Skip to main content

48M CLD HTN grade 4 esophageal varices

Thankyou chandana mam for the case report
 This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

48 year old male patient resident of chityala, auto driver by occupation came to our hospital with cheif complaints of abdominal distension since 20days,Shortness of breath since 10days, bilateral pedal edema since 15 days, blood in stools since 5 days

HOPI ,PAST AND PSYCHOSOCIAL HISTORY: 

CHILDHOOD

FATHER EXPIRED WHEN HE WAS A CHILD

DON'T KNOW THE CAUSE OF HIS DEATH

HIS MOTHER USED TO WORK AS A DAILY WAGE LABOURER .

HE WENT TO GOVERNMENT SCHOOL STUDIED UPTO 10Th

CLASS AND FAILED HIS FINAL EXAMS


ADOLESCENCE 

HE WANTED TO ACHIEVE SOMETHING IN HIS LIFE SO HE STARTED PREPARING FOR RAILWAY

EXAMS

BUT UNFORTUNATELY ON THE DAY OF EXAM HE DID NOT FIND ANY VEHICLE TO REACH THE EXAM HALL AS DURING THAT TIME EVEN PUBLIC

TRANSPORT WAS NOT PROPERLY

AVAILABLE

SO HE LOST INTEREST IN HIS

STUDIES AND STARTED WORKING AS

DAILY WAGE LABOURER



AFTER MARRIAGE

HE HAD 2 CHILDREN ,ONE BOY AND ONE GIRL. 18 YEARS AGO STARTED DRINKING ALCOHOL MAINLY DURING SUMMER

SEASON ALONG WITH HIS FRIENDS.

15YEARS AGO BROUGHT AN AUTO FOR HIMSELF AND GAVE A PARTY TO HIS FRIENDS.HE GRADUALLY INCREASED

DRINKING ALCOHOL BECAUSE OF OTHER AUTO DRIVERS BECOMING HIS FRIENDS AND MORE FREQUENT GATHERINGS (2-3times a week), LATER INCREASED TO

260ml PER DAY OF WHISKEY

AROUND 2013 INCIDENTALLY

DIAGNOSED AS HYPERTENSIVE (ON tab AMLONG AT 5/50)


HABIT TO ADDICTION 

AROUND 2015 PATIENT HAD UNROLLING OF EYES WITH TRANSIENT LOC, NO FURTHER SUCH EPISODES LATER, 2016

PATIENTS HAD DRAGGING KIND OF FEELING IN ALL HIS EXTREMITIES AND GOT ADMITTED IN A HOSPITAL. HE WAS ASKED TO GIVE UP ALCOHOL BY THE DOCTORS

HE RESISTED HIMSELF NOT TO TAKE EVEN A DROP OF ALCOHOL FOR 2YEARS.

IN 2018 IT WAS HIS DAUGHTER'S

MARRIAGE WHEN HE WAS SERVING

ALCOHOL TO THE GUESTS, HIS RELATIVES ASKED HIM TO DRINK.

HE DRANK AGAIN AND IS NOT ABLE TO GIVE UP TILL NOW


WITHDRAWAL SYMPTOMS 

HE COMPLAINED THAT IF HE DOESN'T

DRINK ALCOHOL HE IS HAVING INVOLUNTARY MOVEMENTS OF HANDS, TINGLING SENSATIONS OF HANDS AND SLEEP DISTURBANCES.

URGE FOR DRINKING+

NO CONTROL OVER THE AMOUNT OF ALCOHOL

UPON ALL THIS DUE HIS FINANCIAL ISSUES

(As he got his daughter married and couldn't make his son study after intermediate) HE DRANK MORE AND MORE ALCOHOL

HE KNOWS WHAT HARM ALCOHOL CAN DO TO HIM BUT HE COULD NOT GIVE UP.


ABDOMINAL DISTENSION 

FROM APRIL 2021 PATIENT STARTED

HAVING ABDOMINAL DISTENSION AND OCCASIONAL SHORTNESS OF BREATH.

HE VISITED LOCAL DOCTOR, NO INVESTIGATIONS WERE DONE BUT HE WAS ADVISED TO USE TAB.DYTOR

10mg Half tab OD,TAB UDCA BD AND ADVISED TO STOP ALCOHOL

BUT HE DID NOT STOP DRINKING.

FROM 2018 HE IS HAVING ON AND OFF PEDAL ODEMA AND OLIGURIA ,WHICH USED TO GET RELIEVED BY DIURETICS

ON AND OFF

1YEAR AGO HE HAD 1 EPISODE OF HEMATEMESIS (fresh blood)BUT DID NOT VISIT DOCTOR

ALTHOUGH HE HAD ON AND OFF MILD ABDOMINAL DISTENSION AND PEDAL OEDEMA FROM 2YEARS IT NEVER BOTHERED HIM,BUT SINCE 20DAYS PATIENT IS COMPLAINING OF PROGRESSIVE ABDOMINAL DISTENSION WHICH BECAME TENSE TO THE PRESENT STATE ,ASSOCIATED WITH SHORTNESS OF BREATH ONLY ON WALKING ,GRADE 2 SINCE 10DAYS,NO HISTORY OF ORTHOPNEA,PND.

