A 37YEAR OLD MALE WITH ABDOMINAL DISTENSION
CHIEF COMPLAINTS:
A 37year old male patient presented with the complaints of Abdominal distension and swelling of both lower limbs since 2weeks.
HOPI:
Patient was apparently asymptomatic 1 1/2 month back, then he noticed yellowing of the skin and sclera, for which he was given ayurvedic medicine, but did not subside.
And then 2weeks ago he developed:
Abdominal distension, which is insidious in onset & gradually progressive in size, associated with SOB and pain in the B/L flanks.
Swelling of both lower limbs, insidious in onset, gradually progressive, pitting type extending up to the knees.
No h/o burning micturition, decreased urine output or blood in urine
No h/o constipation, loose motions and vomitings
No h/o Facial puffiness
No h/o disorientation or confusion
PAST HISTORY:
K/c/o DM type-2, (stopped medication 1year ago)
Not a k/c/o HTN, Epilepsy, CAD, CVA, Asthma, Thyroid disorders.
PERSONAL HISTORY:
Diet -mixed
sleep - adequate
appetite - normal
bowel and bladder- Regular
Addictions:
Used to take moderate amount of alcohol daily since 13years. Increased the alcohol quantity to 180ml/day since 7months. Stopped consuming alcohol a month ago.
Smoked 1/2pack of beedi/day since 20years.
GENERAL EXAMINATION:
Patient is c/c/c, moderately built and nourished.
Icterus ++, edema + (both legs)
No cyanosis, clubbing, lymphadenopathy
Temp - 98.6 F
PR-64bpm
BP - 100/60 mmHg
Spo2 - 98% @ RA
RR - 15 CPM
GRBS- 452 mg/dl
SYSTEMIC EXAMINATION:
CVS - S1 S2 +
RS - BAE +, CLEAR,
NVBS.
P/A - Soft, distended
Shifting dullness:
INVESTIGATIONS:
HEMOGRAM: Hb- 9.8gm /dl
Tlc- 5000cells/cumm
N/L/E/M- 46/45/2/7
PCV- 26.3
Plt- 20000
PT: 13seconds
CUE: color: pale yellow
ALB- Nil
Sugar- +++
Pus cells: 3-4
Urine for ketones: Negative
RFT:
Serum creatinine- 0.9mg/dl
Blood urea -26mg/l
Uric acid- 3.0
Na/k/cl/Ca/pO4- 133/4.5/103/9.2/4.8
LFT:
TB- 5.82;
DB- 5.15;
AST- 35 ; ALT-15;
ALP- 409;
TP-6.8;ALB-2.5
Serum albumin: 2.15
Ascitic albumin: 0.43
SAAG:
serum albumin - ascitic fluid albumin =1.72
Ascitic fluid analysis:
sugar- 346;
protein- 0.8;
Amylase- 33,
LDH- 124
HBSAG: POSITIVE
HIV: negative
Anti HCV antibodies: negative
ECG:(31/01/2024)
2D ECHO:(01/02/2024)
Trivial TR, No MR, Trivial AR
No RWMA, No AS/MS, Slerotic AV
Good LV systolic function
No Diastolic dysfunction. No PAH/PE
USG Abdomen:(31/01/2024)
Altered and coarse heterogenous echotexture of the liver
Mild splenomegaly
Gall bladder wall edema with surrounding pericholecystic fluid
Moderate to sever ascites
APRAXIA CHART:
CHILD PUGH SCORE: 11points [class C]
No encephalopathy- 1point
Moderate-severe ascites- 3points
Total bilirubin(5.82mg/dl)- 3points
Albumin(2.15g/dl)- 3points
INR(<1.7)- 1point
Class A- 100%
Class B- 80%
Class C- 45%
(Child Pugh score is used to predict mortality in cirrhosis patients)
MADDREY DISCRIMINANT FUNCTION(MDF) SCORE:
Total bilirubin: 5.82;
PT(patient): 13seconds;
PT(control): 12seconds
4.6 x [13 - 12] + 5.82 = 10.4 points
(MDF Score is a measure of disease prognosis in patients with alcoholic hepatitis. Used to determine the patients at highest risk of mortality and determine the need for initiation of pharmacologic treatment.)
