Liver and Let Die

Welcome to the weekend shift. You’re alone in the lab, the bleeps are coming fast, and you're about to handle multiple complex, time-sensitive liver cases. Each choice you make will influence diagnosis, treatment, and patient outcome. ⚠️ Some paths are subtle. Some mistakes are deadly. There are few certainties. [[The Shift Begins]]

It’s Saturday, 14:52. You’ve just cleared your third batch of LFTs when you receive THREE urgent samples within 15 minutes. You triage them as follows: [[CASE A]]: “Confusion, RUQ pain, ?sepsis, ?OD” Patient: Terry Dalton, 45M [[CASE B]]: “Obstructive picture? Jaundice, pruritus, dark urine” Patient: Rita Benson, 62F [[CASE C]]: “Young, ALT >2000, ?viral, ?autoimmune, ?tox” Patient: Jamie Rivera, 24M You must choose one to process first. Time matters.

Patient: Terry Dalton, 45M Presentation: Confused, mildly jaundiced, agitated History: Lives alone, found by neighbour Request: LFTs, Paracetamol, Ethanol, INR, CRP, Glucose, U+Es Initial Results: ALT: 1345 IU/L AST: 1420 IU/L ALP: 150 IU/L GGT: 260 IU/L Bilirubin: 36 µmol/L Albumin: 28 g/L INR: 2.3 Paracetamol: 97 µmol/L Ethanol: 16 mmol/L CRP: 22 Glucose: 2.9 mmol/L Na+: 132, K+: 3.3, Urea: 3.1, Creatinine: 96 Interpretation: Hepatocellular pattern, mild hypoglycaemia, raised INR. Timing of ingestion unclear. Do you: A. Flag immediately to medical team – suspect acute liver failure ➡️ [[Timely Trigger]] B. Add lab comment but wait for additional history or tox screen ➡️ [[Waiting Game]] C. Recommend checking arterial blood gas and lactate ➡️ [[Dual Path Light]]

Patient: Rita Benson, 62F Presentation: Jaundice, pale stools, dark urine, itchiness Request: LFTs, Hepatitis screen, AMA, ANA, Abdominal ultrasound Initial Results: ALT: 115 IU/L AST: 102 IU/L ALP: 520 IU/L GGT: 412 IU/L Bilirubin: 110 µmol/L Albumin: 36 g/L INR: 1.1 CRP: 18 AMA: Pending Do you: A. Comment: “Cholestatic pattern – suggest biliary obstruction” ➡️ [[Obstruction Alert]] B. Recommend autoimmune liver panel (AMA, IgM) urgently ➡️ [[Autoimmune Focus]] C. Flag raised CRP – query ascending cholangitis, recommend blood cultures ➡️ [[Cholangitis Suspicion]]

Patient: Jamie Rivera, 24M Presentation: Lethargy, myalgia, RUQ pain, no alcohol history, recent backpacking in Thailand Request: LFTs, Hepatitis serology, Autoimmune screen, Ceruloplasmin, Ferritin, Viral PCR Initial Results: ALT: 2230 IU/L AST: 1940 IU/L ALP: 175 IU/L GGT: 120 IU/L Bilirubin: 48 µmol/L INR: 1.6 Albumin: 31 g/L CRP: 12 Ferritin: 980 µg/L Ceruloplasmin: 0.11 g/L Interpretation: Massive hepatocellular injury, potential Wilson’s, viral or autoimmune hepatitis Do you: A. Urgently flag low ceruloplasmin and request serum copper ➡️ [[Wilson's Clue]] B. Recommend urgent viral + autoimmune follow-up + monitor INR ➡️ [[Viral/Autoimmune Pursuit]] C. Add note: Consider pausing paracetamol until tox screen available ➡️ [[Hold Paracetamol]]

You alert the medical team: “ALT/AST >1000, INR 2.3, albumin 28, glucose low. High risk of acute liver failure. Suspect paracetamol injury despite borderline level.” They start NAC, arrange arterial gas and ammonia. You hear later: – ABG: pH 7.26, lactate 5.8 – Ammonia: 86 µmol/L Four hours later, INR rises to 3.1, patient is drowsier. Do you: A. Suggest ICU referral due to progression ➡️ [[Follow Up 1]] B. Let clinicians decide – you’ve already flagged once ➡️ [[Follow Up 2]]

