ABDOMEN CASE DISCUSSION

Preeti thapar

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

HistoryNo 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

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

Personal history

Married

Chronic alcohol intake present = 180ml of brandy per day for 10yrs

Occasional smoker

Denied history of exposure

Family history

Patient married

Has 2 children

Has 13 siblings

No similar complaints in family members

Treatment history

Patient has taken ayurvedic medication as a single dose for his jaundice 3 months back

No h/o taking siddha,unani medications

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 +

• 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

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

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

Percussion- liver dulness confirmed by percussion

Traube space is resonant, shifting dulness absent

Auscultation –no bruit heard

No venous hum

No rub

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

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

Is it a decompensated cirrhosis?

What suggests decompensated cirrhosis?

• The symptom triad of decompensated cirrhosis:

1. Abdominal distension (Ascites)

2. Internal / External bleeding

3. Behavioral/Mental changes

• What is Reitan Chart?

Reitan’s number connection chart

• The number connection chart used to assess Hepatic encephalopathy

• The maximum score is 24

• The maximum permitted time is 30 seconds

• What are the synonyms of asterixis ?

• What is the mechanism of asterixis ?

ASTERIXIS

SYNONYMHepatic flap, Metabolic tremor

MECHANISMNegative myoclonusImpaired inflow of joint position sense to

brainstem RAS resulting in brief lapse of posture

Why etiology is alcoholism? Other etiology?

11.Why decompensated liver disease due to alcohol?

• Convincing history

• Parotid enlargement- a sign common in alcoholism

• Signs of liver cell failure

• Ascites

Other etiology

a) Chronic viral hepatitis

b) Wilson’s disease

c) Auto-immune hepatitis

d) Haemochromatosis

Pre-hepatic etiology of PHT

Causes…..

Pre-hepatic etiology of PHT

1.Non-cirrhotic portal fibrosis [ NCPF]

2.Portal vein thrombosis

Non-hepatic intra-abdominal etiology of ascites

1.Malignancy

2.Tuberculosis peritonitis

3.Protein losing enteropathy, nephrotic syndrome

4.Pancreatic ascitis

5.Meigs syndrome

Acute decompensation of chronic liver disease

Reasons?

Acute decompensation of chronic liver disease

• Superadded hepatitis

• Sepsis including SBP

• Malignant tranformation

What is Non-cirrhotic portal vein obstruction ?

NCPF?

• Common among lower socioeconomic class

• Mean age of presentation 30 years

Symptoms of NCPF?

• Symptoms at diagnosis

GIT Bleed, 50% have multiple episodes

Mass in the abdomen

Pain abdomen

occasionally distension( ascites )

Jaundice rare

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

What are the different mechanisms of ascites?

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

Underfill theory,1963

Overflow theory, 1970

Lymph imbalance theory,1980

Vasodilation theory,1988

What is SAAG?

Why SAAG is elevated in PHT?

Can SAAG be elevated in non-PHT causes

Serum Ascitic Albumin Gradient

• Serum albumin- Ascitic fluid albumin

• Gives a clue about portal hydrostatic pressure

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

Non-PHT causes for ↑SAAG>1.1g/dL

• Cirrhosis

• Alcoholic hepatitis

• CCF

• Massive hepatic metastases

• Vascular occlusion

• Fatty liver disease of pregnancy

• Myxedema

Can you get exudative ascites in portal hypertension

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.

Thank you