Transcript Clinical Case Presentation

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Clinical Case Presentation:
Alcoholic Liver Disease
Gaurav Jain
Roll No: 174/11
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Clinical Case Presentation:
Ascites with ARF
Lakshmi Narayan, 42 years old patient , who is a chronic alcoholic,
farmer by occupation presented with:
• Abdominal distension from 15 days
• Abdominal pain from 15 days
• Fever from 15 days
• Decreased urine output from 10 days
• Decreased passage of stools from 10 days
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HISTORY
 H/O Present illness:
HDBT 15 days when patient developed:
 insidious, gradually progressive Abdominal distension a/w pin-pricking
pain in the epigastrium & right hypochondrium region , relieved by
medication.
 Intermittent, mild to moderate grade fever, insidious onset & subsides on
medication a/w nausea ,retching, cachexia, altered sleep patterns with
day-time sleepiness.
 Pt. developed decrease in urine output without burning or other
discomfort from past 10 days.
 Pt. developed decreases stool passage ,insidious onset and gradually
progressive, not a/w flatulence, dyspepsia, heart burn from 10 days.
 A single episode of haemetemesis containing 30 ml of fresh blood.
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 Negative History: No H/O chills, rigor, sweating,headache,rashes
retrobulbar pain, cough, joint pain, steatorrhea, malena, facial
puffiness, xanthelasma, xanthomata, flapping tremors, blood
transfusion.
 Past History: No H/O TB, Diabetes, Asthma, Hypertension. No
such complaint in the past.
 Personal History: Married with two children
• Non vegeterian diet.
• Smoking-15 pack years but one bundle daily from past 2 months.
• Chronic alcoholic from past 30 years consuming 4.5-5.6 units of
alcohol daily. Tobacco chewing from past 12 years.
• Lost 15 kgs of weight in past 2 months.
 Family History: No such family history.
 Drug History: No significant history.
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EXAMINATION
General Physical Examination
Patient is conscious, oriented to time,place and person and cooperative.
No pallor, icterus, cyanosis, clubbing, JVP and lymphadenopathy.
Pedal edema present.
No gynaecomasatia, skin pigmentation , palmar erythema, spider nevi,
leuconychia, koilonychia, angular stomatitis present.
Axillary ,pubic hair decreased. Mild Glossitis present
PR- 86/min RR-20/min BP-96/60mmHg
Abdominal Girth: 114.3 cm
Umblico-ischial spine distance: 19.05 cm
Umblico-Symphysis distance: 21.59 cm
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Abdominal Examination
 Inspection: globular shape stomach with
full flanks and everted umblicus. There is
a single scar present on the right lateral
side. Engorged veins seen.(downward to
upward blood
flow).
 Palpation: afebrile .Liver not palpable.
Spleen palpable by Dipping method but
size cant be established. Fluid thrill
present. . Tense and tendor
 Percussion: Shifting Dullness present.
 Auscultation: Bowel sounds heard and
Bruits not heard.
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Other systemic findings were normal.
INVESTIGATIONS
Ascitic Fluid
Cytology
No malignant cell
seen
TLC
200/CUMM
DLC
N 20%: L 80%
Fluid Protein
1.5 g/dl
TLC
11700/cumm
SAAG
2.2 g/dl
DLC
ADA
8.58U/L
N 87- L 10- E 1- M
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Inference: Transudative picture:
tubercular ascites ruled out.
Hb
7.5gm
APC
4.5 lacs
SGOT
80U/L
PT/INR
SGPT
32U/L
Prothrombin time
18.3sec
S. Alkaline
Phosphatase
120U/L
Control
11sec
Ratio
1.05
S. Protein
6.1g/dl
INR
2.5
A/G Ratio
0.7
Inference-Coagulopathy
S. Bilirubin
1.5
Blood Urea
123mg/dl
S. Creatinine
3.3mg/dl
S. Uric Acid
9.9mg/dl
HIV, Hep B, Hep C-negative
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Complete Urine Examination: Within normal limits.
S. Triglyceride
104mg/dl
S. Cholesterol
116mg/dl
S. VLDL
21mg/dl
SODIUM
121.7 meq/l
POTASSIUM
3.6 meq/l
Ultrasonography
Free fluid +++
Liver measures 13.5 cm with slightly altered in echotexture.
Gall Bladder is thickwall & oedematous but lumen is echofree.
Portal vein diameter is 13mm.Splenic vein diameter is 5.0mm
Spleen measures 16.2cm with normal echotexture.
Pancrease ,Kidneys, Bladder , Prostate normal in size & shape.
Impression- Cirrhosis with Ascitis
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Differential Diagnosis:
 Based on clinical, lab & USG findings, patient is suffering from Chronic Liver
Disease showing complications of Ascites and Portal Hypertension with
derangement of KFT, cause of which can be 1) Hepato-Renal Syndrome
2) Pre –Renal Azotemia
 High SAAG in the case indicates presence of Portal Hypertension.
 Low Ascitic Protein (1.5g/dl) indicates Transudative Ascites.
 Based on patients alcoholic history & lab findings,Cirrhosis is the cause of
Ascitis and Portal Hypertension.
 Complete Urine Analysis within normal limit shows that Chronic Kidney
Disease is not the cause of acute renal failure.
 Hereditary causes of Cirrhosis are ruled out based on family history while
patient gives no history of skin pigmentation,xanthoma and jaundice
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which rules out Biliary Cirrhosis.
Alcohol Liver Disease
 Chronic alcohol ingestion is one of the major causes of liver disease.
 It causes 3 major lesions: a)fatty liver b)alcoholic hepatitis c)cirrhosis
 Quantity and Duration of alcohol intake are the major risk factors.160g/d
for 10-20 years in man produces cirrhosis.
 Hepatic metabolism of alcohol initiates a process that promotes lipogenesis
& the inhibition of fatty-acid oxidation. Endotoxins, oxidative stress,
immunologic activity, and pro-inflammatory cytokine release contribute to
the resulting liver injury.
 Alcoholic fatty liver and hepatitis is reversible with alcohol abstention but
cirrhosis is not.
 Diagnosis is based on AST, ALT, GGTP, Bilirubin and USG findings.
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 A discriminant function can determine patients with poor prognosis.(>32)
 The presence of ascites, variceal hemorrhage, deep encephalopathy, or
hepatorenal syndrome predicts a dismal prognosis.
Management
 Lifestyle modifications: decreased alcohol intake, smoking obesity
 Appropriate nutrition/nutritional support
 Use of pentoxifylline or prednisone for alcohol hepatitis
 Advice on complementary & alternative medicine for cirrhosis(eg
silymarin)
 Transplantation in selected abstinent patients with severe disease.
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Thank You
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