Ascites due to dcld, ascites in liver...

1. CLINICAL CASE
PRESENTATION
DEPARTMENT OF MEDICINE
PRESENTED BY- DR.BIJAYALAXMI SWAIN
GUIDED BY-DR.VIVEK VARDHAN

2. PATIENT PARTICULARS
• Name- Kabiraj Bisoi
• Age/Sex-50 Years/Male
• Address- Khurdha ,Odisha
• Occupation- Farmer
• Religion- Hindu
• Marital Status-Married

3. CHIEF COMPLAINTS
• Abdominal distension since 2 months
• B/l lower limb swelling since 2 months

4. HISTORY OF PRESENT ILLNESS
• The patient was apparently alright 2 months back. To start with, he
developed abdominal distension which is insidious in onset, gradually
progressed to flanks full , associated with diffuse abdominal pain.
• Later he developed b/l lower limb swelling since 2 months back which
is gradually progressive, not associated with pain, no redness or
discharge.
• No history of fever, vomiting, cough ,pruritus, dyspnea
,orthopnea,hematemesis or malena, facial puffiness ,burning
micturition, loose stools.

5. PAST HISTORY
• No similar episode in the past
• No h/o hypertension, diabetes mellitus, asthma, tuberculosis, thyroid
disorder, kidney disease.
• No surgical history in the past.

6. PERSONAL HISTORY
• Normal sleep pattern.
• Normal bowel and bladder habits.
• The patient is on mixed Indian diet.
• No h/o addictions.
• Appetite is decreased.
• No h/o of allergies.

7. FAMILY HISTORY
• There is no similar history in the family.
SOCIAL HISTORY
• According to Modified Kuppuswamy scale, he belongs to lower class
family.

8. PHYSICAL EXAMINATION
• The patient was examined in a well lit ,well ventilated room, with
proper consent taken.
• Height- 165cm
• Weight-56 kg
• BMI- 20.6
• Moderately built, well nourished.

9. HEAD TO TOE EXAMINATION
• Hair is dry,
• No parotid enlargement,no gynaecomastia, no scrotal swelling, no
palmar erythema.

10. VITALS
• PULSE- 82 bpm,regular, good volume,normal character,no radio-radial
delay, no radio-femoral delay, arterial wall just palpable, all peripheral
pulses well felt.
• BP- 118/84 mm of Hg in right arm supine position
• RR- 16 cycles/min, thoraco-abdominal
• TEMPERATURE- 97.2 F
• SpO2- 98% on room air

11. GENERAL EXAMINATION
• Pallor absent
• Icterus present
• Cyanosis absent
• Clubbing absent
• Lymphadenopathy absent
• Edema present
• Thyromegaly absent
• JVP not raised

12. SYSTEMIC EXAMINATION- GI SYSTEM
• INSPECTION-
 UPPER GIT- good oral hygiene, normal gum and oral mucosa, no fetor
hepaticus
LOWER GIT-
 Shape of abdomen- appears to be distended
 Distance of xiphi stemi to umbilicus> umbilicus to pubic symphysis
 All quadrants move equally with respiration
 Umbilicus is central ,everted , no discharge
 Skin over the abdomen is healthy and shiny.
 No dilated veins, no spider naevi, no caput medusae.
 No scar marks, no mass, no visible pulsation or peristalsis.

13. • SUPERFICIAL PALPATION-
All inspection findings confirmed
Abdomen is soft, non tender
No local rise of temperature
 No guarding, no rigidity
No palpable mass felt
Abdomen circumference at umbilicus-80 cm

14. • DEEP PALPATION-
Fluid thrill absent
Liver- palpable but not enlarged
Spleen- enlarged
Kidney-not ballotable
All hernial orifices intact

15. • PERCUSSION-
 Shifting dullness present
• AUSCULTATION-
bowel sounds present
No hepatic rub, no bruit

16. • CVS EXAMINATION-
S1,S2 heard with no murmurs
• RESPIRATORY EXAMINATION-
 B/L normal vesicular breath sounds heard with no added sounds.
• CNS EXAMINATION-
 conscious ,oriented to time, place and person.

17. SUMMARY
• A 50 year old male presented with complaints of abdominal
distension and b/l lower limb swelling since 2 months. On
examination, icterus and b/l pitting edema were present, shifting
dullness was present and the spleen was enlarged.

18. DIAGNOSES
• Provisional diagnosis-
Decompensated chronic liver disease( DCLD) with ascites
• Differential diagnosis-
budd chiari syndrome
nephrotic syndrome

19. INVESTIGATIONS
• CBC
Hb-13.6
PCV-41.7
TLC-10.24
TPC-372
• RFT
Urea-28
Creatinine-1.09
• HHH
HBs-Ag= 4730

20. • LFT-
T.Bilirubin-0.54
direct bilirubin-0.23
SGOT-155.3
SGPT-150.1
ALP-201
Albumin-1.36
Globulin-3.13
PT-INR-1.08

21. • USG ABDOMEN- CLD, splenomegaly, moderate ascites, mild omental
thickening
• ASCITIC FLUID CYTOLOGY- T.Cell count= 67cells/cu mm; mesothelial
cells= 55%; lymphocytes=30%; polymorphs=15%
• ASCITIC FLUID PROTEIN- T.Protein=0.3gm/dl ,Albumin =0.2gm/dl
• SAAG- 1.36- 0.2=1.16 gm/dl
• UGIE- s/o Grade II esophageal varices

22. FINAL DIAGNOSIS
• Decompensated chronic liver disease secondary to Hepatitis B with
ascites.

23. TREATMENT
• Fluid restriction (1L/day)
• Therapeutic LVP
• Inj TAXIM 1gm IV TDS
• Inj PAN 40 IV OD B/BF
• Inj H.ALBUCEL 20% 100 ml SLOW IV
• Tab RIFAGUT 550mg BD
• Tab HEPAMERZ 1 TAB OD
• Syp. LACTULOSE 30ml OD
• Inj. ONDEM 8mg IV SOS

24. THANK YOU