2Clinical 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 daysAbdominal pain from 15 daysFever from 15 daysDecreased urine output from 10 daysDecreased passage of stools from 10 days
3HISTORY 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.
4Personal 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 childrenNon 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.
5EXAMINATION 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 presentPR- 86/min RR-20/min BP-96/60mmHgAbdominal Girth: cmUmblico-ischial spine distance: cmUmblico-Symphysis distance: cm
6Other systemic findings were normal. Abdominal ExaminationInspection: 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 bloodflow).Palpation: afebrile .Liver not palpable. Spleen palpable by Dipping method but size cant be established. Fluid thrill present. . Tense and tendorPercussion: Shifting Dullness present.Auscultation: Bowel sounds heard and Bruits not heard.Other systemic findings were normal.
7INVESTIGATIONS HIV, Hep B, Hep C-negative PT/INR Ascitic Fluid CytologyNo malignant cell seenTLC200/CUMMDLCN 20%: L 80%Fluid Protein1.5 g/dlSAAG2.2 g/dlADA8.58U/LInference: Transudative picture: tubercular ascites ruled out.Blood Urea123mg/dlS. Creatinine3.3mg/dlS. Uric Acid9.9mg/dlTLC11700/cummDLCN 87- L 10- E 1- M 2Hb7.5gmAPC4.5 lacsPT/INRProthrombin time18.3secControl11secRatio1.05INR2.5Inference-CoagulopathySGOT80U/LSGPT32U/LS. Alkaline Phosphatase120U/LS. Protein6.1g/dlA/G Ratio0.7S. Bilirubin1.5HIV, Hep B, Hep C-negative
8Ultrasonography Complete Urine Examination: Within normal limits. S. Triglyceride104mg/dlS. Cholesterol116mg/dlS. VLDL21mg/dlSODIUM121.7 meq/lPOTASSIUM3.6 meq/lUltrasonographyFree 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 5.0mmSpleen measures 16.2cm with normal echotexture.Pancrease ,Kidneys, Bladder , Prostate normal in size & shape.Impression- Cirrhosis with Ascitis
9Differential 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 AzotemiaHigh 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.
10Alcohol Liver DiseaseChronic alcohol ingestion is one of the major causes of liver disease.It causes 3 major lesions: a)fatty liver b)alcoholic hepatitis c)cirrhosisQuantity 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.
11A discriminant function can determine patients with poor prognosis The presence of ascites, variceal hemorrhage, deep encephalopathy, or hepatorenal syndrome predicts a dismal prognosis.ManagementLifestyle modifications: decreased alcohol intake, smoking obesityAppropriate nutrition/nutritional supportUse of pentoxifylline or prednisone for alcohol hepatitisAdvice on complementary & alternative medicine for cirrhosis(eg silymarin)Transplantation in selected abstinent patients with severe disease.