31 year male with abdominal distention

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*PAST ADMISSION*

PRESENTING COMPLAINTS:

C/O Abdominal distention since 20 days; SOB since 6 days; decreased food intake and altered sleep cycle since 5 days.

HOPI:

A 31 year male presented to the opd with complaints of abdominal distention, gradually increased in size associated with shortness of breath of Grade II-III; History of ocassional low grade intermittent fever not associated with chills and rigors. History of decreased urine output since a day. History of black coloured stools since a day. Now admitted for further treatment and management.

PAST ILLNESS:

A 31 year male had complaints of fever and vomiting 3 months ago, for which he sought for consultation and diagnosed to be having liver disease and jaundice. After 15 days of treatment, the clinical manifestations were resolved. He started drinking 360ml of alcohol per day, after resolution of symtoms for a month. Then he had symtoms of abdominal distention, pedal edema and yellowish discolouration of eye for which he used herbal medication; the symtoms resolved in a week. He again started drinking alcohol and toddy along with herbal medication, he stopped alcohol for 2 days, because of lack of money, he had symtoms like aggitation, irritability and visual hallucinations; resolved after having alcohol. 2 days ago he had similar hallucinatory symtoms. His last binge was on 24/07/2022.

PERSONAL HISTORY:

Smoker since 10 years; initially he used to smoking 3-5 Cigarettes per day which has been increased to 10 Cigarettes per day; during treatment he used to smoking 2 -3 Cigarettes per day.

Alcoholic since 10 years; initially 160ml per day for 3 years which was increased to 240 -360ml per day depending upon the availability of money.

From past 5 months he stopped going to work due to health issue and dependent upon his wife.

He was beaten up by someone in the Left chest for which he was having pain; drinks alcohol to reduce that pain.

GENERAL EXAMINATION:

Patient was conscious and coherent.

Afebrile.

PR: 98bpm; BP: 118/76mmHg; RR: 22cpm; SpO2: 98%@RA; GRBS: 96 mg/dl.

CVS: S1,S2+, No murmurs; R/S: BAE+, Clear; P/A: Soft, distended, non-tender; CNS: NFND.

COURSE IN THE HOSPITAL:

A 25 year make presented with above mentioned complaints. After initial examination, necessary investigatioms were done. Upon admission he was started on salt restricted diet and kept on fluid restriction. USG Abdomen was done which showed Hepatic parenchymal disease with irregular margins, Moderate Ascites and Right minimal pleural effusion; Rt kidney 9.2×4cm and Lt kidney 9.4×3.8cm; liver 15cms, portal vein 10mm, spleen 9 cms. 2D ECHO showed NO RWMA, Minimal Pericardial effusion , IVC size 0.7cms collapsing, EF 62%, RVSP 45mmHg, Mild TR with PAH, Mild AR/PR, No MR/AS/MS, Good LV Systolic function and NO Diastolic dysfunction. Ascitic tap was done under aseptic conditions and samples were sent for analysis. He was started on IV Diuretic, vit K, Thiamine and lactulose syrup. Patient had tremors, apraxia charting was done. His platelet on day 1 were 86000 decreased to 52000 on day 2. Upon examination on day 2, he was hemodynamically stable, no postural drop and bleeding manifestations; His blood group was O+; Ascitic fluid : protein 0.4mg/dl, sugar 96mg/dl, LDH 112 IU/L; Serum LDH 459 IU/L; Serum albumin 2.12 gr/dl, Ascitic albumin 0.17 gr/dl with SAAG 1.42. Normal Thyroid profile, Lipid profile, Serum Lipase and amylase. Ascitic fluid for AFB was negative.

Psychiatry consultation was done I/v/o alcohol dependence and advice followed. The patient and his attendee are not willing for any psychiatrist medications as of now.

He was kept on NBM for Upper GI endoscopy. Which showed:-

Esophagus: Grade II varices >1 column and Grade I varices of 1 coulmn with small hiatus hernia; Stomach : severe portal hypertensive Gastropathy; no blood seen; Duodenum : normal with impression of large esophagiela varices.

Patient has been shifted to Male medical ward and handedover to the ward team as his symptoms were improved. His serum K+ was 2.9, for which k+ correction was done. He was started on PPI and beta blocker.

