Hello doctor, My main concerns are persistent borderline high blood values for the last two years. WBC count 14.5 *10^9/L, neutrophil count 8*10^9 and lymphocytes count 5.3*10^9/L (lab normal for lymphocyte between 1-4.8). Other parameters are mostly normal. Main symptoms are currently upper abdominal pain with frequent indigestion when fatty, oily, or fried food is consumed. Particularly, issues with nuts and dairy products. I previously had IBS like symptoms and was also diagnosed with H. Pylori and stones in the gallbladder a couple of years back, although it was told that the stones were small in size. Please check the attached image for detailed symptoms by period and results of blood tests. I have also been requested for an ultrasound of the abdomen. What bothers me is the referral to a hematologist. Can you please suggest?
Hello. I have gone through the attachments (attachment removed to protect patient identity). Probable cause is cholecystitis. After reviewing your records, it is noticeable that there is persistent leukocytosis with prevailing neutrophilia and a slight microcytosis that is low MCV (mean corpuscular volume) and hypochromia that is low MCH (mean corpuscular hemoglobin) of RBC (red blood cells). Since your ferritin level is normal and no abnormal hemoglobin was detected, it is safe to rule out the presence of both iron deficiency anemia and thalassemia which makes the aforementioned constellation indicative probably of a chronic infection which may cause an impaired iron turnover as evident from the persistently low MCV and MCH. Now, your primary complaint is abdominal pain, which obviously is a chronic one since it spans around two years. Yet, you do not state whether it is in the left or right abdominal half. The presence of gallbladder stones can cause chronic inflammation of the gallbladder and that condition can cause all related lab abnormalities. You have elevated cholesterol levels and TGL (triglycerides) as well as a BMI (body mass index) which is considered obese. It is highly probable that the reason for these gallstones is the increased concentration of cholesterol in bile. It is advisable to repeat the USG (ultrasound) of gallstones that might have increased. You should be offered a treatment regimen to "dissolve" the gallstones starting with the diet such as low fat/cholesterol food, intake of more vegetables and vegetable oil, also increased physical activity; secondarily, if necessary drug treatment or surgery. USG will also yield information regarding your liver and spleen, which is important if one is to suspect a hematologic disorder. In my opinion, there is less reason to suspect a hematological disorder in your case. If such is to be considered, then given the protracted course of two years, this should be either chronic myeloproliferative disorder (such as chronic myeloid leukemia or myelofibrosis) of lymphoproliferative disorder (such as chronic lymphocytic leukemia). Both are diseases of the elderly, then splenomegaly should usually be present. And you should have other symptoms such as nights sweats, weight loss more than 10% for less than six months, malaise, fever.  A simple differential blood count could reveal whether that neutrophilia is due to the presence of segmented cells only, meaning - infection or due to the presence of expanded WBC formula that could prompt further testing. As for the lymphocytes, yes, they are elevated, but their number is fluctuating paralleling and inflammatory state. In case there is spleen enlargement on USG and you have enlarged lymph nodes, then further testing may be necessary to rule out chronic lymphocytic leukemia. It is okay to be seen by a hematologist, who can review the differential manually and examine for the presence of enlarged spleen or liver and then consider whether further and more sophisticated testing is warranted. But most probably your complaints are due to the presence of chronic gallbladder inflammation. As for the H. pylori (Helicobacter pylori), a more informative test is the stool antigen test. Serology for H. Pylori is often falsely positive, but the antigen test before and after the double antibiotic course is much more informative. I would advise you to go through with a gastroenterologist once again and in alkaline phosphatase is present to monitor the WBC parameters with its resolution upon appropriate treatment. Investigations to be done include abdominal ultrasound, GGT (gamma-glutamyl transferase) and ALP (alkaline phosphatase). For more information consult a hematologist online -->