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4. Heatstroke-induced ischemic liver injury with continued supportive care
Gastroenterology (GI) was consulted and attributed the patient’s presentation and lab abnormalities to multiple acute liver injury resulting from alcohol use, drug abuse and ischemic injury with expectation that the elevated total bilirubin would slowly return to normal values. Typically shock liver causes an early rise of AST, ALT and LDH that trend down after 2 to 3 days and normalize at approximately 15 days. Total bilirubin elevation increase is seen after the AST, ALT increase and trails the resolution of the transaminases (5). Surgery was consulted and recommended clinical follow up as none of the studies showed acute acalculous cholecystitis warranting cholecystectomy. HIDA scans are most reliable for the diagnosis of acute cholecystitis compared to acute acalculous cholecystitis with sensitivity and specificity of approximately 96 percent and 90 percent respectively for acute cholecystitis (6). Ascending cholangitis is unlikely given normal alkaline phosphatase and none of the imaging showing biliary ductal dilatation. Pancreatic cancer should show a mass in the imaging studies and Gilbert syndrome presents with elevated bilirubin with elevation in indirect (unconjugated) bilirubin. Clinically, the patient's liver function tests eventually returned to normal limits without intervention and were attributed to the multiple liver injury as suggested by the GI consultant.
With supportive care, the patient’s encephalopathy resolved. He was extubated and had a steady course of recovery until being discharged from the hospital.
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