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Author: Shao Ming, Xiao Yuzhen, Hepatobiliary and Stomach Disease Specialist Hospital, Yongji City, Shanxi Province
.
Introduction Fatty liver is very common in clinical practice.
For example, the value of white blood cells and platelets in the blood routine is increased.
As a clinician, please do not ignore the abnormal signals in the blood routine.
Pay attention to it to avoid missed diagnosis
.
Early diagnosis and early treatment are extremely important for controlling the condition, improving symptoms, and controlling complications
.
What is the situation with today's case? Let us follow the author and find out! Case data Patient Li, male, 38 years old, from Shanxi, was admitted to the hospital for "fatty liver 2 years, fatigue, abdominal distension, and liver discomfort for 10 days" on June 28, 2019
.
History of present illness: Liver function found during physical examination 2 years ago: ALT: 60.
0U/L, AST: 42.
0U/L; abdominal color Doppler ultrasound: fatty liver; no medication and regular review
.
I experienced fatigue, abdominal distension, and liver discomfort 10 days ago.
I took domperidone tablets by myself for 2 days, but the effect was not good
.
Conscious that the above symptoms gradually worsened, I went to a hospital to check liver function 2 days ago: TB: 7.
5 µmol/L, DB: 1.
9 µmol/L, ALT: 137.
0 U/L, AST: 84.
0 U/L
.
Blood routine: WBC: 11.
32×109/L, RBC: 5.
73×1012/L, HGB: 161.
00g/L, PLT: 746.
00×109/L, today for further diagnosis and treatment, the outpatient department will be “1.
Abnormal liver function waiting for diagnosis (1) Viral hepatitis? (2) Non-alcoholic steatohepatitis 2.
Hematological diseases waiting to be discharged?" Admitted to the hospital
.
The illness came with a clear mind, poor spirits, a 1/4 less diet than normal, good night sleep, and normal urination and urination
.
Past history: deny history of hypertension, diabetes, heart disease, deny history of trauma, surgery, deny history of poisoning, deny history of drug allergy
.
Personal history: Born locally, never been to an epidemic area, no addiction to tobacco and alcohol
.
There is no history of travel
.
Marriage and childbirth history: married at the age of 27 and have 1 son and 1 daughter
.
His spouse and children are in good health
.
Family history: Deny a history of related diseases in the family
.
Physical examination: Conscious, normal vital signs, slightly fatter, weighing 81Kg
.
There was no yellowing of the skin and sclera all over the body, no spider moles and liver palms were seen
.
There was no palpable swelling of the superficial lymph nodes throughout the body
.
Lung (-), heart (-)
.
The liver is palpable 1 cm below the ribs, medium quality, and tender (-); the spleen is palpable 2 cm below the ribs, medium quality, and tender (-)
.
Abdominal percussion: fluid wave tremor (-), mobile dullness (-), percussion pain in the liver area (+)
.
Pitting edema of both lower limbs (-)
.
Auxiliary examination: liver function: TB: 11.
00µmol/L, DB: 5.
30µmol/L, ALT: 161.
0U/L, AST: 148.
0U/L, ALP: 130.
0U/L, GGT: 54.
0U/L, ChE: 4320.
0U/L, TP: 66.
0g/L, Alb: 41.
0g/L, CRP: 8.
0mg/L; Renal function, electrolytes, coagulation series: normal; CK, CK-MB, HCY: normal; 8 blood lipids: TG: 1.
8mmol/L, more than normal; blood routine: WBC: 11.
77×109/L, RBC: 5.
45×1012/L, HGB: 162.
00g/L, PLT: 674.
00×109/L; BG: O type, Rh (D): positive; viral hepatitis markers (A ~ G): all negative; anti-HIV: negative, RPR: negative; thyroid function: normal
.
8 items of autoimmune liver disease antibodies: all negative; ANA, ASMA, AMA: all negative; ceruloplasmin: normal; four items of ferritin and iron: normal; three items of immunoglobulin: normal
.
EB virus quantification: negative
.
Cytomegalovirus quantification (CMV-DNA): negative; AFP, CEA, CA-125, CA-199: normal
.
Urine 11 items: normal; stool RT: no abnormalities
.
OB: (-)
.
ECG: Normal ECG
.
Chest CT scan: no obvious abnormalities were found
.
Abdominal color Doppler ultrasound: 1.
