Physician's Assistant

Refined clinic letter Thu 04 September 2025 10:12

Last Modified: 214 days ago

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Diagnosis:
Cholestatic LFTs now resolved - differential diagnosis includes passed stone and drug-induced liver injury secondary to amitriptyline

Other Medical Diagnoses:
• Spinal stenosis - causing significant mobility issues and pain
• Primary open-angle glaucoma
• Colonic polyp - July 2024
• Type 2 Diabetes Mellitus with preproliferative diabetic retinopathy
• CKD Stage 3
• Diverticular disease
• Aortic valve stenosis (Echocardiogram August 2025: moderate)
• Ischaemic heart disease (NSTEMI 2019)
• Diabetic neuropathy
• Hypertension

Current Medications:
• Insulin - for Type 2 diabetes
• Amitriptyline 20mg PO BD - restarted 2-3 weeks ago
• Eye drops - for glaucoma
• Fentanyl patch - prescribed by GP
• Senna 7.5-15mg PO ON - STARTED TODAY (to be added to repeat prescriptions)
• Paracetamol 1g PO QDS - as required for pain

Investigations:
• Ultrasound Abdomen July 2025: 29mm hypoechoic avascular area in gallbladder - could represent gallbladder polyp, adherent sludge or gallstone. Liver normal size but increased echogenicity. Limited scan due to patient mobility
• Non-invasive liver screening 2024: Negative for viral or autoimmune liver disease, normal ferritin
• LFTs August 2025: ALP 131 (normal), normal bilirubin
• LFTs June 2025: ALP 467 with normal bilirubin
• Blood tests requested today - to assess amitriptyline effect on LFTs

Management Plan:
1. Blood test today to assess LFTs now amitriptyline restarted
2. No intervention planned regarding possible gallbladder polyp/stone
3. Senna 7.5-15mg once nightly to be added to repeat prescriptions alongside fentanyl patch
4. Referral to pain management team for spinal stenosis
5. No gastroenterology follow-up planned

I had the pleasure of meeting Mr Atkins on behalf of Dr Neil in hepatology clinic today. The consultation was face-to-face and he was accompanied by his wife.

His mobility is particularly challenging due to his spinal stenosis and he is in significant pain. I'm pleased to hear that he has been started on a fentanyl patch which should be beneficial. He previously had reactions to morphine causing constipation and overflow diarrhoea, so I suggest taking senokot alongside the fentanyl patch to ensure tolerance and achieve adequate pain control. If difficulties continue, referral to the pain team would be sensible.

We discussed that his liver function tests 3 months ago were elevated in a pattern consistent with biliary irritation such as a stone. His ultrasound scan showed what may represent a stone or small gallbladder polyp. Reassuringly, his liver function tests have completely resolved and are back to normal. He had no pain at that time.

His elevated liver tests could have been due to a stone passing through the ducts or drug-induced liver injury secondary to amitriptyline. The amitriptyline was stopped and LFTs returned to normal. He restarted amitriptyline 2-3 weeks ago, so we plan to recheck liver function tests today to ensure drug-induced liver injury is not the cause.

If his liver tests remain normal on amitriptyline, I would not recommend further scans or intervention regarding potential stones or gallbladder polyps. His spinal stenosis is his primary problem and pain control should be the priority. Given his wider health, he would not be a candidate for operative management such as cholecystectomy, so surveillance would not be indicated.

I have not made plans to see him again in hepatology clinic but will write with the blood test results.

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Refined clinic letter Thu 04 September 2025 10:12

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