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CASE REPORT
A 23 year old woman presented with a four month history of epigastric pain, abdominal distention, nausea, and occasional bloodstained vomiting. She had lost 7 kg in weight. She had a complex cardiac history requiring cardiac surgery for tricuspid atresia at the age of three years and again when she was 20 years.
When she was 16 years, she was diagnosed as being hepatitis C positive. Her medications included warfarin.
Significant clinical findings included the presence of jaundice without other stigmata of chronic liver disease. She had a systolic murmur with normal metallic sounds from the prosthetic mitral valve. A pacemaker was in situ. She had right upper quadrant tenderness with a palpable liver edge.
Liver function tests revealed a bilirubin level of 79 μmol/l (normal range 0–17), alkaline phosphatase of 834 u/l (30–130), and alanine transaminase of 193 u/l (0–31). Haemoglobin concentration was 8.7 g/dl (12–16). International normalised ratio was 10. Viral serology was positive for hepatitis C only. Alpha fetoprotein (AFP) measured 11 000 units/l (normal range 0–7). Beta human chorionic gonadotrophin (β-HCG) levels were not elevated. Other laboratory tests were within normal limits.
Upper gastrointestinal endoscopy showed diffuse haemorrhagic gastritis and large oesophageal varices. …