Case report

A male patient presents to the Cottolengo Mission Hospital for dyspnoea, generalized oedema of the body involving more the abdomen. Generally he looks wasted with very thin face.

HISTORY TAKING

Pt 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 edematous.

He needs to sleep with 2 pillows because of orthopnoea.

When he brushes teeth, gums bleed for long time. Sometimes stool is black and loose. He complains of 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 alcoholics, like whisky, rum and others.

He smocks cigarettes and uses miraa.

PHYSICAL 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 either sides.

Auscultation: intestinal sounds present.

Fluid thrill present.

Massive oedema of scrotum and penis.

Mild oedema lower limbs.

Respiratory system: absence of vesicular breathing at the Right side of the chest. Left side of the chest normal but mouvements of the left basis reduced.

Cardiovascular system: heart sounds normal. No gallop rhythm, no murmurs. Blood Pressure= 90/50.

Jugular veins not enlarged. Hepato-jugular reflex negative.

Presence of moderate pallor.

  

INVESTIGATIONS

HB= 6.5 g/dl

Bl sugar= 56 mg/dl

Urinalysis: proteins absent, bilirubine +++, no cylinders in the sediment.

Creatinine= 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 negative

ECG was normal

Abdominal ultrasound 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 (1.6 cm). 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.

Full Haemogram has demonstrated leucopenia and piatrinopenia.

Occult blood in stool was positive. Gastroscopy has demonstrated big oesophageal varices with recent signs of bleeding. Our diagnosis has been of liver cirrhosis, possibly of alcoholic etiology.

MANAGEMENT

We have checked blood group and transfused him: transfusion will help for anaemia and will increase the concentration of albumin in plasma, allowing a better chance of success for paracentesis and diuretics.

We have also performed a paracentesis of 2000 ml because patient was dyspnoeic. We have then instituted an infusion of 500 ml daily of 10% Dextrose, because the patient has very high bilirubine and has risks of hypoglycaemia.

We have prescribed water and sodium restriction, together with low protein and high carbohydrate diet.

We have put the patient on diuretics to reduce oedema (starting with aldactone and following up electrolytes).

We have also given omeprazole at 20 mg once daily, to reduce gastric acidity and risks of further gastrointestinal bleeding. We have also prescribed haematinics because the patient has probably continuous occult bleeding (black stool), leading to iron deficiency anemia.

Vit K 2 ampoules once daily in 100 ml infusion is then our recommendation for 3 days, to help the blood clotting system.

We use propranolol at 20 mg twice daily, to reduce portal hypertension, and to prevent further bleeding from oesophageal varices.

We also advise the use of lactulose, to reduce the amount of ammonium absorbed, and to postpone the risk of porto-systemic encephalopathy.

Then we prescribe metronidazole 200 mg, three times a day, for 1 week each month, to reduce the amount of intestinal bacteria producing ammonium. Antihistamines can be given for itching of the body.

Advising patient on total abstinence from alcohol is as important as all the treatments we have listed above and will prolong his life.

Br Dr Beppe Gaido