Zieve's syndrome

A 50-year-old man presents with shortness of breath. He is a known alcoholic and has a past history of ischaemic heart disease. On examination he looks jaundiced but his abdomen is soft and non-tender and his chest sounds clear with good breath sounds bilaterally.
His serum blood tests show the following results:

Hb	7 g/dl
Bilirubin	35 μmol/l
GGT	400 iu/l
Cholesterol	10 mmol/l

Which of the following diagnosis do you think he has?

	Zieve’s syndrome	Your answer
	Whipple’s disease
	Crigler–Najjar syndrome
	Gilbert’s syndrome
	Non-alcoholic steatohepatitis syndrome (NASH)

Zieve’s syndrome occurs in patients with excessive alcohol consumption with haemolysis and severe hyperlipidaemia, abdominal pain, transient mildly raised bilirubin. It usually occurs in males and resolves once alcohol consumption is stopped. Whipple’s disease is a cause of gastrointestinal (GI) malabsorption usually in middle-aged men, and is caused by the Gram-positive bacteria Tropheryma whippelii. Crigler–Najjar syndrome is a rare congenital disorder of bilirubin conjugation. It has two distinct forms, type 1 and type 2: type 2 patients can survive to adulthood without any neurological impairment, whereas this impairment is seen in neonates in type 1 cases. Gilbert’s syndrome is a benign cause of isolated hyperbilirubinaemia and can be affected by illness, surgery or dehydration. It is inherited in an autosomal recessive pattern. Non-alcoholic steatohepatitis (NASH) is the syndrome of fatty liver not caused by alcohol related to raised cholesterol, obesity and type 2 diabetes.

Depression............

A 62-year-old man comes to the Emergency room with his daughter who is very concerned that he may be depressed. He wakes very early in the morning and seems not to have been eating for the past few weeks. Apparently he has undergone some minor investigations for indigestion which have proved unremarkable. On examination you become quite concerned because he tells you the reason he is depressed is because he is dying of stomach cancer and he has considered a number of ways to kill himself.

Investigations;

Hb	12.1 g/dl
WCC	4.9 x109/l
PLT	175 x109/l
Na+	141 mmol/l
K+	4.2 mmol/l
Creatinine	100 μmol/l

Which of the following would be the most appropriate therapy choice for him?

	Cognitive therapy
	Amitriptyline
	ECT
	Citalopram	Your answer
	Venlafaxine

NICE guidelines on the treatment of moderate to severe depression suggest using a generic SSRI as first line therapy in moderate to severe depression. Potential toxicity of agents which may be used in any suicide attempt should also be considered, for this reason tricyclics such as amitriptyline should be avoided, as should venlafaxine. It is also important to warn both the patient and his daughter that symptoms may not improve for around 2 weeks, although many patients with depression report subjective improvements in their symptoms before the 2 week stage. ECT is reserved for the severest of patients but is highly effective. Input from the psychology service has a role along side drug therapy in this case.