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What is the best managment and medical therapy to reduce bilirubin and will "Silymarin" combined drug be more effective

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Internal Medicine Specialist
Practicing since : 1980
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My daughter Miss XXXXXXX is 18 years old baby suddenly on 24/10/13 evening started vomiting, high fever,headache, cold shivering. she was given paracetamol & Anti-malarial drug Reziz fort which she vomited half an hour later.Then she was admitted where for three day she was administered i/v infusion of DNS ,RL with amikacin .Bcomplex inj, and other Her fever shifted to 12 hrly repeatation with chill & shivering, headache with fever ranging from 99*F to 103.5*F. Optimal test & Widal test- negative.On 2/10/13 her blood figure was -Total WBC Leucocyte-6610 cell/cmm, with Neutrophil-72.6%,Lymph-21.8, Mono-4.8,Eiosin-0.3%. Platelet count-1,53000cell/cmm, Hb-11.9gm, Total Serum bilirubin-4.7mgm, SGPT(ALT)-1662. she started taking -ofloxacin,HepaMerz tab-tid,Polybion-L syrp,Liv-52 syrp,Amoxy+clavulanic acid, Mucain-gel syr,Aciloc-D. Later on 4/11/13 her blood figure-Tatal bilirubin-4.9,SGPT-1004 Test of Hepatits-HBsAg-negative.On 4/11/13She was advised by Another doctor to take Cefixime-200(Secef-200)bid,HepaMerz tab-tid,Rafle(Rifaxitin200) tab-bid, Aristozyme syp. on this treatment she recovered 60% from earlier symptom. her blood figure on 12/11/13 was --Bilirubin level higher to 7mg(earlier-4.49), but SGPT was low to 221units(earlier-1661 on 2/11/13 & 1000 on 4/11/13. Now i want to know why her bilirubin became high 7mg on 12/11/13 and SGPT low 221unit as compared to 2/11/13 & 4/11/13 andLymphocyte XXXXXXX to 27.7% with Monocyt-5.6% Eosin-3.1% as compared to 2/11/13 ? what can be urgently suitable managment and medical therapy to reduce bilirubin level ? whether "Silymarin"combined drug wil be more effective ? kindly advise as She is to appear in IIT-JEE exam for which attending coachin is must. regards My email= YYYY@YYYY . Mobil-0000
Posted Sun, 22 Dec 2013 in Infections
Answered by Dr. Rakesh Karanwal 56 minutes later
Brief Answer: Investigate for Leptospira and liver abscesses Detailed Answer: Hi Dr. XXXXXXX Thanks for your query. Firstly, Jharkhand being an endemic area for malaria (with high incidence of chloroquine resistance), the first diagnosis that comes to the mind is Malaria (?Falciparum ?? Vivax or ???Mixed), all of which are known to associated with liver functions abnormalities (Acute malarial hepatitis). Ideally, IgG and IgM for malaria should have been done, which is much more sensitive than Optimal test. Further, I personally feel that, instead of Reziz, Chloroquine/arteether/artemether + Primaquine; or, Mefloquine/halofantrine should have been given empirically as the initial treatment. With blood counts being within normal range, bacterial infection/septicemia is ruled out; a normal Platelet count excludes Dengue/Viral fever, which is not associated with grossly raised bilirubin levels. Under these circumstances, test should be carried out for Leptospirosis, which is quite common in Jharkhand and Bihar. The other possibility is Acute encephalitis. As far as your queries is concerned, the rapid rise in bilirubin could be due to rapid breakdown of Red blood cells (as in Malaria); and/or, due edema in liver will spilling of bilirubin into the blood. Rise in SGPT is due to destruction of liver cells (hepatocytes), which occurs- amongst other conditions- in malaria too. SGPT came down rapidly, once lysis of liver cells stopped. Acute hepatitis is a known entity in malaria, septicemia and particularly Leptospirosis. Further, there is nothing to worry about raised bilirubin, particularly once SGPT has reverted back to normal range. There is NO effective treatment (including Silymarin alone or in combination) to bring down serum bilirubin rapidly. It will come down steadily now, EXCEPT in case of malaria, where there will be rapid fall in bilirubin levels by way of excretion by the kidneys. Lastly, such changes in Differential Leukocyte Counts, commonly occur during illness. In the initial stages, the proportion of neutrophils was high (as seen in acute illness); as the patient recovers, the neutrophils' proportion comes down with corresponding rise in Lymphocytes' proportion. Change in proportion of other cells is routine and of no significance. Hence, I will suggest that test be carried out for Leptospira; an ultrasound to exclude liver abscess(es) (amoebic or pyogenic); anti-malarial antibodies and appropriate treatment exhibited to your daughter. Consult the treating doctor and discuss my opinion/recommendations with him. I am sure he will agree with me and do the needful. Hope you find my reply helpful, informative and to your satisfaction. I will be happy to answer further queries, if any. Fond regards and have a nice day. Dr. Rakesh Karanwal
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Follow-up: What is the best managment and medical therapy to reduce bilirubin and will "Silymarin" combined drug be more effective 17 days later
on 27/11/13 XXXXXXX blood report is Leukocyte count-6460 cell, neutrophil-57.5 Lymh-31.1,Monocte-5.8 %,Eosino-5.3. Bilirubin-3.4%,SGPT-104unit HB-10.8% . ON 12/11/13 it was Leuko-6200, Neutro-63.4, Lymph-27.7,Mono-5.6, Eosin-3.1 Hb-11.6, Bilirubin-7.0, SGPT-221. As per ur advice her ultrasound and other were got done showing normal . The present medication are- Hepamerz tab thrice a day, Gopan DSR tab once morning in empty stomach,Aristozyme syrp and pancroflat tab twice after meal. But her bilirubin level is still high at 3.4 and SGPT -100 with Hb level reduced to 10.8 so i want know-1. what medicine to normalize Bilirubin & SGPT and Elevate Hb level you advice ? 2. Is vitamin A along with other vitamins be supplemented to support body ? 3. what meal along with special fruits be given to reduce Bilirubin,SGPT and strengthen her earliest to start her left study ?
