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A Man With Intermittent Abdominal Pain, Liver Injury, and Renal Impairment.

Department of Infectious Diseases, The First Affiliated Hospital, China Medical University, Shenyang, Liaoning Province, China 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 Question: A 45-year-old man presented with intermittent abdominal pain, dark urine, and constipation for 6 months. Laboratory tests of the initial episode showed total bilirubin 109.9 mmol/L (reference range, 3.4-20.5), alanine aminotransferase 3500 U/L (reference range, 9-40), aspartate aminotransferase 1860 U/L (reference range, 15-40), gammaglutamyl transferase 763 U/L (reference range, 10-60), and alkaline phosphatase 164 U/L (reference range, 45-125). The patient was discharged with abnormal liver biochemistry. For the past 4 weeks, the abdominal pain became diffuse, and the episodes lasted from a few minutes to several hours. Upon examination, the skin and sclera were mildly icteric; there was diffuse abdominal pain on palpation. A purple-blue line (Figure A) at the edge of the gums was noticed. He had consumed 100-g hot yellow rice wine (10 g alcohol) from the tin pot per day for 20 years. One year prior, he acquired a new tin pot to replace the old one. Laboratory tests on admission showed mild abnormal liver biochemistry, a normocytic anemia with a hemoglobin of 118 g/L (reference range, 130-175), creatinine 138 mmol/L (reference range, 59-104), and blood urea nitrogen 10.5 mmol/L (reference range, 2.85-7.14). Abdominal anteroposterior radiograph showed multiple air–fluid levels and dilated bowel (Figure B). On day 3 of the admission, a repeated abdominal anteroposterior radiograph showed the air–fluid levels significantly decreased (Figure C) after administration with fasting water and gastrointestinal decompression. The liver pathology result showed edema of liver cells and intrahepatic cholestasis (Figure D, E). On day 4,