The following data refer to a 34-year-old male admitted to ICU twenty days after an allogeneic stem cell transplant for acute myeloid leukaemia. Over the last few days he has been complaining of right upper quadrant abdominal pain, and observed to have gained several kilograms in weight.
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Venous Biochemistry |
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Parameter |
Patient Value |
Adult Normal Range |
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Sodium |
142 mmol/L |
135 – 145 |
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Potassium |
4.8 mmol/L* |
3.5 – 4.5 |
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Chloride |
97 mmol/L |
95 – 105 |
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Bicarbonate |
22 mmol/L |
22 – 26 |
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Urea |
11.2 mmol/L* |
2.9 – 8.2 |
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Creatinine |
134 μmol/L* |
70 – 120 |
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Calcium |
2.13 mmol/L |
2.10 – 2.55 |
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Phosphate |
1.21 mmol/L |
0.65 – 1.45 |
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Total bilirubin |
342 μmol/L* |
0 – 25 |
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Aspartate aminotransferase (AST) |
175 U/L* |
< 40 |
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Gamma glutamyl transferase (GGT) |
123 U/L* |
< 40 |
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Alanine aminotransferase (ALT) |
87 U/L* |
< 40 |
a) Veno-occlusive disease of the liver (sinusoidal obstruction syndrome)
b) ascites and reversal of portal vein flow. (2 marks)
The stem gives us everything needed to make the diagnosis here. The biochemical abnormalities are:
The combination of these findings with a recent history of BMT suggests strongly that veno-occlusive disease has developed. Both the Seattle and Baltimore criteria need a recent BMT, raised bilirubin and weight gain:
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Seattle criteria:
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Baltimore criteria:
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Diagnosis does not require ultrasound, but it is usually ordered in this context. The BCSH/BSBMT guidelines (2013) concluded that "the main role of ultrasound is to exclude the presence of other diagnoses" because the ultrasound findings which are usually associated with VOD are insufficiently sensitive and specific. In any case, here they are:
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