Friday, March 21, 2014

Annnnnd ... the biopsy result is now in question :-/

That's how it goes -- particularly if you don't take the first answer you're given ;-)

I reached out to the half-dozen top Liver Pathologists (that I could find) in the States.  This morning, after getting a copy of my actual Pathology Report, I forwarded it on to the same bunch.

One (my first-round draft pick -- the one I was hoping to have on my team, above all the others) wrote back:

I have been thinking about your case since this morning and I just read the pathology report you sent.  My first thought is that this is probably not drug-induced liver injury, mainly because your bilirubin came down so quickly.  The liver biopsy report is consistent with this—there is some residual bile in the liver (a normal liver would not have visible bile) along with the clean-up cells (histiocytes).  It is not a specific pattern, and is probably most often related to acute obstruction. The pathologist noted that they didn’t see evidence of obstruction, but if the obstruction doesn’t last very long all you might see is what was described in the report. It can be related to drugs, but the elevated bilirubin usually lasts for weeks when a drug is the cause.  One possible explanation is that you passed a gallstone that briefly caused obstruction, but then passed, allowing the bile to flow normally and the blood bilirubin to quickly fall into the normal range.  There may be other explanations as well.  Infection could cause bile to accumulate, but usually a blood infection would be required to cause jaundice and you would probably be hospitalized and on IV antibiotics if that were the case.  Drug injury is always possible, but is pretty rare and you have to exclude all the other possibilities before you conclude that a drug is the cause.   In that respect drug-induced liver injury is very different from the more common skin reactions that happen with medications. If you want an official second opinion on the biopsy, I can do that if the slides are sent to me for review.  There is no charge for a second opinion, but I’m not sure I could say much more than was already said.  If you’re still concerned, you could see a hepatologist (liver specialist), rather than someone who mainly does gastroenterology.  I don’t know any of the hepatologists at UCI, but I know one or two at USC.  I’m really only qualified to advise you about the pathology—you would need to see someone else for a more complete review of your symptoms and test results.

Sounds like I'm medically interesting ... again :-(

I'm trying to arrange to have the slides sent to this mensch.

In the immortal words of the bad guy, toward the end of Dirty Harry .... well ... y'know what ?  You take about a minute and a half and figure out what line I was thinking of:

Got work to do.  It's what we do ... here ... in the hystiocytic doldrums of ... The Gulag.

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