long case

A 47 year male patient resident of Nalgonda came with chief complaints of abdominal distension and swelling of bilateral lower limbs since 6 months which is gradually increasing since 10 days and fluid discharge from the umbilical area since 2 days and fever since 2 days.

History of present illness

Patient was apparently asymptomatic 18 months back then he   noticed abdominal distension which is insidious in onset and gradually progessive in nature and subsequently noticed bilateral swelling of lower limbs , he was hospitalized for one week and took medication which increased his urine output and abdominal paracentesis  was done and felt better ,, However he  discontinued medicine 6 months back and presented with similar complaints where he was hospitalized and treated conservatively , he was hospitalized 3 months back again with similar complaints , again abdominal paracentesis of 1.5 to 2 lit was done. He is on medication , 
 the past 10 days he noticed abdominal distension associated associated with swelling of bilateral lower limbs which started at ankle and progressed upto knee , 

C/0 of swelling over umbilical region since 3 months insidious in onset , progessive in nature initially of pea nut size now proggesed to size of 3* 4 cm where he strached it and clear yellow fluid started oozing from last 2 days it and it is not associated with blood.

H/0 of fever high grade, intermittent in nature  not associated with chills, since 2 days,

H/0 of anorexia, fatigue and generalized weakness since 3 months,,

H/0 of itching present since 3 months, which generalized in onset more on the trunk,,

H/0 of disturbed sleep since one month, where he complained of excessive day time sleepiness and night distured sleep,

H/0 of yellowish discoloration of eyes 3 months back now it subsided, 

No h/0 of nausea and vomitings,

No h/0 of pain abdomen

No h/0 of decreased urine output

No h/0 of high coloured urine and clay coloured stools.

No history of shortness of breath

No history of blood transfusions 

Past medical illness- 

 History of abdominal distension , swelling of bilateral pedal oedema, and hematemesis one episode 50 ml 18 months back ,where he admitted in an hospital for 10 days which relieved with diuretics , abdominal paracentesis and gastric oesophageal ligation was done.

Appendicectomy 25 years ago

No history of hypertension, diabetes, thyroid , epilepsy or seizure disorder.


Personal history- 
Diet - mixed
Sleep - disturbed , excessive day time sleep , night time disturbed sleep since one month. 
Appetite- decreased.

Bladder habits- regular and normal.

Habits- chronic consumption of alcohol since 20 years daily , country liquor of 500 ml nearly 110gm per day, and whisky of 150 ml per day nearly 50gm per day, 
Last binge of alcohol - 3 days before admission he took 100gm.

Summary - Decompensated chronic liver disease secondary to ethanol consumption, with ascites, portal hypertension, hepatic encephalopathy stage 1 and spontaneous bacterial peritonitis.

General examination - 

Moderately built and nourished.
Patient is oriented to time , place and person.

GCS - E4 V5 M6  
VITALS - 

Pulse - 82 beats per minute, regular normal volume ,and character, no radio radial or radio femoral delay.

Blood pressure - 100/70 mm Hg, right arm supine position.

Respiratory rate - 18 cpm, thoracoabdominal. 

Spo2- 98 % on room air

Jvp - not elevated.

Physical examination- 

pallor - present
Icterus - absent
No cyanosis
No clubbing
No generalized lymphadenopathy
Pedal edema + 

Head to toe examination- 
Axillary and public hair - sparse.
B/ l parotid enlargement -  negative
No fetor hepaticus
No asterixis
No gynaecomastia
Spider nevi - absent
No planar erythema
No leuconchyia
No evidence of xanthoma and xanthelasma.
Flapping tremors -  seen.

Inspection - 

Oral cavity - No dental caries and no Tobacco staining
Abdomen - flanks full, distension.
Umbilical hernia present
Appendicectomy scar present.
Distened veins present.
No visible peristalsis or no visible pulsations.

Palpation - 
Done in supine position with Both Limbs flexed and hands by side of body.
No tenderness or  local rise of temperature.
Abdomen - soft.
No gaurding and rigidity
Lower border of liver not palpable.
Spleen not palpable 
Kidneys bimanually palpable , ballotable.
Fluid thrill - present
Abdominal girth - 98 cms . 
Xiphisternum to umbilicus -  16 cms
Public symphysis to umbilicus - 13cms

Percussion - 
Liver span -  upper border of liver dullness in 5 th intercoastal space in mid clavicular line, lower border could not be appreciated.

Auscultation : 

Normal bowel sounds heard.
No hepatic bruit , venous hum or friction rub.

Examination of  external genitilia - No testicular atrophy.

Examination of spine - Normal.

Provisional diagnosis - 

Decompensated chronic liver disease
Etiology -  chronic ethanol related.
 Ascites , SBP,  Hepatic encephalopathy 
? Hepatorenal syndrome. Esophageal gastric ligation bands were. 
 
CTP SCORE - C
MELD SCORE - 28.

Investigations-

CBP - 
HB - 10.7 
TLC - 19100,
PLT - 1.50 LAKH
N - 90

CUE -  
Albumin- 2+
Sugar- nil
Rbcs- nil
Pus cells - 4-5

RFT -
Blood urea - 116 mg/ dl
Serum creatinine - 4.8 mg/dl
Sodium - 128 meq/l
Potassium - 5.5meq/l
Chloride - 102 meq/l
Uric acid - 5.0 
Calcium - 9.1
Phosphorus - 8.0 

LFT - 
Total bilirubin - 1.63 mg/ dl
Direct bilirubin - 0.40mg/dl
SGOT - 34 IU/L
SGPT - 20 IU/L
ALP - 186 IU/L
Total protein - 5.4 gm/dl
Albumin - 2.06 gm/ dl
RBS- 70mg/dl

Ascitic fluid analysis -

SAAG - 1.74.   Serumalbumin - 2.01
                         Ascitic albumin - 0.36

Ascitic LDH - 120 IU/ L
Ascitic sugar - 52 mg/ dl
Ascitic protein - 0.8 g/dl
Appearance - Clear
Neutrophil count - 405.
Total count - 675
RBCS - Present.

PT - 16 Sec.
APTT - 32sec.
INR - 1.11
Hiv - negative.
Hbsag -negative.
Hcv - negative.

ECG - 


 X ray - 


Treatment given - 

1. Tab PAN 40 MG OD
2. TAB . RIFAGUT 550 mg po BD
3. SYP.HEPAMERZ 10 ml Bd
4. SYP. Lactulose 10 ml H/ S
5. Tab udiliv 300 mg po  BD.
6. Inj . Ciprofloxacin 500mg iv Bd
7. Daily abdominal girth .
8. Salt restricted diet.

1. Role of rifaximine in treating and preventing hepatic encephalopathy.

https://www.nejm.org/medical-articles/original-article

2. 









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