C/O PEDAL OEDEMA SINCE 15DAYS ,GRADUALLY PROGRESSED UPTO KNEE,PITTING TYPE.

C/O 1EPISODE OF BLOOD IN STOOLS 5DAYS AGO,PASSED FRESH BLOOD.


NO C/O FEVER,LOOSE STOOLS,VOMITING,DIARRHOEA,COUGH,CHEST PAIN,PALPITATIONS,SYNCOPAL ATTACKS,PAIN ABDOMEN,JAUNDICE,PRURITIS,CHANGE OF URINE OR STOOL COLOUR


K/C/O HYPERTENSION SINCE 10YEARS ON Tab AMLONG AT 5/50OD





Personal history:

Mixed diet

Alcoholic since 18years

Non smoker

Regular bowel and bladder habits

Reduced appetite since 20days


FAMILY HISTORY :Mother is a known case of HTN,No other relevant family history 

Currently he is staying with his wife, mother ,son and daughter in law


Drug history:Using Tab Amlong AT 5/50,Used tab dytor and UDCA 2years ago.


ON EXAMINATION 

GENERAL Examination:


Patient is conscious, coherent and co operative

Vitals at presentation:

PR-82bpm

BP-120/80mmhg

RR-22cpm

TEMP-98.3F

Grbs-117mg/dl


On admission


Abdominal girth 102cms




Pictures taken on day 3 of admission:






No pallor ,icterus,clubbing ,Cyanosis,lymphadenopathy

Pitting type of pedal edema+

Loss of muscle mass in extremities+

No alopecia 

No gynecomastia

No spider angioma

No palmar erythema,contractures

Visible abdominal veins+

Asterixis: No

No loss of axillary hair


SYSTEMIC EXAMINATION:


PER ABDOMEN:

On admission




INSPECTION:

Shape of abdomen:Distended

Umbilicus:inverted

Skin over the abdomen is shiny

All quadrants are moving equally with respiration

No visible peristalsis, Hernial orifices intact

Visible superficial abdominal vein running vertically down is seen

External genitalia normal

PALPATION:

Temperature:Not raised

Tenderness:Absent

No Rebound tenderness 

No guarding rigidity

No hepatosplenomegaly 

Abdominal girth: 102cms

Direction of flow in left lateral abdominal vein is downwards (rapidly filling when the upper finger is released compared to when the finger below is released)



PERCUSSION

Shifting dullness +

No fluid thrill

Puddles sign -not elicited

AUSCULTATION:

Bowel sounds+

No arterial bruit. venous him


CARDIOVASCULAR:

Inspection: precordium normal,apex beat :5th ICS half inch medial to mid

clavicular line

Palpation:inspectory findings confirmed, No thrills or parasternal heave

Auscultation: S152+, no murmurs 


RESPIRATORY SYSTEM:

Inspection:

Shape of chest:Bilaterally symmetrical, Elliptical in shape

No visible chest deformities

No kyphoscoliosis,

Abdomino thoracic respiration, No irregular respiration

No tracheal shift

No dropping of shoulders, Spino scapular distance appears equal on both sides no sinuses scars engorged veins

PALPATION

Inspectory findings confirmed by Palpation

Chest movements - normal

Chest expansion-equal on both sides



TVF-Normal in all areas bilaterally

Chest circumference at the level of nipple:84cms-on inspiration:87cms

AP diameter:20cms

Transverse diameter :32cms

PERCUSSION:

Resonant note heard over all areas

AUSCULTATION:

 Norma vesicular breath sounds heard

Vocal resonance: normal in all areas


CNS:

Higher mental functions :intact

Cranial nerves intact

Motor system:Normal power,tone,Gait

Reflexes:normal

Sensory examination:Normal

No meningeal signs


Tremors : absent




CONSTRUCTIONAL APRAXIA TESTING

On the day of admission


Day 3 of admission




SURGERY REFERRAL TAKEN FOR BLOOD IN STOOLS:


On DRE:

Skin tag + in 4’O clock position

Fissure+ at 6’O clock position

Dilated veins+


On PROCTOSCOPY:

Dilated veins in 11’O clock and 3’O clock position

Multiple venous dilatations in anal canal

Bleeding on touch 


Advised for Banding and sclerotherapy


FEVER CHART:




ECG:




ECHO:



No RWMA

Mild LVH+

Minimal pericardial effusion

Good LV systolic function

Grade 1 diastolic dysfunction 

No PAH

RVSP:35mmhg

IVC :1.25cms,non collapsing 


USG abdomen:

Liver :Normal size,coarse echo texture with surface irregularity,No IHBRD

Portal vein and CBD appear normal

Spleen:15cms ,increased size,normal echo texture

Pancreas:obscured by bowel gas

Kidneys:normal size,PCS and CMD, raised echogenecity

Prostate:normal size and echotexture 

Impression:Gross ascites,splenomegaly,features suggestive of Cirrhosis of liver


 

Chest x ray:



Hemogram:

Hb :12.0

TLC: 14000cells/cumm

Platelets:2.05lakhs/cumm

Smear:Normocytic normochromic RBCs



LFT:

Total bilirubin: 1.92mg/dl by JENDRASSIC AND GROFFS Method

Direct bilirubin: 1.40mg/dl by JENDRASSIC AND GROFFS Method

SGOT:38IU/L by modified IFCC method

SGPT:12IU/L by modified IFCC method

ALP:193IU/L by PNPP-DEA method

TOTAL PROTEIN:6.5gm/dl by BIURET method

ALBUMIN: 2.25gm/dl by BCG

A/F 0.53


RFT:

Urea:32mg/dl.               UREASE-GLDH

Creatinine 1.2mg/dl.      Modified Jaffe’s

(Increased to 1.4mg/dl on day 2 of admission)

Uric acid 7.0mg/dl.        Uricase POD with DHBS

Calcium:10.1mg/dl.       Arsenazo III

Phosphorus:3.1mg/dl.   Direct UV without reduction

Sodium:141meq/lit.       Ion selective electrode

Potassium: 3.7meq/lit.   Ion selective electrode

Chloride:104meq/lit.      Ion selective electrode

CUE:

Albumin 1+ by reagent strip method

Sugar nil by reagent strip method

Pus cells 3-4 by light microscopy 

RBC nil by light microscopy 

No casts or crystals in light microscopy


PT. 18 seconds

INR 1.3


APTT. 37seconds


HIV:Negative

HBsAG:Negative

HCV:Negative


UGIE:

Showing grade 4 esophageal varices

Adviced for Endoscopic band ligation



 Ascitic fluid analysis 

1litre therapeutic ascitic tap done on day 2 of admission



Cell count 100cells(100% lymphocytes)
Cytology:Lymphocytic predominant smear with no atypical cells
Protein 1.2g/dl
Sugar 123mg/dl
Serum albumin 2.5g/dl
Ascitic albumin 0.55g/dl
SAAG 1.95
Gram stain awaited
AFB awaited
Culture awaited
Impression:HIGH SAAG,LOW PROTEIN ASCITES likely portal hypertension secondary to cirrhosis of liver

Diagnosis:
Ascites secondary to decompensated liver cirrhosis 
Due to alcoholism 
Grade 4 esophageal varices and haemorrhoids due to portal hypertension 
?Hepato renal syndrome
?Chronic LVF secondary to hypertension(HFpEF)

H2FpEF score:
BMI: <30(0 points)
On only 1 anti hypertensive (0points)
No atrial fibrillation (0 points)
RVSP:35mmhg(0 points)
Age <60years(0 points)
Filling pressure E/e’:

Impression:

Score less than 6,not suggestive of HFpEF

Reference:





Mitral valve pulse wave Doppler:showing E\A ratio:0.4(normal or mild diastolic dysfunction)

———————————————-

Portal hypertension is increased pressure within the portal venous system. A pressure gradient of 6 mmHg or more between the portal and hepatic veins (or inferior vena cava) suggests the presence of portal hypertension in most cases.When the pressure gradient is greater than 10 mmHg, portal hypertension becomes clinically significant. A pressure gradient between 5 to 9 mmHg usually reflects subclinical disease. 
Cirrhosis of the liver is the most prevalent cause of portal hypertension 

Complications of portal hypertension include:

  • Thrombocytopenia due to congestive hepatopathy
  • Abdominal wall collaterals
  • Variceal bleeding secondary to hemorrhage from gastroesophageal, anorectal, retroperitoneal, stomal, and other varices
  • Acute bleeding or iron deficiency anemia due to chronic blood loss from portal hypertensive gastropathy, enteropathy, or coagulopathy
  • Ascites
  • Spontaneous bacterial peritonitis
  • Hepatic hydrothorax
  • Hepatorenal syndrome
  • Hepatic encephalopathy
  • Hepatopulmonary syndrome
  • Portopulmonary hypertension
  • Cirrhotic cardiomyopathy


The complications seen in my patient are:
Ascites
Esophageal and anal varices
?Hepato renal syndrome
——————————————-
TREATMENT GIVEN:

Inj thiamine 200mg IV OD
T spironolactone 50mg PO OD
Syrup Lactulose 10ml PO BD
Daily abdominal girth and weight monitoring 
Fluid and salt restriction 
<1.5litres/day



Popular posts from this blog

A 30 year male presented with c/o grade 4 SOB,fever-high grade

CLD BLOGS.

A 45 yr old male came with complaints of abdominal distension ,sob and swelling in both legs since one week