2. Chief complaints
40 yrs old male patient presented to us with c/o
Jaundice-3months
High coloured urine-2months
Loss of appetite-2 months
Loss of weight (15kgs)-2 months
Blood stained vomitus -1month
Bleeding gums -1 month
Right sided abdominal pain -1month
h/o fever -1day
3. History
No h/o melena
No h/o abdominal distention
No h/o pedal oedema
No h/o oliguria
No h/o pruritis
No h/o rash
No h/o dyspnea
No h/o loose stools
No h/o cough with expectoration
No h/o altered sleep cycle
no h/o seizures/LOC
4. PAST HISTORY
No h/o blood transfusion
No h/o iv drug abuse
No h/o surgeries in past
No h/o diabetes/TB/hypertension/CADin past
No h/o recent travel
5. Personal history
Married
Chronic alcohol intake present = 180ml of brandy per
day for 10yrs
Occasional smoker
Denied history of exposure
6. Family history
Patient married
Has 2 children
Has 13 siblings
No similar complaints in family members
7. Treatment history
Patient has taken ayurvedic medication as a single
dose for his jaundice 3 months back
No h/o taking siddha,unani medications
8. General examination
Patient is concious ,oriented to time place and person
Vitals ;BP -120/80 HR – 78/MIN
TEMP -98.4
No pallor,cynosis,pedal oedema,lymphadenopathy
Icterus present
Clubbing +
Alopecia +
9. • Tatoo mark on rt arm
• Scar mark over right shoulder
• Lipoma over forehead
• Hyperpigmented patch over right popliteal
fossa
• No KF ring
• No Bitot spot
• No xanthelasma
• B/l Parotid enlargement present
• Oral cavity –normal
10. General physical exam
Fetor hepaticus absent
Gynaecomastia +
Loss of axillary hair,chest hair +
No scratch marks
No bruises/rash
No spider naevi
No palmar erythema
No dupuytrens contracture
No testicular atrophy
11. Per abdomen
Inspection –normal shape, all quadrants move equally with
respiration ,no visible veins,no scars, all hernial orifices intact
Palpation
Superficial palpation-normal ,no tenderness
Deep palpation -right hypochondrium tenderness
present,liver enlarged 8 cm below costal margin, rounded
borders,smooth surface ,firm in consistency
Liver span –17.5 cm
Spleen felt 5 cm below costal margin ,splenic notch felt
surface smooth ,firm in consistency
No other mass felt
12. Percussion- liver dulness confirmed by percussion
Traube space is resonant, shifting dulness absent
Auscultation –no bruit heard
No venous hum
No rub
13. Other systems
CVS –S1S2 heard,no murmur heard
Respiratory system – chest b/l symmetrical ,b/l air
entry is equal ,no adventitious sounds heard
CNS –patient is concious ,oriented to time place and
person
Higher functions normal
No flap or tremor seen
Trail making test – 18 sec
14. Provisional diagnosis
Chronic decompensated parenchymal liver
disease - cirrhosis with portal hypertension
probably of alcoholic etiology with no
ascites with no features of hepatic
encephalopathy and coagulopathy
To rule out malignancy
20. • The number connection chart used to
assess Hepatic encephalopathy
• The maximum score is 24
• The maximum permitted time is 30
seconds
21. • What are the synonyms of asterixis ?
• What is the mechanism of asterixis ?
22. ASTERIXIS
SYNONYM
Hepatic flap, Metabolic tremor
MECHANISM
Negative myoclonus
Impaired inflow of joint position sense to
brainstem RAS resulting in brief lapse of
posture
24. 11.Why decompensated liver
disease due to alcohol?
• Convincing history
• Parotid enlargement- a sign common in
alcoholism
• Signs of liver cell failure
• Ascites
25. Other etiology
a) Chronic viral hepatitis
b) Wilson’s disease
c) Auto-immune hepatitis
d) Haemochromatosis
32. NCPF?
• Common among lower socioeconomic
class
• Mean age of presentation 30 years
33. Symptoms of NCPF?
• Symptoms at diagnosis
GIT Bleed, 50% have multiple episodes
Mass in the abdomen
Pain abdomen
occasionally distension( ascites )
Jaundice rare
34. Signs in NCPF
• Splenomegaly is universal
• Two-thirds have massive spleen
• Mild or no ascites
• No anterior abdominal or back veins
• Liver occasionally enlarged
• No signs of liver cell failure
• Encephalopathy rare
44. Serum Ascitic Albumin Gradient
• Serum albumin- Ascitic fluid albumin
• Gives a clue about portal hydrostatic
pressure
45. SAAG
• A gradient >1.1 g/dl indicates PHT as the
probable cause of ascitis
• High gradient due to ↑Portal hydrostatic
pressure pushing the water to peritoneum
leaving albumin in the vasculature
47. Can you get exudative ascites
in portal hypertension
48. Exudative ascites in portal
hypertension
• Cardiac ascites
• Acute Budd-Chiari syndrome
The concept of exudate and transudate in
the evaluation of ascites is no longer
recommended.