Large liver, mild fatty liver seen inside
.
2.
Splenomegaly, no obvious abnormalities in it
.
3.
There are no obvious abnormalities in the gallbladder, pancreas and kidneys
.
4.
No obvious abnormalities in the abdominal cavity
.
Clinically, fatty liver can cause liver and splenomegaly.
The special feature of this patient is that the spleen is enlarged, but the white blood cell and platelet values in the blood routine are increased; we know that in patients with chronic liver disease, some patients with splenomegaly can have blood.
Routine white blood cell and platelet counts are reduced, which is caused by hypersplenism
.
The increase in white blood cell and platelet values cannot be explained by monism.
Further search for the cause is there any hematological disease? Diagnosis of preliminary diagnosis 1.
Non-alcoholic steatohepatitis 2.
Hematological system diseases to be diagnosed Bone marrow fibrosis? Thrombocytosis? In order to further clarify the cause of abnormal blood routine, bone marrow aspiration biopsy, bone marrow morphology examination, cytogenetics, molecular biology and other examinations were performed
.
Bone marrow cell examination results: Blood film: 1.
The smear is stained well
.
2.
There are a lot of white blood cells
.
3.
Mature red blood cells are roughly normal
.
4.
Increased platelets
.
5.
No parasites were seen
.
Opinion: Active bone marrow hyperplasia and increased platelets, please consider clinical considerations
.
The results of bone marrow pathological examination are as follows: Feature description: 1.
The bone marrow hyperplasia is obviously active, and the fat tissue is reduced
.
2.
Grain hyperplasia is active, visible in all stages
.
3.
The erythroid hyperplasia is active, and clusters of young red blood cells can be seen
.
4.
There are more megakaryocytes, and clusters of megakaryocytes can be seen.
Some megakaryocytes have large cell bodies, rich cytoplasm, and disordered nuclei
.
Opinion: Megakaryocytes increase, please consider with medical history
.
Myeloproliferative tumor-related gene mutation test results: JAK2V617F mutation detected
.
The fusion gene BCR/ABL (P210) real-time quantitative RT-PCR result: negative
.
Chromosome test result: no split phase was seen in the whole film, and follow-up is recommended
.
Finally, the diagnosis of non-alcoholic steatohepatitis and primary thrombocytosis was given to support symptomatic treatment such as liver protection, reduction of platelet count (hydroxyurea), and prevention of thrombosis (aspirin), and the condition improved and was discharged from the hospital
.
Discussion Essential thrombocythemia, also known as hemorrhagic thrombocytosis, is a clonal disease of hematopoietic stem cells dominated by megakaryocyte proliferation.
The main clinical manifestations are persistent increase in platelets, splenomegaly, bleeding or thrombosis
.
The exact cause of the disease is unclear, and it may be related to changes in thrombopoietin and thrombopoietin receptors and abnormal gene activation
.
The disease progresses slowly, and many patients are asymptomatic for a long time
.
The main clinical manifestations of this disease are bleeding and thrombosis.
Unlike other myeloproliferative diseases, fever, hyperhidrosis, weight loss, etc.
are very rare
.
Maintaining a benign process for many years, about 10% of patients are likely to transform into other types of myeloproliferative tumors
.
The peripheral blood platelet count is significantly increased and the function is abnormal.
Megakaryocytes in the bone marrow proliferate vigorously.
50% to 70% of patients have JAK2V617F gene mutations
.
This disease can lead to concurrent diseases: cerebrovascular thrombosis, venous thrombosis of limbs, splenic infarction, spleen atrophy
.
Clinically, cases of liver disease with abnormal blood routine are also uncommon, such as white blood cells appearing in blood routine, and blood routine values are abnormally increased
.
Or when the platelet is found to be significantly elevated during the physical examination (greater than 600×10^9/L), seek medical attention in time
.
Clinicians should pay attention to improve relevant inspection items in time to avoid missed diagnosis, so as not to delay the condition
.
Follow-up patients continued to take treatment with hydroxyurea and aspirin after they were discharged from the hospital, and the values of white blood cells and platelets in the blood routine gradually decreased, and various indicators were monitored regularly in accordance with the doctor's advice
.
On September 20, 2021, the liver function and blood routine will be rechecked.
There is no discomfort.
He will continue to take hydroxyurea and aspirin.
