A 49YR OLD FEMALE PT.WITH ITCHING ALL OVER BODY

Diagnosis

CHRONIC LIVER DISEASE SECONDARY TO AUTOIMMUNE TOXIN INDUCED

Case History and Clinical Findings

PATIENT CAME WITH C/O ITCHING ALLOVER THE BODY SINCE 2 YRS YELLOWISH

DISCOLOURATION OF EYES SINCE 2YRS

 ABDOMINAL DISTENTION SINCE 3 DAYS

HOPI:

PATIENT IS APPARENTLY ASYMPTOMATIC 2 YRS AGO THEN SHE DEVOLOPED FEVER

,INSIDIOUS ONSET ,GRADUALLY PROGRESSIVE ASSOCIATED WITH YELLOWISH

DISCOLORATION ,SINCE THEN PATIENT HAS H/O SIMILAR EPISODES ONCE IN EVERY 5-6

MONTHS AND TREATED WITH HERBAL MEDICATION BY QUAKES ,SINCE 2 YRS FOR A

PEROID OF 10-15 DAYS IN EACH EPISODE

H/O ITCHING ALL OVER THE BODY SINCE 2 YRS ,MOREIN NIGHTS ,NO AGGREVATING OR

RELEIVING FACTORS

H/O ABDOMINALDISTENTION SINCE 3 DAYS IMMEDIATELY AFTER FOOD INTAKE AND

RELEIVING WITH MEDICATION ASSOCIATED WITH BELCHING +

NO H/O COUGH,COLD ,BREATHLESSNESS ,ORTHOPNEA,PND

NO H/O ABDOMINALPAIN,PALPITATIONS , CHEST PAIN ,BURNING MICTURITION ,NAUSEA

,VOMITING

NO H/O DM,HTN,ASTHMA ,TB,EPILEPSY ,CAD,CKD,CLD

NO H/O CVA

GENERAL EXAMINATION :

PT IS CONCIOUS , COHERENT AND COOPERATIVE , MODERATLY BUILT AND NOURISHED .

NO PALLOR, ICTERUS , CYANOSIS, CLUBBING ,LYMPHADENOPATHY, EDEMA

TEMP - AFEBRILE

PR- 76BPM

RR-17CPM

BP- 130/70MMHG

GRBS - 157MG/DL

SYSTEMIC EXAMINATION :

CVS - S1,S2 HEARD , NO MURMURS

RS - VESICULAR BREATH SOUNDS HEARD , NO WHEEZE AND DYSPNEA, CREPTS IN RAA,

ISA

P/A- SOFT , NON-TENDER , NO ORGANOMEGALY

CNS - NFND

COURSE IN HOSPITAL:

PATIENT WAS ADMITTED I/V/OITCHING ALLOVER THE BODY SINCE 2 YRS ,YELLOWISH

DISCOLOURATION OF EYES SINCE 2YRS ,ABDOMINAL DISTENTION SINCE 3 DAYS ,AND

WAS INVESTIGATED FURTHER AND ON EVALUTION WAS DIAGNOSED AS CHRONIC LIVER

DISEASE ,? BUDD CHIARI SYNDROME,? NASH .PATIENT WAS MANAGED CONSERVATIVELY.

ON EVALUVATION LFT SHOWED Total Bilurubin 8.11 GM/DL,Direct Bilurubin 5.48 mg/dl,

SGOT(AST) 400 IU/L ,SGPT(ALT) 184 IU/L ,ALKALINE PHOSPHATASE 276 IU/L,TOTAL

PROTEINS 7.3 gm/dl, ALBUMIN 3.2 gm/dl,A/G RATIO 0.78. USG SHOWED COARSE

ECHOTEXTURE AND SURFACE NODULARITY OF LIVER-C/O CHRONIC LIVER DISEASE POOR

VISUVALISATION OF LEFT HEPATIC VEIN AND NARROWED INTRAHEPATIC IVC- BUDD CHARI

SYNDROME TO BE EXCLUDED, BORDERLINE SPLENOMEGALY (12CM), MILD ASCITIS,

MESENTRIC COLLATERALS- S/O PORTAL HYPERTENSION, NORMAL SIZE (9MM) AND

DISECTION OF FLOW IN PORTAL VEIN, E/O 46X30MM CYST NOTED IN MIDPOLE OF RIGHT

KIDNEY. PLANNED CECT IMPRESSION SHOWED CHRONIC LIVER DISEASE, MILD

SPLENOMEGALY, ASCITIS, PARTIALLY RECANALISED UMBILICAL VEIN AND MESENTERIC

COLLATERALS. GASTRO OPINION TAKEN ON 19/3/24, ADVICE FOLLOWED.

