30year old male with ascites

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 30year old male alcoholic since 5years daily 180ml whiskey, occasional toddy

Patient was apparently asymptomatic 1year ago developed Yellowish discoloration of eyes 1year ago(bilirubin was 9mg/dl),not associated with any abdominal distension,used herbal medication,jaundice subsided.

stopped alcohol for 3months after that.

He was fine and he again started taking toddy daily .3months later he again developed yellowish discoloration of eyes (TB was 20mg/dl 6 months ago)

Last intake of alcohol 3months ago

Since 1 week Patient is c/o B/L pedal edema gradually progressed upto knees 

Abdominal distension since 1 week

Yellow discoloration of eyes and urine since 1 week

Dry cough since 6days

shortness of breath since 5days

High grade fever since 2-3days ,not associated with chills and rigors, intermittent

loss of appetite,easy fatiguability since 3days

No h/o facial puffiness,burning micturation,vomitings,loose stools,hematemesis,malena

bowel and bladder habits regular


not a k c o DM,HTN,CAD,CVA,TB


O/E 

Pallor +

Icterus +

Pedal edema pitting present

Jvp not elevated

No lymphadenopathy

Bp 100/60mmhg

PR 150/min ,regular

                         Icterus

 Abdominal distension,ecchymosis at the site of ascitic tap



                    DILATED ABDOMINAL VEIN

               Pedal edema


ASTEREXIS absent


No palmar erythema,echymosis at the site of cannula


No spider navei
No parotid swelling
No loss of axillary hair
No testicular atrophy
No dupytrenes contractures

Flow of blood away from umbilicus above the level of umbilicus


No distension of abdominal veins below the level of umbilicus

Constructional Apraxia testing




SYSTEMIC Examination
Cvs s1s2+,no murmurs
Rs BAE+, decreased BS B/L IAA,ISA
P/A:shifting dullness+,no organomegaly,fluid thrill absent

Ecg



Before pleural tap


After pleural tap








Diagnosis

Spontaneous bacterial peritonitis

Chronic liver disease secondary to ?Alcohol

Hepatic encephalopathy

Hepatic coagulopathy

Severe Hypoalbuminemia

High SAAG ascites

B/L pleural effusion (Hemorrahgic)

Dyselectrolytemia(hyponatremia,hypokalemia)

Microcytic hypochromic anemia


Treatment

Inj cefotaxim 1gm IV TID

Syrup lactulose 10ml TiD

Syrup potchlor 10ml BD

Protein X powder 0.5gm/kg /day

Tab aldactone 50mg BD

Fluid restriction

Salt restriction

Tab methylcobalamine 50microgrms od

Inj thiamine 100mg in 100ml NS IV OD


DAY 2


2FFPs were transfused
1 unit PRBC transfused


Day 3

SOB subsided,pedal edema decreased, appetite improved
Fever spikes +
Passed 4 stools since yesterday




DAY 3

30 year old male with spontaneous bacterial peritonitis ,chronic decompensated liver disease secondary to alcohol,cirrohsis with portal hypertension,with dyselectrolytemia(hyponatremia,hypokalemia),hepatic encephalopathy grade 1,hepatic coagulopathy,dimorphic anemia, thrombocytopenia

CTP class C

Meld score 20points

B/L pleural effusion(exudative)


C/O high grade fever

Passed stools 2 times since morning

SOB subsided


O/E pt c/c 

Bp 110/50

Spo2 88%on RA ,99% on 4lit oxygen

PR 134bpm

Cvs s1s2+

RS BAE+,decreased BS B/L IAA

P/A distended

Soft ,NT

AG 74cms(76 at admission)


Today:

Hb 6.6(not improved after 1prbc transfusion)

TLC 11,650

Platelets 90,000cells/cumm

His total bilirubin has increased from 10.8 to 18

INR reduced from 3.35 to 1.25,APTT reduced from >1min to 35secs (2FFP transfusions done)






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