Decompensated chronic liver disease with grade 1 hepatic encephalopathy

1. CASE PRESENTATION
Dr. Samia Farhin
Intern Doctor (Batch: TM-09)
Department Of Medicine
Tairunnessa Memorial Medical College

2. PARTICULARS OF PATIENT
Name : MD. Abul Kalam
Age : 55 years
Sex : Male
Religion: Islam
Marital Status: Married
Occupation : Farmer
Present Address : Bhola Sadar,Bhola.
Permanent Address: Bhola Sadar,Bhola.
Date Of Admission : 13/12/2016 ; at 11.00 a.m.
Date Of Examination : 13/12/2016 ; at 11.30 a.m.

3. Generalized abdominal swelling with discomfort for
2 months.
Scanty micturition with constipation for 1 month.
CHIEF COMPLAINTS

4. HISTORY OF PRESENT ILLNESS
According to the statement of
patient,he was reasonably well about 2
months back.Since then,he had been suffering
from generalized gradual abdominal swelling
which was increased progressively over last
15 days.It was associated with epigastric
discomfort with sense of heaviness.He also
complained of scanty micturition, constipation,loss
of appetite,malaise & generalized weakness for 1
month.On query,he had disordered sleep rhythm
for 15 days & loss of libido for some duration.

5. ‘CONTINUED’
He suffered from jaundice about 6 months back &
at that time,he took some herbal medications .
There was no history of haematemesis,melaena or
loss of consciousness.He didn’t give any history of
fever,shortness of breath,cough,puffiness of
face,joint pain,skin rash,or pigmentation.
Then he had admitted in this hospital for
proper management.

6. HISTORY OF PAST ILLNESS
He was nondiabetic,normotensive.He
had no history of blood transfusion,I/V drug
abuse,sharing of needles or unsafe sexual
exposure.He didn’t have any other significant
medical or surgical illness.

7. DRUG & TREATMENT HISTORY
He was taking anti viral drugs,
B- adrenoceptor blocking agents & diuretics for
about last 1 month.He hadn’t any other significant
drug or treatment history.

8. FAMILY HISTORY
His father & mother has been died
due to geriatric illness.He had no family history of
liver disease,hypertension,diabetes or any other
familial diseases.His family member was five
including his wife.All of them are alive & healthy.

9. PERSONAL HISTORY
He was non-smoker,non-alcoholic but
habituated with betel leaf & betel nut chewing for
about 20 years.

10. SOCIO-ECONOMIC HISTORY
He was a farmer.He belongs low middle
class family.

11. ALLERGIC HISTORY
He wasn’t allergic to any
specific food or aero allergen or drugs.

12. IMMUNIZATION HISTORY
He wasn’t duly immunized as per
EPI schedule.He also didn’t vaccinated by
hepatitis-B vaccine.

13. GENERAL EXAMINATION
Appearance : Ill looking; pinched face,sunken eyes,
hollowed temporal fossa,shallow & dry
face.
Body Built : Emaciated.
Nutrition : Undernourished
Decubitus : On choice
Anaemia : Mild
Jaundice : Mild
Cyanosis : Absent
Clubbing : Absent
Koilonychias: Absent
Leuconychia: Present
Oedema : Bipedal pitting oedema present

14. “CONTINUED”
Dehydration : Mild
Pigmentation : Absent
Palmer Erythema : Absent
Dupuytren’s Contracture : Absent
Flapping Tremor : Absent
Gynecomastia : Absent
Lymph Node : Not Palpable
Thyroid Gland : Not Enlarged
Body Hair Distribution : Loss of body hair
Pulse : 78 beats/min
Blood Pressure : 120/70 mmhg
Temperature : 98 °F
Respiratory Rate : 16 breaths/min
Weight : 57 kg

15. SYSTEMIC EXAMINATION
Examination Of Gastrointestinal System:
a) Examination of mouth & oropharynx :-
Lips,teeth,gum,buccal mucosa & palate
look normal.Tongue looks pale.

16. “CONTINUED”
b) Abdomen Proper :-
Inspection: ⭕ Size & shape: Distended, flanks are full.
⭕ Umbilicus : Transverse slit
⭕Visible vein : Absent
⭕Visible peristalsis: Absent
⭕ Scar mark & striae : Absent
⭕ Groin : Loss of pubic hair with negative
cough impulse.
Palpation:
Superficial : ⭕Temperature: Normal
⭕Tenderness : Absent
⭕Localized swelling: Absent
⭕Rigidity : Absent
⭕Muscle Guarding: Absent
⭕Abdominal Girth : Increased.

