DCLD WITH ASCITIS case presentation Abdomen case

About DLCD

1. DCLD WITH ASCITIS S.KIRTANA IV M.B.B.S

2. DEMOGRAPHIC DETAILS: 53 Y/o (older age groups more prone for chronic hepatitis B/C, NASH,HCC , alcoholic liver disease. Younger ages- Wilsons, glycogen storage disorders, hemochromatosis, acute hepatitis, PSC, biliary atresia) Male (males- alcoholic liver disease females- autoimmune liver disease, sle ) Mr. Raman Sales assistant ( lower socioeconomic status, stressful occupations- more prone for alcoholism and smoking) Triplicane

3. CHIEF COMPLAINTS: Abdominal distention- 6 months ( feces , fat, fluid, flatus, fetus ) Swelling of legs- 4 months (systemic- hypoproteinemia , right heart failure, chronic kidney failure, chronic liver failure. Local- vascular compromise, filariasis, gangrene)

4. H/O PRESENTING ILLNESS: Patient was apparently normal 6 months ago after which he started developing Abdominal distention: 6 months Insidious ( seen in dcld , right heart failure, ckd , tb, malignant ascites. Acute- bowel obstruction, ruptured bowel{pneumoperitoneum}, trauma- {hemoperitoneum}) Progressive Uniform ( dcld , right heart failure, ckd , hypoproteinemia . Localized- organomegaly, tumors , loculated ascites)

5. Swelling of both the legs: 4 months Insidious Progressive Upto mid calf level Aggravated by prolonged upright posture Relieved on lying down with legs elevated H/O pruritus ( deposition of bile salts in the skin)

6. No H/O abdominal pain , fever, nausea, vomiting, diarrhea /constipation/ hematochezia /worms in stools (to rule out infections and infestations) Abdominal pain- acute gastroenteritis, acute hepatitis, peritonitis, rupture of bowel Fever - acute hepatitis, peritonitis, acute gastroenteritis Nausea, vomiting- acute hepatitis, hepatic failure, obstructive jaundice, acute gastroenteritis Steatorrhea- obstructive jaundice, chronic pancreatitis, giardiasis Worms in stools- ascariasis ( can also affect liver), worms can obstruct intestine causing abdominal distention. Dysentery- blood + loose stools- amoebiasis ( can also affect liver- amoebic abscess) Diarrhoea- >3 times a day, >2oogm stools with altered consistency. Or single passage of liquid/semi solid stool. Causes: acute gastroenteritis, IBD , IBS, malabsorption Constipation - < 3 times a week. Causes: hemarrhoids , low fiber diet Hematochezia - fresh blood in stools due to rectal bleeds

7. (complications of liver failure) No H/O loss of appetite, hematemesis, melena, high coloured urine, clay coloured stools Loss of appetite- acute hepatitis, chronic liver failure, hepatic malignancy, other malignancies, HIV Hematemesis- coffee grounds vomitus (brown color due to acid hematin) causes: bleeding varices (portal hypertension) , bleeding peptic ulcers, Mallory Weiss tears(alcoholism) Melena- black tarry offensive stool that sticks to the toilet bowl (altered blood) indicative of upper GI bleed. Causes: same as above High coloured urine: obstructive jaundice, liver cell failure, drugs like b complex, rifampicin Clay coloured stools: obstructive jaundice No H/O confusion, sleep disturbances, altered mental status Hepatic encephalopathy

8. WEST HAVEN CRITERIA

9. No H/O oliguria, puffiness of face, frothy urine, increased frequency, hematuria or dysuria (For renal failure causing abdominal distention) Oliguria- renal failure Puffiness of face- nephrotic syndrome, chronic renal failure Frothy urine- proteinuria, causes: nephrotic syndrome, nephritis. ( bence jones proteinuria- multiple myeloma, amyloidosis) Hematuria - glomerulonephritis, renal calculi Dysuria- uti , calculi No H/O chest pain, breathlessness, palpitations, syncope (for cvs causes of abdominal distention. Rvf presents with ascites, tender hepatomegaly and elevated jvp ) No H/O cough with sputum, evening rise of temperature, night sweats (rule out tuberculous etiology )

10. PAST H/O: No previous similar complaints (recurrent/resistant ascites, unmotivated patient who has not quit drinking) Not a K/C/O DM (immunocompromise- increased risk of spontaneous infection of ascitic fluid, hepatitis B/C, diabetic nephropathy) , HT ( hypertensive nephropathy) , IHD ( IHD at 50 years would suggest associated hyperlipidemic states which can cause NASH) , TB (tuberculous ascites, intestinal tb- obstruction, tb of liver, immunocompromise) , asthma (beta blockers contraindicated) , epilepsy ( hepatotoxic antiepileptic medication) No previous surgeries/ blood transfusions ( hepatitis B/C, HIV)

11. PERSONAL H/O: Consumption of alcohol for last 33 years- 180 ml/day whiskey ( risk factor for cirrhosis. Safe limit- 21 units per week in males, 14 in females. 1 unit= 30 ml whiskey) Not a smoker No H/O iv drug abuse, tattooing, exposure to STDs (hepatitis b/c HIV) Takes mixed diet (food borne hepatitis- a, e. lack of hygiene- amoebiasis, ascariasis, other infestations) Normal sleep habits (altered in hepatic encephalopathy) Normal bowel and bladder habits

12. SUMMARY: A 53 Y/o man, an alcoholic for the last 33 years came with the complaints of abdominal distention for the last 6 months and swelling of both legs for the last 4 months with no other complaints The system involved is the abdomen.