Investigation

LIVER FUNCTION TEST (LFT) 15-03-2024 04:39:PM

Total Bilurubin 8.11 mg/dl 1-0 mg/dl

Direct Bilurubin 5.48 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 400 IU/L 31-0 IU/L

SGPT(ALT) 184 IU/L 34-0 IU/L

ALKALINE PHOSPHATASE 276 IU/L 98-42 IU/L

TOTAL PROTEINS 7.3 gm/dl 8.3-6.4 gm/dl

ALBUMIN 3.2 gm/dl 5.2-3.5 gm/dl

A/G RATIO 0.78

RFT 15-03-2024 04:39:PM

UREA 14 mg/dl 42-12 mg/dl

CREATININE 0.8 mg/dl 1.1-0.6 mg/dl

URIC ACID 2.7 mmol/L 6-2.6 mmol/L

CALCIUM 9.8 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 3.5 mg/dl 4.5-2.5 mg/dl

SODIUM 140 mmol/L 145-136 mmol/L

POTASSIUM 3.2 mmol/L. 5.1-3.5 mmol/L.

CHLORIDE 102 mmol/L 98-107 mmol/L

HBsAg-RAPID 15-03-2024 08:08:PM Negative

Anti HCV Antibodies - RAPID 15-03-2024 08:08:PM Non Reactive

COMPLETE URINE EXAMINATION (CUE) 15-03-2024 08:35:PM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN Nil

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 2-3

EPITHELIAL CELLS 2-3

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

BLOOD UREA 17-03-2024 10:19:PM 18 mg/dl 42-12 mg/dl

SERUM CREATININE 17-03-2024 10:19:PM 0.7 mg/dl 1.1-0.6 mg/dl

LIVER FUNCTION TEST (LFT) 17-03-2024 10:19:PM

Total Bilurubin 5.83 mg/dl 1-0 mg/dl

Direct Bilurubin 5.00 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 313 IU/L 31-0 IU/L

SGPT(ALT) 138 IU/L 34-0 IU/L

ALKALINE PHOSPHATASE 221 IU/L 98-42 IU/L

TOTAL PROTEINS 5.6 gm/dl 8.3-6.4 gm/dl

ALBUMIN 2.6 gm/dl 5.2-3.5 gm/dl

A/G RATIO 0.88

LIVER FUNCTION TEST (LFT) 18-03-2024 11:16:PM

Total Bilurubin 6.82 mg/dl 1-0 mg/dl

Direct Bilurubin 6.00 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 337 IU/L 31-0 IU/L

SGPT(ALT) 138 IU/L 34-0 IU/L

ALKALINE PHOSPHATASE 212 IU/L 98-42 IU/L

TOTAL PROTEINS 5.5 gm/dl 8.3-6.4 gm/dl

ALBUMIN 2.57 gm/dl 5.2-3.5 gm/dl

A/G RATIO 0.88

USG ABDOMEN DONE ON 15/3/24:

LIVER- NORMAL S/INCREASED ECHOGENICITY

 PV-NORMAL,NO IHBRD

 CBD- 10-11MM DILATED

GALL BLADDER- DISTENDED

PANCREAS- HEAD VISUALISED NORMAL S/E

RIGHT KIDNEY- 9.9 X 4.1 CM

LEFT KIDNEY- 10.7 X 3.3 CM

AORTA I.V.C. - NORMAL

NO ASCITES

NO LYMPHADENOPATHY

U.BLADDER-distendd,INTERNAL ECHOS NOTED

IMPRESSION:

ALTERTED ECHOTEXTURE WITH HYPOECHOIC LIVER PARENCHYMA

GB WALL EDEMA

GRADE III RPD CHANGES IN RT KIDNEY WITH RIGHT SIMPLE CORTICAL CYST

GRADE II RPD CHANGES IN LEFT CORTICAL

MINIMAL INTER BOWEL FLUID

REVIEW USG -16/03/24

COARSE ECHOTEXTURE AND SURFACE NODULARITY OF LIVER-C/O CHRONIC LIVER

DISEASE

POOR VISUVALISATION OF LEFT HEPATIC VEIN AND NARROWED INTRAHEPATIC IVC- BUDD

CHARI SYNDROME TO BE EXCLUDED

BORDERLINE SPLENOMEGALY (12CM), MILD ASCITIS, MESENTRIC COLLATERALS- S/O

PORTAL HYPERTENSION

NORMAL SIZE (9MM) AND DISECTION OF FLOW IN PORTAL VEIN

E/O 46X30MM CYST NOTED IN MIDPOLE OF RIGHT KIDNEY

CECT ABDOMEN

LIVER - HETEROGENOUS DENSITY WITH SURFACE NODULARITY ,HEPATIC VEINS FAINTLY

VISUALISED MOST LIKELY DUE TO COMPRESSION OF NODLARITY OF LIVER ,NO FOCAL

LESIONS ,MESENTERIC COLLATERALS AND PARTIALLY RECANALISED UMBILICAL VEINS

PVAND SMV -NORMAL

GALL BLADDER /BILIAR TRACT -WELL DISTENDED ,NO IHBRD ,DIFFUSE GALL BLADDER

EDEMA

PANCREAS -NORMAL NRMAL S/E

SPLLEN -13CM ,MILD SPLENOMEGALY

ADRENALS - NORMAL

KIDNEY -BOTH ARE NORMAL ,NO CALICULI/HYDRONRPHROSIS ,46X 33MM CYST NOTED IN

MIDPOLE OF RIGHT KIDNEY

URETERS- BOTH AR NORMAL

U BLADDER - UNREMARKABLE

L NODES - NOT ENLARGED OF CT CRITERIA

GI TRACT - STOMACK,SMALL,LARGE BOWELS ARE COLLAPSED ,NO EVIDENCE OF

OBIVIOUS WALL THICKENING ,MILD ASCITIS

RECANALISED UMBILICAL VEIN AND MESENTERIC COLLATERALS

AORTA AND IVC NORMAL

VISUALISED BONES - NORMAL

CHEST BASE -LUNG FIELDS ARE CLEAR ,NO NODULES/MASS/PLEURAL EFFUSION

IMPRESSION

CHRONIC LIVER DISEASE

MILD SPLENOMEGALY

ASCITIS

PARTIALLY RECANALISED UMBILICAL VEIN AND MESENTERIC COLLATERALS

2D ECHO DONE ON 15/3/24:

-NO RWMA.

-GOOD LV SYSTOLIC FUNCTION(EF:63%).

-GRADE 1 DIASTOLIC DYSFUNCTION.

-TRIVIAL MR+/TR+;NO PAH.

-NO AR.

-NO PE/LV CLOTS.

ON 16/3/24

ESR -10

BGT-O+VE

LDH ON 15/3/24-212

LDH ON 16/03/24- 237

APTT: 30 SEC

BLEEDING TIME: 2MIN

CLOTTING TIME: 4MIN

UPPER GI ENDOSCOPY ON 19/3/24

OESOPHAGUS -NO VARICES

STOMACH -NO FUNDAL VARICES ,MILD GASTRITIS

DUODENUM -D1,D2 NORMAL

IMPRESSION -

MILD GASTRITIS

Treatment Given(Enter only Generic Name)

1 IV FLUIDS DNS @ 75ML/HR

2 TAB UDILIV 300MG PERORAL TWICE A DAY

3 TAB RIFIXAMINE 550MG PER ORAL TWICE A DAY

4 TAB ATARAX PER ORAL /HS

5 HEPOMERZ SACHETS PER ORAL THRICE A DAY

6 CALAMINE LOTION TWICE A DAY

7 TAB N ACETYLCYSTIENE 600MG PERORALTWICE A DAY

Advice at Discharge

TAB RIFIXAMINE 550MG PER ORAL TWICE A DAY X 1 WEEK

TAB CARVEDILOL 3.125MG PER ORAL ONCE A DAYX 1 WEEK

TAB LASILACTONE 20/50 PER ORAL ONCE A DAYX 1 WEEK

HEPOMERZ SACHETS PER ORAL THRICE A DAYX 1 WEEK

SYP LACTULOSE 15ML PER ORAL /HSX 1 WEEK

TAB N ACETYLCYSTIENE 600MG PERORALTWICE A DAYX 1 WEEK

CALAMINE LOTION TWICE A DAYX 1 WEEK

PROTEIN POWDER 2SCOOPIS IN 1 GLASS OF MILK / TIDX 1 WEEK

Follow Up

REVIEW TO GM OPD WITH ANA WITH TITER, ANTI SMOOTH MUSCLE ANTIBODIES, ANTI LKM

ANTIBODIES, ANTI MITOCHONDRIAL ANTIBODIES, ALPHA FETOPROTEINE, SERUM GAMMA

GLOBULIN LEVELS.

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.