17. “CONTINUED”
Deep :- ⭕Liver & Spleen : not palpable.
⭕Kidneys : not ballot able
⭕Para aortic lymph node : couldn’t examine due
to ascites.
⭕Testes : both were small & soft,non-tender
⭕Hernial orifices : intact
Percussion :- ⭕ Shifting Dullness : Present
⭕Fluid thrill : Present
Auscultation :- ⭕Bowel Sound : Present

18. “CONTINUE”
Examination Of Nervous System:
A)Higher Psychic Function:
1.Appearance & Behaviour : Ill looking, anxious
2.State of Consciousness : Good
3.Orientation with time,place & person: Oriented
4.Memory : A slight tendency of
forgetfulness
5.Emotional state : Good
6.Speech & language : Normal
 B)Examination Of All Cranial Nerves:
1.Olfactory Nerve : Intact
2.Optic Nerve : Intact
3.Oculomotor Nerve : Intact
4.Trochlear Nerve : Intact
5.Trigeminal Nerve : Intact
6.Abducent Nerve : Intact
7.Facial Nerve : Intact
8.Vestibulo-cochlear Nerve : Intact
9.Glossopharyngeal nerve : Intact
10.Vagus Nerve : Intact
11.Accessory Nerve : Intact
12. Hypoglossal Nerve : Intact

19. “CONTINUE”
 C)Motor Functions:
1.Bullk of the muscle: Normal
2.Tone of the muscle: Normal
3.Power of the muscle: Normal
4.Involuntary movement (Tremor) : Absent
5.Coordination test : Coordinated
6.Gait & Posture : Normal
7.Reflexes (Superficial & Deep) : Intact
 D)Sensory Functions:
1.Sense of touch : Intact
2.Pain sensation : Intact
3.Temperature : Intact
4.Position Sense : Intact
 E)Signs Of Meningeal Irritation:
1.Neck Rigidity : Absent
2.Kernig’s Sign : Absent
3.Brudzininski’s Sign : Absent

20. “CONTINUE”
 Examination Of Cardiovascular System:
 Pulse : 78 b/min;regular;catacrotic;condition of vessel wall is normal.
 Neck Veins : JVP not Raised
 Blood Pressure : 120/70 mmhg
 Precordium:
 Inspection: ⭕ Any Chest Deformity : Absent
⭕Visible Cardiac Impulse : Absent
⭕Any Scar Mark : Absent
 Palpation:
⭕Apex Beat : Left 5th intercostal space,9 cm away from midline
⭕Thrill : Absent
⭕ Left Parasternal heave ; Absent
⭕ Palpable P2 : Absent
 Auscultation:
1st & 2nd heart sounds are audible in all auscultatory area.There
is no murmur or any other added sound.

21. “CONTINUE”
 Examination Of Respiratory System:
 Inspection:
⭕ Shape of the chest: elliptical, bilaterally symmetrical.
⭕ Movement of the chest : Regular
⭕ Respiratory Rate : 16 b/min
⭕Visible impulse,scar mark,engorged vein: absent
 Palpation:
⭕ Trachea: Central in position
⭕ Chest expansibility: Normal
⭕ Vocal fremitus : normal
⭕ Rib tenderness : Absent
 Percussion:
⭕Percussion note : Resonant
 Auscultation:
⭕ Breath sound: Vesicular
⭕Vocal resonance : Normal
⭕ Added sound : Absent

22. SALIENT FEATURES
Mr.Abul Kalam,a 55 years old
muslim,married,farmer; normotensive,nondiabetic,
non-smoker,non-alcoholic gentleman; hailing from
Bhola; presented with generalized gradual abdominal
distension for 2 months & scanty micturition with
constipation,loss of appetite, malaise, generalized
weakness for 1 month.On query, he had disordered
sleep rhythm with loss of libido for some duration.He
suffered from jaundice about 6 months back ,but had

23. “CONTINUE”
no history of blood transfusion,I/V drug abuse,needle
sharing or unsafe sexual exposure.He had no positive
family history of liver disease & not immunized by
hepatitis-B vaccine.He was taking anti-viral drugs,
B-adrenoceptor blocking agents & diuretics for about
1 month.
On examination,he was emaciated, anxious with
hepatic facies,mildly anaemic & mildly icteric.

