A 40-year-old male NKCM,but the history of iv drug abuser for many years presented to the ER with C/O severe abdominal pain associated with fever since 3 days Also history of black or tarry stool (malena) 4 weeks ago Also c/o anorexia since 10 days.

. O/E revealed "track" marks on both arms. PALE looks skin Distended abdomen

Lab investigations Hb 8.1 Tlc 4.0 Plts 80 MCV 102 Ur 35 Cr 0.65 Na 138 K 4.5 Chl 104 Bicarb 22

PT 28 APTT 42 INR 4 Albumin 2.3 ECG Normal CHEST X .RAY Unremarkable

LFTs Bilirubin 2.o D/billi 2.43 ID /billi 1.5 SGPT 102 (serum glutamic-pyruvic transaminase, ALT) SGOT 128 (serum glutamic-oxaloacetic transaminase ,AST) ALT PHOSPHTASE 102 GAMMA GT 60

What is the differential diagnosis of abdominal pain????

Acute gastroentiritis Intestinal obstruction Appendicits Renal stone Viral hepatitis Liver abcess Gastric ulcer Abdominal TB Malignancy Acute pancreatitis

What is the differential diagnosis of abdominal pain with fever????

What is the differential diagnosis of faver?

(i) hematemesis vomiting of blood Bleeding from a lesion in the esophagus,stomach, and duodenum is called upper GI bleed. (i) hematemesis vomiting of blood (ii) malena, passage of black tarry stool

Causes of upper GI bleed Esophagitis Esophageal varices Mallor_weiss tear Gastric ulcer Duodenal ulcer Ca stomach

Mallory-Weiss tear A Mallory-Weiss tear occurs in the mucus membrane of the lower part of the esophagus or upper part of the stomach, near where they join. The tear may bleed. Mallory-Weiss tears are usually caused by forceful or long-term vomiting or coughing. They may also be caused by epileptic convulsions. Any condition that leads to violent and lengthy bouts of coughing or vomiting can cause these tears.

Bleeding esophageal varices Bleeding esophageal varices are enlarged veins in the walls of the lower part of the esophagus that bleed. The esophagus is the tube that connects your throat to your stomach.

Causes of oesophageal varices Pre-hepatic Portal vein thrombosis. Portal vein obstruction - congenital atresia/stenosis. Increased portal blood flow - fistula. Increased splenic flow. Intra-hepatic Cirrhosis due to various causes, including alcoholic, chronic hepatitis (eg viral or autoimmune). Idiopathic portal hypertension (hepatoportal sclerosis). Acute hepatitis (especially alcoholic). Schistosomiasis. Congenital hepatic fibrosis. Myelosclerosis. Post-hepatic Compression (eg from tumour). Budd-Chiari syndrome. Constrictive pericarditis (and rarely right-sided heart failure).

Oesophageal varices

WHAT FURTHER INVESTIGATIONS YOU WILL ADVISE ON THE BASIS OF THESE LABS??

HbsAg IF +VE THEN GO FOR PCR OF HBV (DNA) Anti HCV . If +ve , then get PCR for HCV (RNA). U/S abdomen . Liver status ,shrinkage,any tumor,margins.

There is no vacanation of HCV due to RNA genotype There is a vacination of HBV due to DNA genotype

How many types of viral hepatitis?

Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E ( PREGNANCY)

Three things for liver function monitoring LFTs (If LFT derrange specialy SGPT it means liver problem developed) PT, APTT, INR (if pt ,aptt,INR incresase it means acute liver problem) Albumin (If Albumin decrease it means with PT,APTT,INR, increase it means chronic liver problem)

PCR OF HCV (RNA) POSITIVE OR PCR OF HBV (DNA) POSITIVE WITH Decompensated liver disease Decompensated liver disease means that the medications and treatments used to treat the liver is no longer working very well and the liver is near total failure It means only symptomatic treatment

IVF IV Antibiotics (if infections develop) Diuretics (k sparing diuretics Aldactone) Antipyretic (if fever spike)

Mangement of upper GI Bleed IV access Oxygen Sedation Blood transfusion PPI (proton pump inhibitor) Octreotide (vasopressin) surgery

IF PCR OF HCV (RNA) POSITIVE WITHOUT DECOMPENSATION THEN START INJ INTERFERON WITH CAPSULE RIBAVIRIN

IF PCR OF HBV (DNA) POSITIVE WITHOUT DECOMPENSATION INTERFERON THERAPHY (interferon alpha,peginterferon alfa-2b) NUCLEOSIDE ANALOGUES (lamivudine tab zeffix 100mg 1 OD , and adefovir 10mg 1.OD)

Side effects of interferon theraphy Thrombocytopenia Flu like symptoms