You delay action, waiting for a clearer paracetamol history. But the patient has no known ingestion time. Clinicians request nomogram plotting – but it’s useless without timing. Meanwhile, INR rises to 2.9, GCS drops to 12. Do you: A. Push for NAC initiation now ➡️ [[Follow Up 3]] B. Wait for tox review ➡️ [[Follow Up 4]]

You add a comment: “ALT>AST, INR raised, paracetamol present. Pattern suggests toxic injury. Consider NAC and alcohol-related injury.” This prompts clinicians to dig deeper. They discover: – Patient took paracetamol + alcohol 12 hours ago – No vomiting, so serum level may underestimate total absorbed They start NAC late. Do you: A. Add follow-up comment as INR rises further ➡️ [[Follow Up 5]] B. Assume they’ll monitor appropriately ➡️ [[Follow Up 6]]

''CASE COMPLETE ''– You caught deterioration early. ICU accepts patient. NAC continued. Liver transplant team informed. Excellent clinical escalation. What would you like to do now? A. Work on [[CASE B]] B. Work on [[CASE C]] C. Work on the [[Optional Cases]]

''CASE COMPLETE ''– Patient deteriorates to GCS 7. ICU call made later. Consultant asks: 'Why didn’t lab flag again?' Near miss – lab trust affected. What would you like to do now? A. Work on [[CASE B]] B. Work on [[CASE C]] C. Work on the [[Optional Cases]]

You’ve handled the standard presentations — now welcome to the grey zones, where guidelines are fuzzy, time is short, and consequences are real. These are optional challenge cases designed to stretch your clinical reasoning, ethical decision-making, and resilience under pressure. Which will you choose first? A. Go to [[CASE D]] B. Go to [[CASE E]] C. Go to [[CASE F]] D. Go to [[CASE G]]

''CASE COMPLETE ''– NAC started just in time. INR stabilises. Clinicians thank lab for pushing past uncertainty. Clinical judgement overruled numbers correctly. What would you like to do now? A. Work on [[CASE B]] B. Work on [[CASE C]] C. Work on the [[Optional Cases]]

''CASE COMPLETE ''– No NAC given. Liver failure worsens. Patient admitted to ICU late. Post-mortem notes delayed treatment. Avoidable harm recorded. What would you like to do now? A. Work on [[CASE B]] B. Work on [[CASE C]] C. Work on the [[Optional Cases]]

''CASE COMPLETE'' – INR climbed to 3.6. Your second note led to ICU escalation. Clinicians grateful for continued lab vigilance. Great situational awareness. What would you like to do now? A. Work on [[CASE B]] B. Work on [[CASE C]] C. Work on the [[Optional Cases]]

''CASE COMPLETE'' – Lab note read but not acted upon. INR peaks at 4.2. ICU team confused why earlier action wasn’t taken. Passive role led to harm. What would you like to do now? A. Work on [[CASE B]] B. Work on [[CASE C]] C. Work on the [[Optional Cases]]

You comment: “Marked cholestatic picture – possible biliary obstruction. Recommend imaging.” Ultrasound delayed 8 hours due to weekend staffing. ALP rises to 740, bilirubin to 138. Do you: A. Chase imaging and recommend MRCP if US delayed ➡️ [[Follow Up 7]] B. Wait and hope ultrasound happens soon ➡️ [[Follow Up 8]]

You request ANA/AMA. AMA comes back strong positive. IgM raised. GP letter later reveals long-standing fatigue and dry eyes. Do you: A. Suggest urgent hepatology referral for likely PBC ➡️ [[Follow Up 9]] B. Let clinicians interpret result – it’s not your call ➡️ [[Follow Up 10]]

