Case report

A male patient presents to the hospital with dyspnoea, generalized oedema of the body involving above all the abdomen. Generally he looks wasted with very thin face.

HISTORY TAKING 

The client says that the oedema has developed in the last 2 months, when he has started feeling fulness 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 the teeth, the gums are bleeding for long time. Sometimes his stool is black and loose. The patient experiences frequent epigastric burning pains, above all when fasting. When far from meals often complains of diziness, loss of eye vision, feeling to faint. He is a heavy drinker: taking local beer and superalcoholics, like whisky, rum and others. He smoks cigarettes and uses miraa

EXAMINATION 

Abdominal distension. Liver very difficult to palpate because of abdominal 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 positive Massive oedema of scrotum and penis Mild oedema of the lower limbs 

RESPIRATORY/SYSTEM: absence of vescicular breathing at the Rt Chest. Left Chest normal but mouvements of the left basis is reduced. CARDIOVASCULAR SYSTEM: HS1 and HS2 normal. No gallop rhythm, no murmurs. BP= 90/50. Jugular veins not enlarged. Hepato-jugular reflex negative. Very Pale 

OUR DIFFERENTIAL DIAGNOSIS Liver cirrhosis CCF (CONGESTIVE CARDIAC FAILURE) Kidney failure Malnutrition 

OUR 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 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 hypertension. Kidneys were normal. 

Diagnostic paracentesis showed clear fluid Full Hemogram, on top of anaemia, has indicated leucopenia and piatrinopenia Occult blood in stool has been positive for conceiled bleeding Our diagnosis has been of liver cyrrhosis, possibly secondary to alcool consumption. 

MANAGEMENT 

We have checked blood group and we have done cross matching; then we have transfused: transfusion will help for anaemia and will increase the concentration of albumin in plasma, allowing a better chance of success for paracentesis. Actually we do not have albumin in our hospital. We have done a paracentesis of 2000 ml because the patient was dyspnoeic. We started the infusion of 500 ml OD of 10% Dextrose because patient has very high bilirubine and has risks of hypoglycaemia. We have prescribed water and sodium restriction; low protein, high carbohydrate diet. We have put the patient on diuretics to reduce oedema (starting with aldactone and following up K levels) We have prescribed omeprazole 20 mg OD to reduce gastric acididity and risks of GIT bleeding. Other treatments were haematinics because the patient has probably continuous GIT bleeding (black stool). Then Vit K 10 mg OD for 3 days to help the blood clotting system As we always do we have put the patient on propranolol at 20 mg BD to reduce portal hypertension and to prevent bleeding from oesophageal varices. We have given lactulose 10 ml three times a day, to reduce the amount of ammonium absorbed Flagyl 200 TDS 1 week per month to reduce the amount of intestinal bacteria producing ammonium 

Br Dr Beppe Gaido