24. “CONTINUE”
Leuconychia was present but had no flapping
tremor or palmer erythema.He was oriented in
time,place & person but had a slight tendency to
forgetfulness . His abdomen was distended
but soft,non-tender & had no visible superficial
engorged vein.There was no palpable organomegaly
but shifting dullness & fluid thrill was present.
Examination of other systems reveals no
abnormality.

25. PROVISIONAL DIAGNOSIS
??

26. PROVISIONAL DIAGNOSIS
Decompensated Chronic Liver Disease
with Grade-1 Hepatic Encephalopathy.

27. DIFFERENTIAL DIAGNOSIS
????

28. DIFFERENTIAL DIAGNOSIS
 Hepatocellular Carcinoma
 Hereditary Haemochromatosis

29. INVESTIGATIONS
NAME RESULT
1.USG of whole
Abdomen
Liver: Normal in size,irregular outline & course
echotexture.Intrahepatic biliary channels are not
dialeted,Intrahepatic vessels are poorly visualized.
Spleen: Normal in size & uniform echotexture.
COMMENT: CLD with Moderate Ascites.
2. S. Total Protein 2.40 gm/dl (normal: 6 – 8.3 gm/dl)
3.Prothrombin
Time
13.9 sec
4. INR 1.16
5. ISI (international
sensitivity index)
1.05
6.S. Bilirubin 1.40 mg/dl
7.SGPT (ALT) 218 U/L
8. SGOT (AST) 89 U/L

30. NAME RESULT
9.Upper GI Endoscopy Oesophagus: 4 column of varices seen,without any active
bleeding point.
Body & Fundus of Stomach: signs of congestive
gastropathy (Rugal folds are enlarged with snake skin like
appearance.)
IMPRESSION: - Non bleeding O.V. within grade 2-4
-Portal hypertensive
gastropathy
10. HBsAg POSITIVE
11. HBeAg Positive
12. CBC with ESR HB% : 7.9 g/dl ; ESR : 45 mm/1st hour
T. RBC Count : 4.23 m/µl
(PCV: 27% ; MCV: 64 fl; MCH: 19 pg; )
T. WBC Count : 6,000 /cumm
(Neutrophils : 55%)
Platelet count : 2,11,000 / cumm
13. S. Creatinine 1.32 mg/dl
14. S. Electrolytes S.Na+ : 128.60 mmol/l; S.Cl- : 104.0 mmol/l
S. K + : 4.08 mmol/l

31. Plan Of Investigations :
Ascitic fluid aspiration & study :
# Total albumin & protein (to calculate SAAG)
# Amylase
# Neutrophil count
# Cytology
# Microscopy & culture
 S.HBV-DNA by PCR
S.Iron Profile
S. alpha-fetoprotein
Liver Biopsy under USG control
S. Ammonia
Blood Urea
Electroencephalography (EEG)

32. CONFIRMATORY DIAGNOSIS
Decompensated Chronic Liver
Disease with Grade-1 hepatic Encephalopathy
with Grade 2-4 Oesophageal Varices.

33. TREATMENT
That Patient was referred to DMCH.
Following treatment was given when he was admitted in
our hospital-
1. Bed rest in horizontal position
2. Tab. Frusemide+Spironolactone (40/50 mg)
1+0+0
3. Tab. Teviral (0.5 mg)
0+0+1
4. Tab. Propranolol (40 mg)
1 +0+ 1
5. Syp. Lactulose
4 TSF ✖ thrice daily
6. Tab. NaCl
1+1+1
7. Cap. Multivitamin
0+0+1

34. ADVICE
 Dietary Advice:
 1. Avoid salt containing & salt retaining diets like as-
cheese,butter,tomato,peanut,pickle,olive etc.
2. Can intake fresh milk,yoghurt,eggs,legumes,chicken,
fish,fresh vegetables.
3. Drinking of water not more than 1.5 L/day.Replace tea
coffee or water with fluids that provide energy (such
as milk).
4. Stictly avoid any kind of NSAIDs,steroids & antacids.
 Advice To His spouse :
To do HBsAg screening test as soon as possible.If the result is
negative,then get immunized by hepatitis-B vaccine.
 Social Advice:
Never donate blood or share needle.All the family members
should be vaccinated by hepatitis-B vaccine.

35. FOLLOW UP
 Daily Follow Up:
 Monitor weight (wt loss
should be 0.5 to 1 kg/day)
 Abdominal girth
 Urinary output
 Bowel movement
 Orientation
 Sleep rhythm
 Flapping Tremor
 Vital signs
 Follow Up After 1
Month:
 S. Bilirubin
 S. Electrolytes
 S. Total Protein
 Prothrombin Time