You suggest possible ascending cholangitis: “CRP 18, ALP 520, jaundice. Consider sepsis screen.” Clinicians delay blood cultures. 12 hours later: Temp 38.9°C, HR 118, WCC 14. Do you: A. Flag again – urgent blood cultures and antibiotics needed ➡️ [[Follow Up 11]] B. Leave note in LIMS but don’t escalate ➡️ [[Follow Up 12]]

''CASE COMPLETE'' – MRCP confirms CBD stone with cholangitis. ERCP done urgently. Your push for imaging changed management timeline. Well done. What would you like to do now? A. Work on [[CASE A]] B. Work on [[CASE C]] C. Work on the [[Optional Cases]]

''CASE COMPLETE'' – Ultrasound delayed further. Patient spikes fever and hypotension. Emergency ERCP needed. Learning point: don’t wait silently. What would you like to do now? A. Work on [[CASE A]] B. Work on [[CASE C]] C. Work on the [[Optional Cases]]

''CASE COMPLETE'' – PBC diagnosis confirmed. Urso started early. Liver enzymes improve. Your early AMA flag led to timely specialist care. What would you like to do now? A. Work on [[CASE A]] B. Work on [[CASE C]] C. Work on the [[Optional Cases]]

''CASE COMPLETE ''– Diagnosis delayed. AMA result reviewed days later. Symptoms worsen. Avoidable delay in treatment documented in audit. What would you like to do now? A. Work on [[CASE A]] B. Work on [[CASE C]] C. Work on the [[Optional Cases]]

''CASE COMPLETE ''– Blood cultures positive. IV antibiotics started within the hour. Your second escalation prevented sepsis progression. Great persistence. What would you like to do now? A. Work on [[CASE A]] B. Work on [[CASE C]] C. Work on the [[Optional Cases]]

''CASE COMPLETE ''– Blood cultures taken late. Patient develops sepsis and AKI. Timeline review flags lab missed opportunity to escalate. What would you like to do now? A. Work on [[CASE A]] B. Work on [[CASE C]] C. Work on the [[Optional Cases]]

Low ceruloplasmin (0.11 g/L) and high ferritin catch your eye. You recommend serum copper and 24h urinary copper urgently. Four hours later, labs confirm low ALP, rising bilirubin, haemolysis on blood film. Do you: A. Alert medics to consider Wilson’s with liver failure ➡️ [[Follow Up 13]] B. Wait for haematology to comment ➡️ [[Follow Up 14]]

You add: “ALT >2000, INR 1.6 – recommend urgent virology and autoimmunity screen.” Serologies pending, but INR creeps to 2.1. GCS drops slightly. Do you: A. Push for NAC while investigations continue ➡️ [[Follow Up 15]] B. Wait for results before suggesting treatment ➡️ [[Follow Up 16]]

You suggest holding any further paracetamol until tox screen clears. Team initially ignores comment. Patient receives regular IV paracetamol. Next day: ALT 2890, INR 3.4 Do you: A. Escalate as potential iatrogenic harm ➡️ [[Follow Up 17]] B. Document but do not formally raise incident ➡️ [[Follow Up 18]]

''CASE COMPLETE'' – Wilson’s disease diagnosed. Liver failure managed in time. Patient transferred for transplant listing. Rare diagnosis, great pickup. What would you like to do now? A. Work on [[CASE A]] B. Work on [[CASE B]] C. Work on the [[Optional Cases]]

''CASE COMPLETE ''– Haemolysis noted but Wilson’s not considered. Delayed diagnosis leads to irreversible liver injury. Learning: think beyond routine. What would you like to do now? A. Work on [[CASE A]] B. Work on [[CASE B]] C. Work on the [[Optional Cases]]

''CASE COMPLETE'' – NAC started empirically. Patient improves. Later confirmed to have autoimmune hepatitis – treatment adapted early. What would you like to do now? A. Work on [[CASE A]] B. Work on [[CASE B]] C. Work on the [[Optional Cases]]

''CASE COMPLETE ''– NAC withheld. INR climbs to 3.5. Viral screen negative. Autoimmune hepatitis confirmed late. Delay led to worse outcome. What would you like to do now? A. Work on [[CASE A]] B. Work on [[CASE B]] C. Work on the [[Optional Cases]]

