Transcript Slide 1
A 40-year-old male NKCM,but the history of iv drug abuser for many years presented to the ER with C/O severe abdominal pain associated with fever since 3 days Also history of black or tarry stool (malena) 4 weeks ago Also c/o anorexia since 10 days. • . O/E revealed "track" marks on both arms. • PALE looks skin • Distended abdomen Lab investigations • • • • • • • • • • Hb 8.1 Tlc 4.0 Plts 80 MCV 102 Ur 35 Cr 0.65 Na 138 K 4.5 Chl 104 Bicarb 22 • • • • • • PT 28 APTT 42 INR 4 Albumin 2.3 ECG Normal CHEST X .RAY Unremarkable LFTs • • • • Bilirubin 2.o D/billi 2.43 ID /billi 1.5 SGPT 102 (serum glutamic-pyruvic transaminase, ALT) • SGOT 128 (serum glutamic-oxaloacetic transaminase ,AST) • ALT PHOSPHTASE 102 • GAMMA GT 60 •What is the differential diagnosis of abdominal pain???? • • • • • • • • • • Acute gastroentiritis Intestinal obstruction Appendicits Renal stone Viral hepatitis Liver abcess Gastric ulcer Abdominal TB Malignancy Acute pancreatitis •What is the differential diagnosis of abdominal pain with fever???? What is the differential diagnosis of faver? • Bleeding from a lesion in the esophagus,stomach, and duodenum is called upper GI bleed. • (i) hematemesis • (ii) malena, vomiting of blood passage of black tarry stool Causes of upper GI bleed • • • • • • Esophagitis Esophageal varices Mallor_weiss tear Gastric ulcer Duodenal ulcer Ca stomach Mallory-Weiss tear • A Mallory-Weiss tear occurs in the mucus membrane of the lower part of the esophagus or upper part of the stomach, near where they join. The tear may bleed. • Mallory-Weiss tears are usually caused by forceful or long-term vomiting or coughing. They may also be caused by epileptic convulsions. • Any condition that leads to violent and lengthy bouts of coughing or vomiting can cause these tears. Bleeding esophageal varices • Bleeding esophageal varices are enlarged veins in the walls of the lower part of the esophagus that bleed. The esophagus is the tube that connects your throat to your stomach. Causes of oesophageal varices Pre-hepatic •Portal vein thrombosis. •Portal vein obstruction - congenital atresia/stenosis. •Increased portal blood flow - fistula. •Increased splenic flow. Intra-hepatic •Cirrhosis due to various causes, including alcoholic, chronic hepatitis (eg viral or autoimmune). •Idiopathic portal hypertension (hepatoportal sclerosis). •Acute hepatitis (especially alcoholic). •Schistosomiasis. •Congenital hepatic fibrosis. •Myelosclerosis. Post-hepatic •Compression (eg from tumour). •Budd-Chiari syndrome. •Constrictive pericarditis (and rarely right-sided heart failure). Oesophageal varices • WHAT FURTHER INVESTIGATIONS YOU WILL ADVISE ON THE BASIS OF THESE LABS?? • HbsAg • IF +VE THEN GO FOR PCR OF HBV (DNA) • Anti HCV . If +ve , then get PCR for HCV (RNA). • U/S abdomen . Liver status ,shrinkage,any • tumor,margins. • There is no vacanation of HCV due to RNA genotype • There is a vacination of HBV due to DNA genotype How many types of viral hepatitis? • • • • • Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E ( PREGNANCY) Three things for liver function monitoring • LFTs (If LFT derrange specialy SGPT it means liver problem developed) • PT, APTT, INR (if pt ,aptt,INR incresase it means acute liver problem) • Albumin (If Albumin decrease it means with PT,APTT,INR, increase it means chronic liver problem) • PCR OF HCV (RNA) POSITIVE OR • PCR OF HBV (DNA) POSITIVE • WITH • Decompensated liver disease • Decompensated liver disease means that the medications and treatments used to treat the liver is no longer working very well and the liver is near total failure • It means only symptomatic treatment • • • • IVF IV Antibiotics (if infections develop) Diuretics (k sparing diuretics Aldactone) Antipyretic (if fever spike) Mangement of upper GI Bleed • • • • • • • IV access Oxygen Sedation Blood transfusion PPI (proton pump inhibitor) Octreotide (vasopressin) surgery IF PCR OF HCV (RNA) POSITIVE • WITHOUT DECOMPENSATION • THEN START INJ INTERFERON CAPSULE RIBAVIRIN WITH IF PCR OF HBV (DNA) POSITIVE • WITHOUT DECOMPENSATION • INTERFERON THERAPHY (interferon alpha,peginterferon alfa-2b) • NUCLEOSIDE ANALOGUES (lamivudine tab zeffix 100mg 1 OD , and adefovir 10mg 1.OD) Side effects of interferon theraphy • Thrombocytopenia • Flu like symptoms