Follow-up is underway
.
Contribution email: tougao@medlive.
cn
.
Introduction Fatty liver is very common in clinical practice.
For example, the value of white blood cells and platelets in the blood routine is increased.
As a clinician, please do not ignore the abnormal signals in the blood routine.
Pay attention to it to avoid missed diagnosis
.
Early diagnosis and early treatment are extremely important for controlling the condition, improving symptoms, and controlling complications
.
What is the situation with today's case? Let us follow the author and find out! Case data Patient Li, male, 38 years old, from Shanxi, was admitted to the hospital for "fatty liver 2 years, fatigue, abdominal distension, and liver discomfort for 10 days" on June 28, 2019
.
History of present illness: Liver function found during physical examination 2 years ago: ALT: 60.
0U/L, AST: 42.
0U/L; abdominal color Doppler ultrasound: fatty liver; no medication and regular review
.
I experienced fatigue, abdominal distension, and liver discomfort 10 days ago.
I took domperidone tablets by myself for 2 days, but the effect was not good
.
Conscious that the above symptoms gradually worsened, I went to a hospital to check liver function 2 days ago: TB: 7.
5 µmol/L, DB: 1.
9 µmol/L, ALT: 137.
0 U/L, AST: 84.
0 U/L
.
Blood routine: WBC: 11.
32×109/L, RBC: 5.
73×1012/L, HGB: 161.
00g/L, PLT: 746.
00×109/L, today for further diagnosis and treatment, the outpatient department will be “1.
Abnormal liver function waiting for diagnosis (1) Viral hepatitis? (2) Non-alcoholic steatohepatitis 2.
Hematological diseases waiting to be discharged?" Admitted to the hospital
.
The illness came with a clear mind, poor spirits, a 1/4 less diet than normal, good night sleep, and normal urination and urination
.
Past history: deny history of hypertension, diabetes, heart disease, deny history of trauma, surgery, deny history of poisoning, deny history of drug allergy
.
Personal history: Born locally, never been to an epidemic area, no addiction to tobacco and alcohol
.
There is no history of travel
.
Marriage and childbirth history: married at the age of 27 and have 1 son and 1 daughter
.
His spouse and children are in good health
.
Family history: Deny a history of related diseases in the family
.
Physical examination: Conscious, normal vital signs, slightly fatter, weighing 81Kg
.
There was no yellowing of the skin and sclera all over the body, no spider moles and liver palms were seen
.
There was no palpable swelling of the superficial lymph nodes throughout the body
.
Lung (-), heart (-)
.
The liver is palpable 1 cm below the ribs, medium quality, and tender (-); the spleen is palpable 2 cm below the ribs, medium quality, and tender (-)
.
Abdominal percussion: fluid wave tremor (-), mobile dullness (-), percussion pain in the liver area (+)
.
Pitting edema of both lower limbs (-)
.
Auxiliary examination: liver function: TB: 11.
00µmol/L, DB: 5.
30µmol/L, ALT: 161.
0U/L, AST: 148.
0U/L, ALP: 130.
0U/L, GGT: 54.
0U/L, ChE: 4320.
0U/L, TP: 66.
0g/L, Alb: 41.
0g/L, CRP: 8.
0mg/L; Renal function, electrolytes, coagulation series: normal; CK, CK-MB, HCY: normal; 8 blood lipids: TG: 1.
8mmol/L, more than normal; blood routine: WBC: 11.
77×109/L, RBC: 5.
45×1012/L, HGB: 162.
00g/L, PLT: 674.
00×109/L; BG: O type, Rh (D): positive; viral hepatitis markers (A ~ G): all negative; anti-HIV: negative, RPR: negative; thyroid function: normal
.
8 items of autoimmune liver disease antibodies: all negative; ANA, ASMA, AMA: all negative; ceruloplasmin: normal; four items of ferritin and iron: normal; three items of immunoglobulin: normal
.
EB virus quantification: negative
.
Cytomegalovirus quantification (CMV-DNA): negative; AFP, CEA, CA-125, CA-199: normal
.
Urine 11 items: normal; stool RT: no abnormalities
.
OB: (-)
.
ECG: Normal ECG
.
Chest CT scan: no obvious abnormalities were found
.
Abdominal color Doppler ultrasound: 1.
Large liver, mild fatty liver seen inside
.
2.
