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Abstract: An elderly female patient came to the hospital with complaints of malaise and abdominal distension for half a month, and was hospitalized for further detailed investigation of liver function abnormalities, which were found to be mainly elevated alkaline phosphatase (ALP) and gamma-glutamyl transpeptidase (GGT), and was diagnosed as primary biliary cirrhosis (PBC) with underlying diseases of type 2 diabetes, hypertension, hyperlipidemia, and fatty liver. After clinical treatment with medication, the patient’s symptoms were alleviated and all indicators improved significantly, and she was discharged successfully.
Basic information】Female, 83 years old
Disease Type】Primary biliary cirrhosis (PBC), type 2 diabetes, hypertension, hyperlipidemia, fatty liver
Hospital】Liaoning Provincial People’s Hospital
Consultation time】January 2019
【Treatment plan】Medication (multi-diluted phosphatidylcholine injection + magnesium isoglycyrrhizate injection + ursodeoxycholic acid capsule + silymarin capsule + levocarnitine oral solution + metoprolol tartrate tablet + insulin injection)
[Treatment period] 8 days in hospital, 4 weeks after outpatient follow-up
Treatment effect】Symptoms reduced and indicators improved significantly
I. Initial consultation
The patient was an elderly woman with limited mobility who came to the clinic accompanied by her family. The family described that the patient developed weakness, abdominal distension and poor appetite with no obvious cause half a month ago, and the symptoms gradually worsened without treatment. He has been suffering from hypertension for more than 10 years, and is currently taking metoprolol tartrate tablets with fair blood pressure control; diabetes mellitus for 6-7 years, and is currently taking Reglanet tablets with poor fasting glucose control; hyperlipidemia for many years, and has been taking simvastatin tablets for 6-7 years; with depression for many years, and is taking haloperidol melitrexin tablets. The patient was admitted to the ward with the consent of the patient and his family after the liver function tests indicated that the liver function was obviously abnormal.
II. Treatment process
After admission, the patient was routinely given secondary care, bed rest, low-salt, low-fat diabetic diet, and improved relevant tests to clarify the diagnosis. The results of autoimmune hepatitis tests were: positive anti-nuclear antibody; positive anti-mitochondrial antibody M2-3E; positive anti-Ro-52 antibody; elevated triglycerides, cholesterol and LDL; decreased HDL; glucose 9.44 mmol/L; uric acid 360 μmol/L; glucose (2h) 16.81 mmol/L. Liver, bile and spleen Ultrasound suggested fatty liver. Combined with the patient being an elderly female (high prevalence of PBC), symptoms and signs such as malaise and abdominal distension and positive anti-mitochondrial antibody M2-3E and anti-Ro-52 antibody, and elevated ALP and GGT suggesting biliary liver function abnormalities, the diagnosis of primary biliary cirrhosis (PBC), type 2 diabetes mellitus, hypertension, hyperlipidemia, and fatty liver was determined. He was given hepatoprotective, enzyme-lowering, biliary improvement and symptomatic antihypertensive, hypoglycemic and lipid-lowering treatments. Use polydiluted phosphatidylcholine injection, magnesium isoglycyrrhizate injection for sedation; ursodeoxycholic acid capsule and silymarin capsule for oral improvement of biliary stasis, liver protection and enzyme lowering. Levocarnitine oral solution is taken orally to improve lipid metabolism and assist in the treatment of hyperlipidemia and fatty liver. Metoprolol tartrate tablets are taken orally to lower blood pressure treatment. For the problem of diabetes mellitus, insulin injection was given subcutaneously in the morning and evening after consultation with the endocrinology department, and blood glucose was monitored.
III. Treatment effect
After 5 days of symptomatic treatment with improvement of cholestasis, liver protection, enzyme lowering, lipid lowering and blood glucose lowering, the effect was remarkable. The patient’s fatigue and abdominal distension were reduced, appetite was increased, and all abnormal indexes were returned on reexamination, lipid decreased, blood glucose decreased, and liver function tests were significantly improved: glutathione transaminase 39.4 U/L, glutathione transaminase 27.4 U/L, alkaline phosphatase 110 U/L, transpeptidase 264 U/ After the improvement, the patient was discharged from the hospital after 3 days of consolidation treatment, and was advised to continue the medication of hepatoprotective, cholestatic, lipid-lowering, antihypertensive and hypoglycemic drugs, and to come back to the hospital for a review in 4 weeks. The results of the review showed that the patient had no discomfort, his condition was stable and the effect of drug treatment was good.
IV. Notes
The patient’s symptoms gradually disappeared and the indexes improved, so we are really happy for him. Because primary biliary cirrhosis is an autoimmune disease and an intrahepatic cholestatic disease, the main lesion is in the bile ducts, which will cause bile stasis and progressive aggravation, and finally progress to cirrhosis portal hypertension and liver failure. Therefore, even after discharge from the hospital, ursodeoxycholic acid capsules need to be taken for a long time, with dose adjustment according to the results and weight, and regular follow-up. In addition, continue to apply medications to improve bruising, protect the liver, lower blood lipids, lower blood pressure and blood sugar, and monitor blood sugar. In daily life, a low-salt, low-fat diabetic diet should be maintained. Since the patient’s albumin level was low at the time of discharge and renal function was normal, a high-protein diet was recommended.
V. Personal insight
Primary biliary cirrhosis (PBC) is one of the more common types of autoimmune liver disease. The main manifestation is intrahepatic cholestasis, dominated by elevated alkaline phosphatase (ALP) and gamma-glutamyl transpeptidase (GGT), which is mainly treated clinically with ursodeoxycholic acid capsules. The high prevalence of this disease is in middle-aged and elderly women, with a male to female ratio of 1:9. Moreover, patients with primary biliary cirrhosis may have more than 2 autoimmune diseases at the same time, such as dry syndrome, ulcerative colitis and systemic lupus erythematosus. Therefore, if abnormalities appear, medical attention should be sought for early detection, diagnosis and treatment. Usually, after active and effective treatment, the effect can be effectively controlled and remitted as in this patient.