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Thursday, April 16, 2015

A 45 Year Old Man Presents With Abdominal Distention

A 45 year old man is brought to the doctor's office by his wife in a confused state, and complains of fatigue, weakness and pain under his right rib cage for the past several months. He is a drug abuser and has a history of jaundice in the past. His wife says he has been diagnosed with hepatitis C but they don't have any medical record with them.

On examination the patient is acting strangely and is not able to give a proper history. He has anemia and a mild jaundice. His abdomen is distended, tender and firm with prominent veins at the umbilicus. Liver and spleen are both enlarged and palpable.

The lab work shows:

  • AST = 145 IU/L
  • ALT = 150 IU/L
  • Serum total billirubin = 7.5 mg/dl
  • PT = 18.2
The patient's bedside abdominal view is shown below:



Based on the given history in the above case what is the most likely case of the patient's abdominal distension?

Answer: Portal Hypertension.

Explanation: The long standing liver disease leads to cirrhosis of the liver and the patients may develop portal hypertension. Portal hypertension is defined as an increase in blood pressure in a system of blood vessels known as the portal venous system that drain blood from the stomach, pancreas, spleen and the intestine. the portal vein then branches into smaller vessels and travels through the liver. If there is an underlying damage in the liver, blood can not flow properly and so leads to an increase in the pressure in the portal system. 

The main symptoms and complications of portal hypertension are 
  • Gastrointestinal bleeding that may lead to black tarry stools or hemetemesis (Vomiting of blood) 
  • Ascites that is defined as accumulation of fluid in the abdomen. that leads to abdominal distension.
  • Encephalopathy or mental confusion.
  • Bleeding and clotting disorders. 
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1 comment:

  1. Dr. Maqsood AliApril 18, 2015 at 1:39 AM

    This patient with long-standing hepatitis-c has developed cirrhosis leading to portal hypertension and ascites BUT the present presentation is NOT just portal hypertension BUT the complications of the cirrhosis i.e. Hepatic Encephalopathy (confused, disoriented and unable to give history of the illness) and Bacterial Peritonitis (ascites & tender abdomen). In fact ANY patient with cirrhosis and ascites presenting with tender abdomen should be considered as a case of bacterial peritonitis until proved otherwise. Bacterial peritonitis can be diagnose by presence of 250 or more Neutrophils per deciliter of ascetic fluid.

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