Case 24 A slightly raised AST in an Asian woman

Mrs Choudhury was 42 and overweight when she consulted Dr Sastry with multiple symptoms. She had been in the UK for two years, had three children and was very tired, suffered from headaches, nausea, weight gain, abdominal pain, loose stools, palpitations, dizziness and pains in the legs. Dr Sastry considered that, because of her multiple symptoms, Mrs Choudhury could be depressed. However, he decided to check some blood tests including TSH. These showed that Mrs Choudhury had a mild microcytic anaemia which proved to be due to beta thalassaemia trait. Dr Sastry arranged to check her husband. She also had a minimally elevated bilirubin and an AST of 82 IU/L (normal range less than 40).

What would you do now?

Over the next 18 months Mrs Choudhury saw Dr Sastry on many occasions. She suffered from allergic rhinitis, mouth ulcers, head colds, generalized itch, vaginal discomfort, epigastric pain and irregular periods. Upper abdominal ultrasound showed gallstones and a fatty liver. Dr Sastry referred her for a surgical opinion. A repeat ALT 14 months after the original one showed an AST of 90 with a normal bilirubin, albumin and alkaline phosphate.

What would be your differential diagnosis and how would you discriminate between them?

Mrs Choudhury had a laparascopic cholecystectomy but continued to suffer from multiple symptoms. Eventually three years later she began to lose weight, an abdominal ultrasound showed ascites, hepatitis C serology was positive and she was diagnosed with cirrhosis secondary to hepatitis C.

It was alleged that Dr Sastry was negligent in failing to follow up the abnormal liver function tests.

Do you think her claim will succeed?

Expert comment

The unexpected mildly abnormal blood test result is a very common problem in general practice. Statistically, if the ‘normal range’ of a test is defined as the mean +/− two standard deviations for the ‘normal population’ then 5% of the healthy population will fall outside the normal range and if there are 12 results (for example in biochemistry) there is nearly a 50% chance of at least one falling outside the ‘normal range’ (1 – 0.9512). A further difficulty is what Deyo refers to as the ‘cascade effects of medical technology’ (Deyo, 2002) – the unexpectedly abnormal result leads to further (often unnecessary) investigations and significant patient and clinician anxiety. It is the basis of the old medical adage: ‘What is the definition of a normal patient? Someone who has not had enough tests.’

However, in the case of minor abnormalities of liver function tests, which are often ignored, there is an increasing awareness of several causes of chronic hepatitis that are probably increasing in incidence and do have an associated significant morbidity that is potentially avoidable with treatment. These are chronic hepatitis C and B, alcoholic and nonalcoholic steatosis, haemochromatosis and autoimmune hepatitis.

In a Nottingham study Ryder investigated 157 patients who had had LFT requests from primary care in which transaminases or alkaline phosphatase results were more than twice the upper limit of the normal range, had not normalized and were not under investigation. The study investigated these patients and found that 97 (62%) had conditions requiring intervention. The majority had alcoholic liver disease or nonhepatic steatosis but 20 had one of the other conditions listed above (Sherwood et al., 2001). Ryder’s recommendation was that, for raised transaminases that are below three times the upper of limit of normal the test should be repeated in 1 to 3 months and investigated if still raised. The standard initial investigations would be an FBC, ferritin, autoimmune antibodies and hepatitis B and C serology.

As a woman from the Asian subcontinent Mrs Choudhury was at significantly increased risk of chronic hepatitis C. She did have a potential cause for her raised AST results over some years because she was overweight, had a fatty liver and potentially had biliary disease (though the stones may have been asymptomatic). A particular difficulty was also that she was polysymptomatic.

However, a difficulty in this case was that Dr Choudhury had not recorded any reasoning in his interpretation of the raised AST results.

Legal comment

Dr Sastry and his lawyers will have to analyze this obviously complex case very carefully. It is so easy in hindsight to point to the mistake, but one cannot help but feel rather sorry for him, faced as he was with such an array of symptoms.

After Dr Sastry’s solicitor has obtained expert opinion, a meeting will probably be arranged with a barrister and the experts where Dr Sastry will be closely questioned. The lawyers will take into account how well they think he will cope with cross-examination if the case goes to trial.

An expert hepatologist will have to consider whether earlier intervention would have made a difference. It could be that the outcome would not have been significantly altered. If Dr Sastry’s expert comes to this conclusion, then whatever his shortcomings, the case could be defended on this causation point alone.

This is a case where there are strengths and weaknesses to the defence. A pragmatic decision will have to be made on whether it will be taken to trial.

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