1. Alcoholic Liver Disease
Clinical Case Presentation:
Alcoholic Liver Disease
Gaurav Jain
Roll No: 174/11

2. Clinical Case Presentation: Ascites with ARF
Lakshmi Narayan, 42 years old patient , who is a chronic alcoholic, farmer by occupation presented with:
Abdominal distension from 15 days
Abdominal pain from 15 days
Fever from 15 days
Decreased urine output from 10 days
Decreased passage of stools from 10 days

3. HISTORY H/O Present illness: HDBT 15 days when patient developed:
insidious, gradually progressive Abdominal distension a/w pin-pricking pain in the epigastrium & right hypochondrium region , relieved by medication.
Intermittent, mild to moderate grade fever, insidious onset & subsides on medication a/w nausea ,retching, cachexia, altered sleep patterns with day-time sleepiness.
Pt. developed decrease in urine output without burning or other discomfort from past 10 days.
Pt. developed decreases stool passage ,insidious onset and gradually progressive, not a/w flatulence, dyspepsia, heart burn from 10 days.
A single episode of haemetemesis containing 30 ml of fresh blood.

4. Personal History: Married with two children
Negative History: No H/O chills, rigor, sweating,headache,rashes retrobulbar pain, cough, joint pain, steatorrhea, malena, facial puffiness, xanthelasma, xanthomata, flapping tremors, blood transfusion.
Past History: No H/O TB, Diabetes, Asthma, Hypertension. No such complaint in the past.
Personal History: Married with two children
Non vegeterian diet.
Smoking-15 pack years but one bundle daily from past 2 months.
Chronic alcoholic from past 30 years consuming units of alcohol daily. Tobacco chewing from past 12 years.
Lost 15 kgs of weight in past 2 months.
Family History: No such family history.
Drug History: No significant history.

5. EXAMINATION General Physical Examination
Patient is conscious, oriented to time,place and person and cooperative.
No pallor, icterus, cyanosis, clubbing, JVP and lymphadenopathy. Pedal edema present.
No gynaecomasatia, skin pigmentation , palmar erythema, spider nevi, leuconychia, koilonychia, angular stomatitis present.
Axillary ,pubic hair decreased. Mild Glossitis present
PR- 86/min RR-20/min BP-96/60mmHg
Abdominal Girth: cm
Umblico-ischial spine distance: cm
Umblico-Symphysis distance: cm

6. Other systemic findings were normal.
Abdominal Examination
Inspection: globular shape stomach with full flanks and everted umblicus. There is a single scar present on the right lateral side. Engorged veins seen.(downward to upward blood
flow).
Palpation: afebrile .Liver not palpable. Spleen palpable by Dipping method but size cant be established. Fluid thrill present. . Tense and tendor
Percussion: Shifting Dullness present.
Auscultation: Bowel sounds heard and Bruits not heard.
Other systemic findings were normal.

7. INVESTIGATIONS HIV, Hep B, Hep C-negative PT/INR
Ascitic Fluid Cytology
No malignant cell seen
TLC
200/CUMM
DLC
N 20%: L 80%
Fluid Protein
1.5 g/dl
SAAG
2.2 g/dl
ADA
8.58U/L
Inference: Transudative picture: tubercular ascites ruled out.
Blood Urea
123mg/dl
S. Creatinine
3.3mg/dl
S. Uric Acid
9.9mg/dl
TLC
11700/cumm
DLC
N 87- L 10- E 1- M 2 Hb
7.5gm
APC
4.5 lacs
PT/INR
Prothrombin time
18.3sec
Control
11sec
Ratio
1.05
INR
2.5
Inference-Coagulopathy
SGOT
80U/L
SGPT
32U/L
S. Alkaline Phosphatase
120U/L
S. Protein
6.1g/dl
A/G Ratio
0.7
S. Bilirubin
1.5
HIV, Hep B, Hep C-negative

8. Ultrasonography Complete Urine Examination: Within normal limits.
S. Triglyceride
104mg/dl
S. Cholesterol
116mg/dl
S. VLDL
21mg/dl
SODIUM
121.7 meq/l
POTASSIUM
3.6 meq/l
Ultrasonography
Free fluid +++
Liver measures 13.5 cm with slightly altered in echotexture.
Gall Bladder is thickwall & oedematous but lumen is echofree.
Portal vein diameter is 13mm.Splenic vein diameter is 5.0mm
Spleen measures 16.2cm with normal echotexture.
Pancrease ,Kidneys, Bladder , Prostate normal in size & shape.
Impression- Cirrhosis with Ascitis

9. Differential Diagnosis:
Based on clinical, lab & USG findings, patient is suffering from Chronic Liver Disease showing complications of Ascites and Portal Hypertension with derangement of KFT, cause of which can be 1) Hepato-Renal Syndrome ) Pre –Renal Azotemia
High SAAG in the case indicates presence of Portal Hypertension.
Low Ascitic Protein (1.5g/dl) indicates Transudative Ascites.
Based on patients alcoholic history & lab findings,Cirrhosis is the cause of Ascitis and Portal Hypertension.
Complete Urine Analysis within normal limit shows that Chronic Kidney Disease is not the cause of acute renal failure.
Hereditary causes of Cirrhosis are ruled out based on family history while patient gives no history of skin pigmentation,xanthoma and jaundice which rules out Biliary Cirrhosis.

10. Alcohol Liver Disease
Chronic alcohol ingestion is one of the major causes of liver disease.
It causes 3 major lesions: a)fatty liver b)alcoholic hepatitis c)cirrhosis
Quantity and Duration of alcohol intake are the major risk factors.160g/d for years in man produces cirrhosis.
Hepatic metabolism of alcohol initiates a process that promotes lipogenesis & the inhibition of fatty-acid oxidation. Endotoxins, oxidative stress, immunologic activity, and pro-inflammatory cytokine release contribute to the resulting liver injury.
Alcoholic fatty liver and hepatitis is reversible with alcohol abstention but cirrhosis is not.
Diagnosis is based on AST, ALT, GGTP, Bilirubin and USG findings.

11. A discriminant function can determine patients with poor prognosis
The presence of ascites, variceal hemorrhage, deep encephalopathy, or hepatorenal syndrome predicts a dismal prognosis.
Management
Lifestyle modifications: decreased alcohol intake, smoking obesity
Appropriate nutrition/nutritional support
Use of pentoxifylline or prednisone for alcohol hepatitis
Advice on complementary & alternative medicine for cirrhosis(eg silymarin)
Transplantation in selected abstinent patients with severe disease.

12. Thank You