Answered by Dr. Rakesh Karanwal 17 hours later
Brief Answer: Rate of recovery is good and as per expectations Detailed Answer: Hi Dr. XXXXXXX Nice to hear from you. Firstly, I am sorry for the delay in reply due to internet server failure. I can fully appreciate your concern for your daughter. Latest Blood counts are normal; Bilirubin and SGPT too are MILDY raised (which too is of NO concern) and reflect a normal rate of recovery of liver functions. Further, whenever there is damage to the liver, the latter (as well as liver functions) take their own time (usually 6-8 weeks) to recover and regenerate. The gradual recovery is manifested by falling Bilirubin and SGPT levels, which will probably take a minimum of another 2-3 weeks to revert back to normal. I am personally of the opinion that the rate of recovery is normal in your daughter's case. Hence, PLEASE DO NOT WORRY AT ALL. As such, 80% recovery has already taken place. Further, as already mentioned, there is NO DRUG to hasten the rate of recovery. Hepamerz simply helps in recovery. A good, balanced diet, avoidance of drugs which are toxic to liver and, avoidance of severe physical exertion are the ONLY precautions to be taken. Hb level reflects anemia. In India, the routine Hb levels in females is between 11-13gm%. Supplementation of Iron + Folic acid + Vitamin B12 for 3 months, will elevate the Hb levels. There is an unduly high incidence of worms infestation in Jharkhand. Hence, a monthly deworming course should be taken regularly. All vitamins (Vitamin A, B, C, Vitamin D, E and K) are required for normal functioning of the body. A well-balanced diet provides daily requirements. Hence, no additional supplement is justified, UNLESS there are features of deficiency. As mentioned above, a WELL BALANCED (high Protein) diet is the only requirement. Lastly, She can safely resume her studies now, PROVIDED there is NO undue physical exertion. Let her continue with the same treatment that she is presently on. Also, her Eosino being 5.3%, get her blood for microfilaria and stools for worms checked up. (Jharkhand being an endemic region for these conditions). Hope I have answered your query to your satisfaction. I will be happy to address to further queries, if any. Fond regards, Dr. Rakesh Karanwal
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Follow-up: What is the best managment and medical therapy to reduce bilirubin and will "Silymarin" combined drug be more effective 6 hours later
THANK U VERY MUCH SIR Ur advice is convincing. As u have advised balanced diet in this regard i am to say that she is taking only Moom Dal with Roti or rice,& Curd. whether she can take milk or dry froot(Almond) or what other protein diet can be given kindly specify the protein food item's name so that flatulence should not increase as she is taking Gopan DSR once daily. whether she can sit in sunlight for some time or not . i will ask follow up querry after some hour
Answered by Dr. Rakesh Karanwal 29 minutes later
Brief Answer: Suggested diet is given below Detailed Answer: Hi Dr. XXXXXXX XXXXXXX can take an absolutely NORMAL diet, that she has been taking before her illness: Rice, chappati, ALL green leafy vegetable, ALL variety of dals, curd, fruits; full cream milk; dry fruits; chicken/fish (if she is non-veg) but NO MUTTON. THERE IS NO RESTRICTION ON HER DIET, EXCEPT in the situation of not tolerating fatty foods. JUNK FOOD/FAST FOOD, Noodles, Chinese food is strictly prohibited. If she has the tendency of increased flatulence since years, tried to avoid legumes (rajma, chholey, beans etc). Some people have lactose intolerance who get abdominal discomfort on taking milk/milk-products. If she has no such symptoms, let her take plenty of milk. Soyabean, Nutri Nuggets, peanuts are good source of proteins. Also, Protein powder/granules is available in the market under the name of Protinex. 4 spoons daily will be OK. A 4 weeks' course of Probiotics, such as, Lactobacilli, will cure her flatulence. PLESE DO NOT RESTRICT HER FROM EXERCISING OR EXPOSURE TO SUNLIGHT. Encourage her to go for long walks. Lastly, you are most welcome to send further queries. Fond regards, Dr. Rakesh Karanwal
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