Male patient presents to the hospital with dyspnoea, generalized oedema of the body involving mainly the abdomen.
Generally he looks wasted with very thin face
HISTORY TAKING
Patient says that the oedema has developed in the last 2 months, when he has started with fullness of the stomach, anorexia, tiredness. The abdomen has increased greatly, and for the last week even the scrotum and penis have become oedematous.
He needs to sleep with 2 pillows because of orthopnoea
When he brushes teeth, gums are bleeding for long time. Sometimes stool is black and loose. Frequent epigastric burning pains above all when fasting. When far from meals often complains of dizziness, loss of eye vision, feeling to faint.
He is a heavy drinker: taking local beer and super alcoolics, like whisky, rum and others.
Smoking cigarettes
Using miraa
OBJECTIVE EXAMINATION
Abdominal distension. Liver very difficult to palpate because of distension.
Splenomegaly (palpable at 5 cm below the ribs)
Percussion: abdomen very dull, looking full of fluid which changes position when patient lies on the side
Auscultation: intestinal sounds present.
Fluid thrill +
Massive oedema of scrotum and penis
Mild oedema lower limbs
Respiratory System: absence of vescicular breathing at the Right Chest. Left Chest normal but mouvements of the left basis reduced.
Cardiovascular system: Heart Sound1 and Heart Sound2 normal. No gallop rhythm, no murmurs. BP= 90/50.
Jugular veins not enlarged. Hepato-jugular reflex negative.
Pallor.
INVESTIGATIONS
HB= 6.5 g/dl
Bl sugar= 56 mg/dl
Urinalysis: proteins absent, bilirubine +++, no cilinders in the sediment.
Creat 0.9 mg/dl
Urea 50 mg/dl
Bilirubine total 10 U/l (direct 2.3 U/l)
GOT 45 U/l
GPT 60 U/l
HBsAg and HCV neg
OTHER INVESTIGATIONS
ECG was normal
U/S was suggestive of massive ascites, pleural effusion at the right side of the Chest. Liver was reduced in volume with very irregular parenchymal texture, and irregular edges. Hepatic veins were normal and portal vein was dilated, as a sign of portal HTN. Pancreas was normal. Splenomegaly with normal parenchymal texture. Splenic vein was dilated in features of portal HTN. Kidneys were normal. Diagnostic paracentesis showed clear fluid
MANAGEMENT
We will check blood group and transfuse: transfusion will help for anaemia and will increase the concentration of albumin in plasma, allowing a better chance of success for paracentesis.
After we will do a paracentesis of 900 ml because patient is dyspnoeic.
We will infuse 500 ml OD of 10% Dextrose because patient has very high bilirubine and has risks of hypoglycaemia.
Water and sodium restriction in diet
Low protein, high carbohydrate diet
Diuretics to reduce oedema (starting with aldactone and following up potassaemia)
Zantac or omeprazole to reduce gastric acididity and risks of GIT bleeding
Haematinics because the patient has probably continuous GIT bleeding (black stool).
Vit K 2 amps OD in 100 ml infusion is recommended for 3 days to help the blood clotting system
Propranolol at 20 mg BD to reduce portal HTN and to prevent bleeding from oesophageal varices.
Senna 1 tab OD to reduce the amount of ammonium absorbed
Flagyl 200 TDS 1 week per month to reduce the amount of intestinal bacteria producing ammonium
Piriton can be given for itching of the body
We will tell the patient he will not heal he must continue with clinic the whole life
WHAT IS THE POSSIBLE CAUSE OF THIS CIRRHOSIS?
Most probably it is alcoholic, because viral hepatitis were negative, while shistosomiasis and Kala Azar are rare
SO…
We will advise patient on total abstinence from alcohol.
This will prolong his life
Dr Bro Giuseppe Gaido
Dr James Ogembo
Clinical Officers
Nursing Officers
Cottolengo Mission Hospital
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