Srmc abdomen

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  • 1. ABDOMEN CASE DISCUSSION Preeti thapar

2. Chief complaints 40 yrs old male patient presented to us with c/o Jaundice-3months High coloured urine-2months Loss of appetite-2 months Loss of weight (15kgs)-2 months Blood stained vomitus -1month Bleeding gums -1 month Right sided abdominal pain -1month h/o fever -1day 3. History No h/o melena No h/o abdominal distention No h/o pedal oedema No h/o oliguria No h/o pruritis No h/o rash No h/o dyspnea No h/o loose stools No h/o cough with expectoration No h/o altered sleep cycle no h/o seizures/LOC 4. PAST HISTORY No h/o blood transfusion No h/o iv drug abuse No h/o surgeries in past No h/o diabetes/TB/hypertension/CADin past No h/o recent travel 5. Personal history Married Chronic alcohol intake present = 180ml of brandy per day for 10yrs Occasional smoker Denied history of exposure 6. Family history Patient married Has 2 children Has 13 siblings No similar complaints in family members 7. Treatment history Patient has taken ayurvedic medication as a single dose for his jaundice 3 months back No h/o taking siddha,unani medications 8. General examination Patient is concious ,oriented to time place and person Vitals ;BP -120/80 HR 78/MIN TEMP -98.4 No pallor,cynosis,pedal oedema,lymphadenopathy Icterus present Clubbing + Alopecia + 9. Tatoo mark on rt arm Scar mark over right shoulder Lipoma over forehead Hyperpigmented patch over right popliteal fossa No KF ring No Bitot spot No xanthelasma B/l Parotid enlargement present Oral cavity normal 10. General physical exam Fetor hepaticus absent Gynaecomastia + Loss of axillary hair,chest hair + No scratch marks No bruises/rash No spider naevi No palmar erythema No dupuytrens contracture No testicular atrophy 11. Per abdomen Inspection normal shape, all quadrants move equally with respiration ,no visible veins,no scars, all hernial orifices intact Palpation Superficial palpation-normal ,no tenderness Deep palpation -right hypochondrium tenderness present,liver enlarged 8 cm below costal margin, rounded borders,smooth surface ,firm in consistency Liver span 17.5 cm Spleen felt 5 cm below costal margin ,splenic notch felt surface smooth ,firm in consistency No other mass felt 12. Percussion- liver dulness confirmed by percussion Traube space is resonant, shifting dulness absent Auscultation no bruit heard No venous hum No rub 13. Other systems CVS S1S2 heard,no murmur heard Respiratory system chest b/l symmetrical ,b/l air entry is equal ,no adventitious sounds heard CNS patient is concious ,oriented to time place and person Higher functions normal No flap or tremor seen Trail making test 18 sec 14. Provisional diagnosis Chronic decompensated parenchymal liver disease - cirrhosis with portal hypertension probably of alcoholic etiology with no ascites with no features of hepatic encephalopathy and coagulopathy To rule out malignancy 15. Is it a decompensated cirrhosis? 16. What suggests decompensated cirrhosis? The symptom triad of decompensated cirrhosis: 1. Abdominal distension (Ascites) 2. Internal / External bleeding 3. Behavioral/Mental changes 17. What is Reitan Chart? 18. Reitans number connection chart 19. The number connection chart used to assess Hepatic encephalopathy The maximum score is 24 The maximum permitted time is 30 seconds 20. What are the synonyms of asterixis ? What is the mechanism of asterixis ? 21. ASTERIXIS SYNONYM Hepatic flap, Metabolic tremor MECHANISM Negative myoclonus Impaired inflow of joint position sense to brainstem RAS resulting in brief lapse of posture 22. Why etiology is alcoholism? Other etiology? 23. 11.Why decompensated liver disease due to alcohol? Convincing history Parotid enlargement- a sign common in alcoholism Signs of liver cell failure Ascites 24. Other etiology a) Chronic viral hepatitis b) Wilsons disease c) Auto-immune hepatitis d) Haemochromatosis 25. Pre-hepatic etiology of PHT Causes.. 26. Pre-hepatic etiology of PHT 1.Non-cirrhotic portal fibrosis [ NCPF] 2.Portal vein thrombosis 27. Non-hepatic intra-abdominal etiology of ascites 1.Malignancy 2.Tuberculosis peritonitis 3.Protein losing enteropathy, nephrotic syndrome 4.Pancreatic ascitis 5.Meigs syndrome 28. Acute decompensation of chronic liver disease Reasons? 29. Acute decompensation of chronic liver disease Superadded hepatitis Sepsis including SBP Malignant tranformation 30. What is Non-cirrhotic portal vein obstruction ? 31. NCPF? Common among lower socioeconomic class Mean age of presentation 30 years 32. Symptoms of NCPF? Symptoms at diagnosis GIT Bleed, 50% have multiple episodes Mass in the abdomen Pain abdomen occasionally distension( ascites ) Jaundice rare 33. Signs in NCPF Splenomegaly is universal Two-thirds have massive spleen Mild or no ascites No anterior abdominal or back veins Liver occasionally enlarged No signs of liver cell failure Encephalopathy rare 34. What are the different mechanisms of ascites? 35. Mechanisms of ascitis 1. Underfill theory, S.Sherlock-1963 2. Overflow theory, Libermann-1970 3. Lymph Imbalance theory,Witt-1980 4. Vasodilation theory,Schrier-1988 36. Underfill theory,1963 Na reabsorption,Body water and ascitis Stimulates RAAS,ADH,etc Decreased effective plasma 37. Overflow theory, 1970 Ascitis Facilitates fluid retention Retention of Na already exists 38. Lymph imbalance theory,1980 Ascitis Renal Hypoperfusion and RAAS Impedence in splanchnic lymph drainage 39. Vasodilation theory,1988 40. What is SAAG? 41. Why SAAG is elevated in PHT? 42. Can SAAG be elevated in non-PHT causes 43. Serum Ascitic Albumin Gradient Serum albumin- Ascitic fluid albumin Gives a clue about portal hydrostatic pressure 44. SAAG A gradient >1.1 g/dl indicates PHT as the probable cause of ascitis High gradient due to Portal hydrostatic pressure pushing the water to peritoneum leaving albumin in the vasculature 45. Non-PHT causes for SAAG >1.1g/dL Cirrhosis Alcoholic hepatitis CCF Massive hepatic metastases Vascular occlusion Fatty liver disease of pregnancy Myxedema 46. Can you get exudative ascites in portal hypertension 47. Exudative ascites in portal hypertension Cardiac ascites Acute Budd-Chiari syndrome The concept of exudate and transudate in the evaluation of ascites is no longer recommended. 48. Thank you