Physician's Assistant

Patient Details

Refined clinic letter (214 days ago 11:24)

Refined clinic letter Thu 04 September 2025 11:24

Last Modified: 214 days ago

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Content:

Diagnosis:
Early portal hypertension with portal gastropathy - June 2025

Other Medical Diagnoses:
• Severe diffuse hepatic steatosis
• Sigmoid diverticular disease
• Previous oesophagitis with early peptic stricture (April 2022)
• Recent melaena (June 2025)

Current Medications:
Unknown

Investigations:
• Upper GI endoscopy (June 2025): No stigmata of GI bleeding, changes consistent with early portal gastropathy, no varices
• CT liver triple phase (July 2025): Severe diffuse steatosis, mild left lobe liver contour irregularity, no features of advanced cirrhosis, no biliary dilatation, possible early collaterals from portal hypertension, no large varices, no ascites, no splenomegaly
• Blood tests (June 2025): ALT 90 U/L (elevated), Bilirubin 31 μmol/L, Albumin 47 g/L, AST 105 U/L (elevated), Platelets 155 x10⁹/L
• OGD (April 2022): Oesophagitis and early peptic stricture

Management Plan:
1. Continue monitoring liver function and portal hypertension progression
2. Regular surveillance endoscopy for variceal screening
3. Next appointment - 6 months for review and repeat investigations

I had the pleasure of meeting Mr Barratt in gastroenterology clinic.

Mr Barratt presented with a 2-week history of melaena in June 2025. Upper GI endoscopy revealed changes consistent with early portal gastropathy but no varices or active bleeding stigmata. Subsequent CT liver imaging in July 2025 demonstrated severe diffuse steatosis with mild left lobe contour irregularity and possible early collaterals suggestive of portal hypertension, though no features of advanced cirrhosis were present. His liver function tests show elevated transaminases (ALT 90, AST 105) with normal albumin and platelet count. Mr Barratt works night shifts at McDonald's. He requires ongoing monitoring of his liver condition and portal hypertension with regular surveillance endoscopy.

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Refined clinic letter Thu 04 September 2025 11:24

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