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Clinical Case Presentation:

Alcoholic Liver Disease

Gaurav Jain

Roll No: 174/11

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Clinical Case Presentation:Ascites with ARF

Lakshmi Narayan, 42 years old patient , who is a chronic alcoholic, farmer by occupation presented with:• Abdominal distension from 15 days • Abdominal pain from 15 days• Decreased urine output from 10 days• Decreased passage of stools from 10 days• Fever from 15 days

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HISTORY

H/O Present illness:HDBT 15 days when patient developed:

insidious, gradually progressive Abdominal distension a/w pin-prickingpain in the epigastrium & right hypochondrium region , relieved bymedication.

Intermittent, mild to moderate grade fever, insidious onset & subsides onmedication a/w nausea ,retching, cachexia, altered sleep patterns withday-time sleepiness.

Pt. developed decrease in urine output without burning or otherdiscomfort from past 10 days.

Pt. developed decreases stool passage ,insidious onset and graduallyprogressive, not a/w flatulence, dyspepsia, heart burn from 10 days.

A single episode of haemetemesis containing 30 ml of fresh blood.

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Negative History: No H/O chills, rigor, sweating,headache,retrobulbar pain, cough, joint pain, steatorrhea, malena, facialpuffiness, xanthelasma, xanthomata, flapping tremors, bloodtransfusion.

Past History: No H/O TB, Diabetes, Asthma, Hypertension. Nosuch complaint in the past.

Personal History: Married with two children• Non vegeterian diet.• Smoking-15 pack years but one bundle daily from past 2 months.• Chronic alcoholic from past 30 years consuming 4.5-5.6 units of

alcohol daily. Tobacco chewing from past 12 years.• Lost 15 kgs of weight in past 2 months.

Family History: No such family history.

Drug History: No significant history.

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EXAMINATIONGeneral Physical ExaminationPatient is conscious, oriented to time,place and person and cooperative.No pallor, icterus, cyanosis, clubbing, JVP and lymphadenopathy.Pedal edema present.

No gynaecomasatia, skin pigmentation , palmar erythema, spider nevi,leuconychia, koilonychia, angular stomatitis present.Axillary ,pubic hair decreased. Mild Glossitis present

PR- 86/min RR-20/min BP-96/60mmHg

Abdominal Girth: 114.3 cmUmblico-ischial spine distance: 19.05 cmUmblico-Symphysis distance: 21.59 cm

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Abdominal Examination Inspection: globular shape stomach with

full flanks and everted umblicus. There isa single scar present on the right lateralside. Tense and tendor. Engorged veinsseen.(downward to upward bloodflow).

Palpation: afebrile .Liver not palpable.Spleen palpable by Dipping method butsize cant be established. Fluid thrillpresent.

Percussion: Shifting Dullness present.

Auscultation: Bowel sounds heard andBruits not heard.

Other systemic findings were normal.

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INVESTIGATIONSBlood Urea 123mg/dl

S. Creatinine 3.3mg/dl

S. Uric Acid 9.9mg/dl

SGOT 80U/L

SGPT 32U/L

S. Alkaline

Phosphatase

120U/L

S. Protein 6.1g/dl

A/G Ratio 0.7

S. Bilirubin 1.5

TLC 11700/cumm

DLC N 87- L 10- E 1- M

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Hb 7.5gm

APC 4.5 lacs

PT/INR

Prothrombin time 18.3sec

Control 11sec

Ratio 1.05

INR 2.5

Inference-Coagulopathy

HIV, Hep B, Hep C-negative

Ascitic Fluid

Cytology

No malignant cell

seen

TLC 200/CUMM

DLC N 20%: L 80%

Fluid Protein 1.5 g/dl

SAAG 2.2 g/dl

ADA 8.58U/L

Inference: Transudative picture:

tubercular ascites ruled out.

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Free fluid +++

Liver measures 13.5 cm with slightly altered in echotexture.

Gall Bladder is thickwall & oedematous but lumen is echofree.

Portal vein diameter is 13mm.Splenic vein diameter is 5.0mm

Spleen measures 16.2cm with normal echotexture.

Pancrease ,Kidneys, Bladder , Prostate normal in size &

shape.

Impression- Cirrhosis with Ascitis

S. Triglyceride 104mg/dl

S. Cholesterol 116mg/dl

S. VLDL 21mg/dl

SODIUM 121.7 meq/l

POTASSIUM 3.6 meq/l

Complete Urine Examination: Within normal limits.

Ultrasonography

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Differential Diagnosis: Based on clinical, lab & USG findings, patient is suffering from Chronic Liver

Disease showing complications of Ascites and Portal Hypertension withDerangement of KFT cause of which can be 1) Hepato-Renal Syndrome2) Pre –Renal Azotemia

High SAAG in the case indicates presence of Portal Hypertension.

Low Ascitic Protein (1.5g/dl) indicates Transudative Ascites.

Based on patients alcoholic history & lab findings,Cirrhosis is the cause ofAscitis and Portal Hypertension.

Complete Urine Analysis within normal limit shows that Chronic KidneyDisease is not the cause of acute renal failure.

Hereditary causes of Cirrhosis are ruled out based on family history whilepatient gives no history of skin pigmentation,xanthoma and jaundicewhich rules out Biliary Cirrhosis.

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Alcohol Liver Disease

Chronic alcohol ingestion is one of the major causes of liver disease.

It causes 3 major lesions: a)fatty liver b)alcoholic hepatitis c)cirrhosis

Quantity and Duration of alcohol intake are the major risk factors.160g/dfor 10-20 years in man produces cirrhosis.

Hepatic metabolism of alcohol initiates a process that promotes lipogenesis& the inhibition of fatty-acid oxidation. Endotoxins, oxidative stress,immunologic activity, and pro-inflammatory cytokine release contribute tothe resulting liver injury.

Alcoholic fatty liver and hepatitis is reversible with alcohol abstention butcirrhosis is not.

Diagnosis is based on AST, ALT, GGTP, Bilirubin and USG findings.

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A discriminant function can determine patients with poor prognosis.(>32)

The presence of ascites, variceal hemorrhage, deep encephalopathy, orhepatorenal syndrome predicts a dismal prognosis.

Management

Lifestyle modifications: decreased alcohol intake, smoking obesity

Appropriate nutrition/nutritional support

Use of pentoxifylline or prednisone for alcohol hepatitis

Advice on complementary & alternative medicine for cirrhosis(egsilymarin)

Transplantation in selected abstinent patients with severe disease.

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Thank You