''CASE COMPLETE ''– Iatrogenic overdose avoided after your flag. Patient placed under toxicology watch. Clinical governance note recorded your intervention. What would you like to do now? A. Work on [[CASE A]] B. Work on [[CASE B]] C. Work on the [[Optional Cases]]

''CASE COMPLETE ''– Continued paracetamol leads to overdose. Family raises complaint. Lab’s early caution not followed up. Missed chance to intervene. What would you like to do now? A. Work on [[CASE A]] B. Work on [[CASE B]] C. Work on the [[Optional Cases]]

Patient: Mia Shah, 28F, 33 weeks pregnant Presentation: Confusion, RUQ pain, jaundice, low platelets Labs: ALT 780, AST 820, ALP 310, INR 2.6, Platelets 72, Glucose 2.5 Do you: A. Flag suspected HELLP syndrome vs. acute fatty liver of pregnancy ➡️ [[Outcome 1]] B. Assume viral hepatitis — await virology ➡️ [[Outcome 2]]

Patient: Alex Moore, 19M, refused bloods, suspected OD, brought in by police History: Note found referencing 'paracetamol and vodka' Medics want samples run “without consent”. Do you: A. Escalate to Duty Biochemist and check Trust policy on unconscious samples ➡️ [[Outcome 3]] B. Refuse until formal consent is obtained ➡️ [[Outcome 4]]

ALT reported as 78. Clinician rings furious: “This doesn’t match the patient! Repeat shows 2120!” Turns out the sample was severely haemolysed — result suppressed accidentally. Do you: A. Acknowledge error and issue amended report with duty of candour ➡️ [[Outcome 5]] B. Quietly issue amended report and don’t draw attention ➡️ [[Outcome 6]]

Patient: Linda Fraser, 71F, polypharmacy for epilepsy, arthritis, depression Presents with fatigue, jaundice. No alcohol or viral risk. ALT 650, ALP 210, Bilirubin 90. INR 1.5 On: Sodium valproate, methotrexate, sertraline, omeprazole Do you: A. Suggest DILI panel, recommend stopping hepatotoxic meds ➡️ [[Outcome 7]] B. Assume alcoholic hepatitis due to AST:ALT ratio near 2 ➡️ [[Outcome 8]]

''COMPLETE:'' Emergency delivery initiated. Liver function stabilises. Multidisciplinary win! Would you like to: A. Go to [[CASE E]] B. Go to [[CASE F]] C. Go to [[CASE G]] D. Return to [[START]]

''OUTCOME:'' Delay in diagnosis. Maternal and fetal compromise. M&M review cites missed lab opportunity. Would you like to: A. Go to [[CASE E]] B. Go to [[CASE F]] C. Go to [[CASE G]] D. Return to [[START]]

''OUTCOME:'' Ethical protocol followed. Sample accepted under Mental Capacity Act. Would you like to: A. Go to [[CASE D]] B. Go to [[CASE F]] C. Go to [[CASE G]] D. Return to [[START]]

Delay in processing. Patient admitted to ICU later. Legal ambiguity noted. Ethics committee involved. Would you like to: A. Go to [[CASE D]] B. Go to [[CASE F]] C. Go to [[CASE G]] D. Return to [[START]]

Trust maintained. Governance team satisfied. Lab reflective practice initiated. Would you like to: A. Go to [[CASE D]] B. Go to [[CASE E]] C. Go to [[CASE G]] D. Return to [[START]]

Incident discovered in audit. Lab credibility questioned. Re-training mandated. Would you like to: A. Go to [[CASE D]] B. Go to [[CASE E]] C. Go to [[CASE G]] D. Return to [[START]]

Methotrexate suspected. Liver enzymes improve. Good call. Would you like to: A. Go to [[CASE D]] B. Go to [[CASE E]] C. Go to [[CASE F]] D. Return to [[START]]

Wrong assumption. Delay in stopping methotrexate. Outcome worse. Would you like to: A. Go to [[CASE D]] B. Go to [[CASE E]] C. Go to [[CASE F]] D. Return to [[START]]