DIAGNOSIS:
DECOMPENSATED CHRONIC LIVER DISEASE
DIRECT HYPERBILIRUBINEMIA SECONDARY TO HEPATITIS B
K/C/O DM TYPE- II
(31/01/2024):
Pt - c/c/c
Temp - 98F
PR- 90bpm
BP - 100/60mmHg
GRBS: 450mg/dl
Systemic Examination :
CVS - S1 S2 +, no murmurs
RS - BAE +, NVBS
P/A - soft, distended
CNS - NAD
TREATMENT:
1) FLUID RESTRICTION <1.5 LITRE/DAY
2) SALT RESTRICTION <2GM/DAY
3) T. UDILIV 30MG PO/BD
4) T. ALDACTONE 50MG PO/OD
5) T. RIFAGUT 550MG PO/OD
6) INJ. HAI 6U SC STAT
7) T. BENFOMET PLUS PO/BD
(01/02/2024):
Pt - c/c/c
Temp - 98.4F
PR- 76bpm
BP - 120/70mmHg
Systemic Examination :
CVS - S1 S2 +, no murmurs
RS - BAE +, NVBS
P/A - soft, distended
CNS - NAD
GRBS TRENDS:
2:00 am- 397 mg/dl
8:00 am- 238 mg/dl inj. HAI 6U, NPH 4U given
10.00 am- 366mg/dl
2:00 pm -272mg/dl
4:00pm- 295mg/dl inj.HAI 6U, NPH 4U given
10:00 pm- 239mg/dl
TREATMENT:
1) FLUID RESTRICTION <1.5 LITRE/DAY
2) SALT RESTRICTION <2GM/DAY
3) INJ. HAI SC/TID, INJ. NPH SC/BD ACC. TO GRBS
4) T. UDILIV 300MG PO/BD
5) T. RIFAGUT 540MG PO/BD
6) T. BENFOMET PLUS PO/BD
7) PROTEIN POWDER 2SCOOPS IN 1GLASS OF WATER/MILK
8) 2EGGS/DAY
9) SYP. LACTULOSE 10ML/PO TID
10) T. LACILACTONE 10/50 PO/OD
(02/02/2024):
Pt - c/c/c
Temp - 98.4F
PR- 78bpm
BP - 120/80mmHg
Systemic Examination :
CVS - S1 S2 +, no murmurs
RS - BAE +, NVBS
P/A - soft, distended
CNS - NAD
I/O: 800/1050
GRBS TRENDS:
2:00am- 324 mg/dl
8:00am- 214 mg/dl INJ. HAI 8U, NPH 6U given
TREATMENT:
1) FLUID RESTRICTION <1.5 LITRE/DAY
2) SALT RESTRICTION <2GM/DAY
3) INJ. HAI SC/TID, INJ. NPH SC/BD ACC. TO GRBS
4) T. UDILIV 300MG PO/BD
5) T. RIFAGUT 540MG PO/BD
6) T. BENFOMET PLUS PO/BD
7) PROTEIN POWDER 2SCOOPS IN 1GLASS OF WATER/MILK
8) 2EGGS/DAY
9) SYP. LACTULOSE 10ML/PO TID
10) T. LACILACTONE 10/50 PO/OD
(03/02/2024):
Pt - c/c/c
Temp - Afebrile
PR- 76bpm
BP - 120/70mmHg
Systemic Examination:
CVS - S1 S2 +, no murmurs
RS - BAE +, NVBS
P/A - soft, non- tender
CNS - NAD
TREATMENT:
1) FLUID RESTRICTION <1.5 LITRE/DAY
2) SALT RESTRICTION <2GM/DAY
3) INJ. HAI SC/TID, INJ. NPH SC/BD ACC. TO GRBS
4) T. UDILIV 300MG PO/BD
5) T. RIFAGUT 540MG PO/BD
6) T. BENFOMET PLUS PO/BD
7) SYP. HEPAMERZ 10ML TID
8) 4EGG WHITES/DAY
9) SYP. LACTULOSE 10ML/PO TID
10) T. LACILACTONE 10/50 PO/OD
Must know topics- A basic understanding on CLD:
*Pathophysiology of portal hypertension
*Hypoalbuminemia & Edema in liver disease
*Elevated levels of Nitric oxide and its effects on fluid retention
*Complications of Chronic liver disease
*Hepatic Encephalopathy in the setting of chronic liver disease
*HBV- Mode of transmission and clinical course
*A look into the Serum markers of liver pathology:
Enzymes released in liver damage(AST, ALT, ALP, GGT)
Functional liver markers- Abnormal in advanced diseases (Bilirubin, Albumin, PT, Platelets)
How are they affected in various disorders?
*Interpretation of SAAG and its significance in determining the etiology of ascites.
(Peritoneal and non-peritoneal causes)
*Child Pugh score
Spot urine creat: 2
