver and skeletal muscle damage

20. What this tells us: Tissue damage Possible liver disease
Possible anaemia
Muscle injury MI

21. Haptoglobins
Plasma proteins that carry “free” haemoglobin (i.e., Hb NOT in RBCs)
Blood levels used to detect haemolysis (intravascular destruction of RBC)
Normally ~10% of haemolysis is handled by haptoglobins and haemopexin
Haemolysis > Haptoglobin synthesis  decrease in serum haptoglobin
Lower than normal levels may indicate chronic liver disease, haemolytic anaemia, primary liver disease, AMI and some cancers
Increased levels in certain chronic diseases and inflammatory disorders
Haptoglobins
If haemolysis outpaces haptoglobin synthesis, serum haptoglobin decreases

22. Mr X – are his haptoglobin results consistent with alcoholic liver disease?
0.3g/L is boarder-line low for the normal range (0.3 – 2.0g/L)
Parameter
Value
Reference Range
Haptoglobin
0.3g/L
g/L

23. Ferritin
An iron compound synthesised in response to erythrophagocytosis
Ferritin is stored in the liver, spleen & bone marrow for eventual encorporation into haemoglobin
Ferritin iron is the principle form of iron storage therefore serum ferritin levels indicate the body’s iron stores
·       

24. Ferritin Two main functions:
sequester potentially toxic iron into the apoferritin protein shell
provide a readily accessible store of iron
Can be used to diagnose iron deficiency anaemia
In combination with serum iron and total iron-binding capacity tests, it can differentiate and classify different types of anaemia's
Ferritin consists of H (heavier) and L (lighter) subunits
L ferritin predominates in the liver

25. Mr X – are his ferritin results consistent with alcoholic liver disease?
442μg/L is significantly higher than the upper normal range (33-330μg/L)
This suggests a high level of erythrophagocytosis, most likely due to severe inflammatory liver disease
Parameter
Value
Reference Range
Ferritin
442μg/L (H)
33-330μg/L

26. Folate (Vitamin B9) Obtained from green, leafy vegetables
Total body folate is ~70mg
1/3 of this is stored in the liver
In folate deficiency anaemia, the red cells are abnormally large (“megalocytes”)
Precursors, in the bone marrow are “megaloblasts”
Thus, this anaemia is referred to as megaloblastic anemia
Polyglutamate folate is the most common form of folate in food
Reduced to dihydrofolate and tetrahydrofolate
They are bound to protein and transported as methyltetrahydrofolate.

27. Folate–Deficient Anaemia
Causes of the anaemia are poor dietary intake of folic acid as in chronic alcoholism
Causes of folic acid depletion include:
Poor intake (e.g., chronic alcoholism, diet lacking in fresh vegetables)
Inadequate absorption/malabsorption syndrome (e.g, drug-induced by phenytoin, primidone, barbiturates; celiac disease)
Inadequate utilisation via antagonists such as methotrexate and trimethoprim
Alcohol also interferes with its intestinal absorption, intermediate metabolism & entero-hepatic salvage

28. Megaloblastic Anemia
Results from defective DNA synthesis. RNA synthesis continues  increased cytoplasmic mass & maturation
I.e., All cells have dyspoiesis: cytoplasmic maturity > nuclear maturity  production of megaloblasts
Dyspoiesis  increased intramedullary cell death  hyperbilirubinemia & hyperuricemia
All cell lines are affected, so leukopenia & thrombocytopenia may occur
Main causes: defective utilisation of folic acid or vitamin B12 deficiency; cytotoxic drugs; Di-Guliemo Syndrome
Di-Guliemo Syndrome: rare autonomous neoplastic disease which sometimes converts to leukaemia.

29. Mr X – are his results consistent with megaloblastic anaemia?
The patient’s Hb is low, indicating anaemia, while his elevated MCV indicates macrocytic anaemia.
The patient has a serum folate of 0.7nmol/L, & a RBC folate level of 125nmol/L which are well below the normal ranges. His serum B12 is within the normal range
Normal serum B12 assay with a low RBC folate level are consistent with alcoholism
Both of these results
also support the diagnosis of
megaloblastic anaemia due
to folic acid deficiency.
Laboratory results reporting these levels can differentiate folate deficiency from other forms of megaloblastic anaemia as low levels are consistent with folate deficiency.
To confirm the diagnosis, serum homocysteine measurement gives the best evidence of tissue deficiency, however B12 uses the same pathway and so both methylmalonic acid and homocysteine need to be measured. A normal methylmalonic acid level with an elevated homocysteine level confirms the diagnosis of folate deficiency.
Parameter
Value
Reference Range
Serum B12
138 pmol/L
Serum folate
0.7 nmol/L (L)
7-45
Red cell folate
125 nmol/L (L)

30. Mr X’s Biochemistry - FBC
Initial biochemistry:
PARAMETER
VALUE
REFERENCE RANGE Hb
33 g/L (L)
MCV
125 fL (H)
80-100
WCC
2.4 x109/L (L)
x109/L
Neutrophils
30% (L)
0.72 x109/L
x109/L
Monocytes
5% (L)
0.12 x109/L
x109/L
Lymphocytes
65%
1.56 x109/L
x109/L
Platelets
49 x109/L (L)
x109/L
Blood film
marked anisocytosis (marked variation in size between individual RBCs (oval macrocytes common in b12 & folate deficiencies)
poikilocytes (abnormally-shaped RBCs) (tear drop & fragmented cells ++).
Red cells normochromic
Neutropenia (decrease in number of neutophils) with marked neutrophil hypersegmentation.
Thrombocytopenia (low numbers of platelets).
Blood flim:
Marked anisocytosis (oval macrocytes +++)
Poikilocytes (tear drop & fragmented cells ++)
Red cells normochromatic
Neutropenia with marked neutrophil hypersegmentation
Thrombocytopenia.

31. Mr X – are his results consistent with megaloblastic anaemia?
Mr X’s neutrophils are below the normal range.
This tends to occur in chronic disease states and megaloblastic anaemias
Hypersegmentation of neutrophils occurs in 91% of cases megaloblastic anaemia
Hypersegmentation: where greater than 5% nuclei have 6 or more lobes

32. Conclusions
Mr X is experiencing multiple biochemical changes due to his chronic alcohol intake.
Treatment for him is primarily supportive. He needs to improve his diet, and ideally, should cease alcohol intake.
Corticosteroids may be indicated.