13. GENERAL EXAMINATION: Conscious (altered in hepatic encephalopathy) Oriented to time place and person altered in hepatic encephalopathy Moderately built and nourished obese- NASH, poorly built/nourished- malabsorption, malignancy, dcld , tb, chronic inflammatory conditions Icteric check in upper palpebral conjunctiva, palate, underside of tongue, palms and soles. Under natural light. Icterus is seen when bilirubin levels are >3mg/dl Grade 3 pan-digital clubbing (grade 3- parrot beaking , causes: chronic liver failure, ibd , hepatoma other causes: suppurative lung diseases, cyanotic heart diseases) Bilateral pitting pedal edema extending upto the mid calf level (bilateral – ivc compression by abdominal mass/distention, heart failure, kidney failure. Unilateral- lymphatic obstruction, vascular compromise, filariasis. Pitting- fluid retention states, non pitting- filariasis, myxoedema) NO pallor, cyanosis, generalized significant lymphadenopathy Pallor- chronic liver failure, chronic inflammatory states, chronic kidney failure, nutritional Lymphadenopathy- tb hiv malignancy lymphomas

14. VITALS: Pulse: 80/min, regular, normal volume and character, felt in all peripheral pulses rapid pulse seen in sepsis, bacterial peritonitis BP: 120/80 mm Hg peritonitis may present with shock and hypotension Temp: 98.4 F increased in peritonitis RR: 18/min, thoracoabdominal type ascites prevents abdominothoracic respiration JVP : not elevated elevated in right heart failure

15. MARKERS OF LIVER CELL FAILURE: Alopecia increased estrogen Medial madarosis increased estrogen Xanthalasma - dyslipidemia Icterus deposition of bile pigments in the sclera Bitot spots- vit a deficiency Sch - hypocoagulability Parotid enlargement Fetor hepaticus- mercaptans Palmar erythema Duputryn contracture Excoriation marks over limbs deposition of bile salts in the skin Asterxis /flapping tremors More than 5 spider nevi Gynecomastia increased estrogen Sparse body hair increased estrogen Abdominal distention ascites hernia Sparse pubic hair increased estrogen Testicular atrophy Pedal edema ivc obstruction, hypoproteinemia

16. EXAMINATION OF ABDOMEN: After obtaining informed consent patient was exposed from xiphisternum to mid thigh On inspection in supine and upright postures: Abdomen is uniformly distended (local distension seen in organomegaly, tumor mass, loculated ascites) Flanks are full (indicates >1L fluid in abdomen) Umbilicus is in midline and horizontally slitted (horizontal slitting is seen in ascites) All quadrants move equally with respiration (local inflammation and peritoneal irritation may lead to guarding and absence of respiratory movements in one or more quadrants) No visible pulsations/peristalsis (visible peristalsis is seen in early stage of bowel/gastric obstruction, visible pulsations are seen in abdominal aorta aneurysm, highly vascular tumors close to the surface) No scars, sinuses, dilated veins (scars- previous surgeries, previous ascitic fluid tapping sinuses- tuberculosis dilated veins- portal hypertension, svc obstruction, ivc obstruction. Better seen than felt, after milking direction of blood flow indicates if svc (filling up to down) or ivc (filling down to up) veins are affected. CAPUT MEDUSA –dilated veins leading away from umbilicus) On raising the head, divarication of recti is seen (chronic abdominal distention weakens recti, weak recti increase chance of herniation) Hernial orifices are free (raised intraabdominal pressure due to ascites can cause hernias) Pubic hair is sparse (excess estrogens in liver failure) External genitalia is normal and penis is in midline

17. On palpation: No warmth/tenderness (warm/tender- acute condition, infection, trauma, inflammation) Inspectory findings are confirmed Liver - not palpable (cirrhotic liver is shrunken. Normal span- 10-12 cm) Spleen – not palpable (splenomegaly seen in portal ht ) Measurements: Abdomen girth- 120 cm (important to know baseline to assess response to treatment) spinoumbilical distance- 23 cm on both sides (in case of ovarian or other lateral tumors spinoumbilical distance is increased ipsilaterally) xiphisternum to umbilicus- 27 cm umbilicus to pubic symphysis- 18 cm ( xiphi to umbilicus > umbilicus to symphysis implies that the pathology causing the distention is abdominal and not pelvic) No palpable inguinal/supraclavicular nodes ( lt supraclavicular node enlarged in abdominal malignancies- Virchow node, troiser sign)