Splenomegaly, no obvious abnormalities in it
.
3.
There are no obvious abnormalities in the gallbladder, pancreas and kidneys
.
4.
No obvious abnormalities in the abdominal cavity
.
Clinically, fatty liver can cause liver and splenomegaly.
The special feature of this patient is that the spleen is enlarged, but the white blood cell and platelet values in the blood routine are increased; we know that in patients with chronic liver disease, some patients with splenomegaly can have blood.
Routine white blood cell and platelet counts are reduced, which is caused by hypersplenism
.
The increase in white blood cell and platelet values cannot be explained by monism.
Further search for the cause is there any hematological disease? Diagnosis of preliminary diagnosis 1.
Non-alcoholic steatohepatitis 2.
Hematological system diseases to be diagnosed Bone marrow fibrosis? Thrombocytosis? In order to further clarify the cause of abnormal blood routine, bone marrow aspiration biopsy, bone marrow morphology examination, cytogenetics, molecular biology and other examinations were performed
.
Bone marrow cell examination results: Blood film: 1.
The smear is stained well
.
2.
There are a lot of white blood cells
.
3.
Mature red blood cells are roughly normal
.
4.
Increased platelets
.
5.
No parasites were seen
.
Opinion: Active bone marrow hyperplasia and increased platelets, please consider clinical considerations
.
The results of bone marrow pathological examination are as follows: Feature description: 1.
The bone marrow hyperplasia is obviously active, and the fat tissue is reduced
.
2.
Grain hyperplasia is active, visible in all stages
.
3.
The erythroid hyperplasia is active, and clusters of young red blood cells can be seen
.
4.
There are more megakaryocytes, and clusters of megakaryocytes can be seen.
Some megakaryocytes have large cell bodies, rich cytoplasm, and disordered nuclei
.
Opinion: Megakaryocytes increase, please consider with medical history
.
Myeloproliferative tumor-related gene mutation test results: JAK2V617F mutation detected
.
The fusion gene BCR/ABL (P210) real-time quantitative RT-PCR result: negative
.
Chromosome test result: no split phase was seen in the whole film, and follow-up is recommended
.
Finally, the diagnosis of non-alcoholic steatohepatitis and primary thrombocytosis was given to support symptomatic treatment such as liver protection, reduction of platelet count (hydroxyurea), and prevention of thrombosis (aspirin), and the condition improved and was discharged from the hospital
.
Discussion Essential thrombocythemia, also known as hemorrhagic thrombocytosis, is a clonal disease of hematopoietic stem cells dominated by megakaryocyte proliferation.
The main clinical manifestations are persistent increase in platelets, splenomegaly, bleeding or thrombosis
.
The exact cause of the disease is unclear, and it may be related to changes in thrombopoietin and thrombopoietin receptors and abnormal gene activation
.
The disease progresses slowly, and many patients are asymptomatic for a long time
.
The main clinical manifestations of this disease are bleeding and thrombosis.
Unlike other myeloproliferative diseases, fever, hyperhidrosis, weight loss, etc.
are very rare
.
Maintaining a benign process for many years, about 10% of patients are likely to transform into other types of myeloproliferative tumors
.
The peripheral blood platelet count is significantly increased and the function is abnormal.
Megakaryocytes in the bone marrow proliferate vigorously.
50% to 70% of patients have JAK2V617F gene mutations
.
This disease can lead to concurrent diseases: cerebrovascular thrombosis, venous thrombosis of limbs, splenic infarction, spleen atrophy
.
Clinically, cases of liver disease with abnormal blood routine are also uncommon, such as white blood cells appearing in blood routine, and blood routine values are abnormally increased
.
Or when the platelet is found to be significantly elevated during the physical examination (greater than 600×10^9/L), seek medical attention in time
.
Clinicians should pay attention to improve relevant inspection items in time to avoid missed diagnosis, so as not to delay the condition
.
Follow-up patients continued to take treatment with hydroxyurea and aspirin after they were discharged from the hospital, and the values of white blood cells and platelets in the blood routine gradually decreased, and various indicators were monitored regularly in accordance with the doctor's advice
.
On September 20, 2021, the liver function and blood routine will be rechecked.
There is no discomfort.
He will continue to take hydroxyurea and aspirin.
Follow-up is underway
.
Contribution email: tougao@medlive.
cn
