A 57-year-old man presents with fatigue for several months. He underwent a blood transfusion with several units in 1982 after car accident. Physical examination reveals generalized jaundice, a firm nodular liver edge, and a mildly protuberant abdomen with a fluid wave. Initial laboratory studies show, mildly elevated transaminases, increased serum bilirubin(total&direct) as well as hypoalbuminemia and coagulopathy (prolonged PT).

1-What is the most likely diagnosis?2- What are the possible etiologies of this disorder?3- What other tests would be appropriate?4- What are the possible complications?

Answers

◆ Most likely diagnosis: Chronic hepatitis/cirrhosis. ◆ Possible etiologies of this disorder: Most commonly caused by

chronic viral infection( HBV orHCV) or ◆ Other appropriate tests: Hepatitis virus serologies and possibly a liver biopsy. ◆ Possible complications:

Hepatic failure, gastrointestinal bleeding, hepatocellular carcinoma.

Case45 year old man with cirrhosis and ascites admitted with 2 days of confusion. On lactulose for 1 year, wife doesn’t know if compliant. Wife says no fever, abdominal pain, cough, diarrhea. Examination reveled blood pressure 100/60,pulse 72, afebrile. Sleepy but arousable. Spiders angiomas, jaundice, ascites, edema, +ve reflexesInvestigations reveled : WBC = 8,000, Hb: 10.0, pltatlets = 70,000. Na = 129, K = 3.0, = 21; creatinine = 0.9. Albumin= 2.5, bilirubin = 3.9, NH4 = 65. CXR and Urine Analysis was negative.

Clinical questions

1. Does this patient have hepatic encephalopathy?

2. Should I order a CT scan of head?3. Should I do a diagnostic paracentesis to

exclude SBP?4. Where should this patient be admitted?5. Will initial therapy be lactulose, rifaximin, or

both?

Diagnosis of HE1. Identify underlying liver disease– Acute with severe transaminitis– Chronic - portal HTN

2. Ascertain neuropsychiatric symptoms:– Sleep disturbance, alteration in level of

consciousness, confusion

3. Elicit neurologic signs – Asterixis, hyperreflexia, clonus, +Babinski

4. Exclude other causes

Ahmed is a 62 years old Egyptian male admitted to Mansours emergency hospital on 13 May, 2009 with Confusion since today morning, disorientation, lethargy, abdominal pain, constipation. • Past medical history: DM ( on oral hypoglycemic agent) , chronic liver

disease (liver cirhhosis and Hematemesis), HCV, HBV, Portal hypertension, post spleenoctomy, esophagitis.

• Family history: No family history of similar condition

Vital signs:RR: 22 BP: 135/78 Pulse: 75 bpm Temp: 36.22º CLab:Na: 144 mmol/L K: 4.1 mmol/L Bilirubin: 7 umlo/L Cr: 100 umol/LGlucose: 12.1 mmol/LAlbumin: 2.2 g/L ALT: 69 U/LAST: 110 U/L GGT: 92 U/L

Examination:o General condition: Disorientation &

Confusiono Skin: No jaundice, no skin rasho CVS: normalo CNS: Normal reflexes, flapping tremorso Chest: Bilateral basal crepitationo Abdomen: Distended, soft, lax,

hepatomegally, mild ascitits