18. On percussion: Shifting dullness is present (1-1.5L fluid necessary to elicit. >2L fluid thrill, <500ml puddle sign) Shifting dullness- percuss from midline down towards the axilla till point of dullness is reached, without removing the hand make the patient to turn onto the opposite side. After few seconds percuss at the same spot. Resonant note is heard due to shifting of the fluid to the opposite side and bowel floating up Fluid thrill- stand at foot end, make an assistant place his hand firmly over the midline of abdomen, with one hand tap on the flanks, with the other hand feel for thrill on the opposite flank Puddles sign- patient is put in knee elbow position and auscultopercussion is done near the umbilicus Liver dullness felt at 5 th ics Liver span 7 cm Traube space resonant (no splenomegaly) On auscultation: Normal bowel sounds heard No bruits/rubs

19. OTHER SYSTEMS: RS: trachea in midline, normal vesicular breath sounds over all lung fields, no added sounds, no evidence of pleural effusion (ascites can lead to pleural effusion, tb can cause ascites) CVS: S1 S2 heard no added sounds or murmurs (rule out right heart failure as a cause) CNS: no focal neurological deficit ( cns examination is important to rule out hepatic encephalopathy)

20. SUMMARY: A 53 y/o male alcoholic for the past 35 years who came with the complaints of abdominal distention for the last 6 months and swelling of legs for the past 4 months on general examination was conscious, oriented, icteric, with bilateral pitting pedal edema upto mid calf level, grade 3 pandigital clubbing and markers of liver cell failure, on examination of the abdomen it was found to be uniformly distended with flanks full and girth was 120cm, umbilicus was in midline and horizontally slitted, liver was not palpable, on percussion shifting dullness was elicited.

21. DIAGNOSIS: A CASE OF CHRONIC DECOMPENSATED LIVER DISEASE WITH ASCITES AND NO OTHER COMPLICATIONS (decompensated- liver cell failure signs seen. Ascites seen) Cirrhosis-irreversible chronic injury to the liver parenchyma with extensive fibrosis and regenerative nodule formation Complications- ascites- abdominal distention, pedal edema , sbp , protein loss portal hypertension- splenomegaly, bleeding varices, hepatic encephalopathy- confusion, delirium, asterixis, coma

22. INVESTIGATIONS: (GENERAL) CBC ( hb levels for anemia , tc /dc for infections- neutrophilia in acute bacterial infections, lymphocytosis in tb, esr elevated in inflammatory conditions) Blood urea sugar creatinine electrolytes Urine albumin sugar cytology ECG Chest X ray Lipid profile ( nash ) Viral markers (hep b/c) Covid rtpcr

23. INVESTIGATIONS: (SPECIFIC) USG abdomen (ascites, organomegaly, portal vein) Doppler of portal veins CT abdomen MRI abdomen LFT ( bt,ct , clotting factor assays, albumin:globulin ratio inverted, serum albumin reduced, ast , alt elevated, ggt specific for alcoholic cirrhosis, alp elevated in obstructive jaundice, serum bilirubin ( conj and unconj ) elevated) Ascitic fluid analysis (ascitic fluid- gross- color , turbidity, blood staining. Biochemistry- albumin, ldh , saag- >1.1 in portal Ht , <1.1 in non portal ht causes, ada . Cytology- gram stain, afb , culture sensitivity, malignant cells) Upper GI Endoscopy (bleeding varices) Liver biopsy (confirmatory, if cause is unclear)

24. INVESTIGATION: (special) Autoimmune hepatitis- anca , ana, ra , tests for sle Parasites- stool examination Wilsons- serum cu, urine cu, serum ceruloplasmin hemochromatosis- serum fe , ferritin, hemosiderin in tissues Storage disorders – liver or tissue biopsies

25. TREATMENT: Bed rest Abstinence from alcohol Ascites- salt and fluid restriction, diuretics, paracentesis with salt free albumin infusion (massive tapping >3L not advocated due to risk of rebound ascites and hypotension.large volume Tapping always in conjunction with albumin transfusion) Varices- resuscitate, blood transfusion if required, ryles tube insertion, vasopressin, somatostatin, balloon tamponade with sengstaken Blakemore tube, propranolol to prevent recurrence,sclerotherapy or banding of varices, TIPSS (bypasses portal circulation, anticipated side effect- hepatic encephalopathy) HE- protein restricted diet, lacutulose,rifaximin , LOLA to sterilize gut, ensure calorie, fluid and electrolyte requirements met by diet, zn supplements Bleeding tendency- inj.vitK End stage- liver transplantation (motivated patient after 6mo abstinence from alcohol)