ECG:

CHEST X RAY PA VIEW:

INVESTIGATION CHART:

FEVER CHART:

Ascitic fluid study/ Thyroid and Lipid profile/ Sr. Amylase and Lipase

APRAXIA CHART:-

TREATMENT:

1. FLUID RESTRICTION.

2. SALT RESTRICTED NORMAL DIET.

3. INJ. CEFOTAXIM 2 GRAM TWICE DAILY INTRAVENOUSLY.

4. INJ. VIT K 1 AMP IN 100 ML NS ONCE DAILY INTRAVENOUSLY.

5. INJ. THIAMINE 1 AMP IN 100 ML NS ONCE DAILY INTRAVENOUSLY.

6. INJ. PAN 40 MG TWICE DAILY INTRAVENOUSLY.

7. INJ. ZOFER 4 MG THRICE DAILY INTRAVENOUSLY.

8. TAB. PCM 650 mg SOS (<1 GRAM / DAY).

9. SYP. LACTULOSE 15 ML 30 MINUTES BEFORE FOOD THRICE DAILY.

*PRESENT ADMISSION*

Discharged on Aug 10th; He used medication for 5 days and stopped them for drinking alcohol. On 17th Aug he consumed Alcohol and he ate more chocolates from the time of discharge.

Now presented to the casuality with complaints of :

SOB since 10 days.

Abdominal distention since 10 days.

Fever spike 2 days ago.

HOPI:

A 31 year male who was discharged after recovery and asked to follow up in gastroenterology OPD presented to the casuality with complaints of SOB of Grade III NYHA; which was more on sitting/standing position, releived on supine position and Abdominal distension since 10 days. No history of chest pain/ PND/ Orthopnea. Now admitted for management .

ECG at Presentation:

Chest x ray PA VIEW:

INVESTIGATION CHART:

FEVER CHART:

COURSE IN THE HOSPITAL:

A 31 year male presented to the casuality with above mentioned complaints. Initial evaluation and workup was done. Diagnostic and Therapeutic ascitic tapping(2 liters) was done under asceptic conditions and samples were sent for study. His saturations below 90%@RA, he was on oxygenation @4 lit /min to maintain his 02 saturations at 98%@RA. Upon admission his TLC was 11700 ;Hb 10.1; TB 4.75; DB 2.11 and raised liver enzymes; CUE showed +1 Albumin. He was started on K+ sparing and thiazide diuretics and other liver supplementary medications. He was advised to be on salt and fluid restriction. Abdominal girth was 90cms; asterixes present. On day 2 Propranolol was added and syrup lactulose was started.

Ascitic fluid analysis:

Cell count 50cells/mm³ with 100% lymphocytes.

Sugars : 166mg/dl

Protein: 2.1g/dl

Amylase: 20.8 IU/L

LDH: 150 IU/L

Albumin: 2.01gm/dl

Serum albumin was 0.22gm/dl

SAAG 1.79.

His serum K+ was 2.8, k+ correction was done with 2 ampules in 200ml NS over 6 hours. On day 3 , he had complaints of fever spikes and abdominal distention associated with SOB; IV Antibiotic was added even thought his ascitic fluid counts were low.

USG ABDOMEN was done on 23/08/2022 which showed e/o :

Liver 12.1cms with altered echotexture and surface irregularities and having normal hepatoportals flow - S/O Chronic liver disease. Contracted gall bladder; spleen of 10?6cmswith normal size and echotexture; Rt kidney of 10.2×4.1cma and Lt kidney of 8.5×4.5 CNS with normal size and echotexture with CMD maintained and PCS normal; Gross ascites at perihepatic, perispleenic and pelvic spaces.

2D ECHO was done on 23/08/2022 which showed:

Trivial TR; No MR/AR; No RWMA; No MS/AS/PAH; EF 66%; Minimal pericardial effusion; IVC 1.3 cms; RVSP 35mmHg; Good LV Systolic function; No Diastolic dysfunction.

On day 3, 500ml of ascitic fluid was removed. He was advised to include protein in diet. Ascitic fluid gram stain and ZN stain was negative.