Abdomen system

short case

• Dr.P.santhosh Kumar post graduate

 General examination

• Middle aged male individual

• Conscious oriented , afebrile

• Thin built and poorly nourished

• Generalised muscle wasting present

• BMI - 23.2 kg/m2

• Pallor + icterus ++

• No icterus clubbing cyanosis pedal edema and lymphadenopathy .

 SIGNS OF LIVER
FAILURE
KF RING ABSENT
PREMATURE ARCUS ABSENT
SUB CONJUCTIVAL BLEED ABSENT
BITOT’S SPOT ABSENT
LOSS OF STERNAL AND AXILLARY PRESENT
HAIR
PAROTID ENLARGEMENT ABSENT
FETOR HEPATICUS ABSENT
GYNAECOMASTIA ABSENT
SPIDER NAEVI ABSENT
DUPUYTREN’S CONTRACTURE ABSENT

PALMAR ERYTHEMA ABSENT

SPLINTER HAEMORRHAGES ABSENT
KOILONYCHIA ABSENT
LEUKONYCHIA ABSENT
ASTERIXIS ABSENT
 Vitals
• Afebrile - 98.4 F

• Pulse - 66/min regular in rhythm , normal in

volume and character , no vessel wall thickening ,
no radioradial , no radiofemoral delay , all
peripheral pulses felt

• JVP- not elevated

• B.P- 100/60 mm/Hg measured in right upper limb

in sitting posture

• R.R - 20/min
 Systemic
examination
• On inspection , abdomen examined in supine position

• Abdomen distended and flanks are full , umbilicus is

everted and pushed down.

• Umbilical hernia present .

• Divarication of recti present

• All quadrants move equal with respiration

• No dilated veins / no visible pulsation seen

 System examination

• Skin : dry scaly skin

present with multiple
iatrogenic needle marks
seen over the flanks .

• Umbilical hernia with

divarication of recti seen

• Inguinal orifice , genitalia

and left clavicular fossa
appears normal .
 Palpation on supine
position
• Superficial palpation : no warmth no tenderness

• Deep : liver and spleen not palpable .

• Measurements :

• From xiphysternum - umbilicus 24 cms

• From umbilicus to pubic symphysis - 14 cms

• Abdominal girth - 82 cms at the level of umbilicus

 Percussion
• Liver span measures around 7.5 cms from right
fifth intercostal space

• Shifting dullness present and fluid thrill absent

• AUSCULTATION:

• Bowel sounds heard

• No hepatic bruits , No renal artery bruit, No splenic

rub
 Differential diagnosis

• Decompensated chronic liver disease - cirrhosis

with portal hypertension .
 Causes of cirrhosis ?
• Alcoholic liver disease

• Chronic viral hepatitis B &C

• Hemochromatosis

• Nonalcoholic fatty liver disease

• Autoimmune hepatitis

• Primary and secondary biliary cirrhosis

• Primary sclerosis cholangitis

• Medications ( methotrexate ,isoniazid )

 Causes of cirrhosis
• Wilson disease

• Alpha -1 anti trypsin deficiency

• Celiac disease

• Granulomatous liver disease

• Idiopathic portal fibrosis

• Polycystic liver disease

• Infection ( brucellosis , sylphilis , echinococcosis)

• Right sided heart failure

• Hereditary hemorrhagic telangiectasia

• Veno-ooclusive disease
 How to prevent
superimposed insults on
liver ?

• Vaccinations - against hepatitis A , B, influenza and

pneumococcal.

• Avoidance of hepatotoxins

• Medication adjustments- non opioid , opioids, anti-

convulsants, anti-microbial , cardiovascular and
anti diabetes drugs.
 Can cirrhosis be
reversed?

• Significant reversibility documented in early

fibrosis (<F2 ) , in hepatitis B, C , and NASH with
advent of non invasive radiographic staging of
early fibrosis along with anti-fibrotic therapies.
 How to manage
refractory ascites ?
1)An inability to mobilize ascites (manifested by minimal to no weight loss)
despite confirmed adherence to the dietary sodium restriction (88 mEq [2000
mg] per day) and the administration of maximum tolerable doses of oral
diuretics (400 mg per day of spironolactone and 160 mg per day
of furosemide.This dose is only infrequently reached because patients often
develop side effects at much lower doses.

2)Rapid reaccumulation of fluid after therapeutic paracentesis despite

adherence to a sodium-restricted diet.

3)The development of diuretic-related complications such as progressive

azotemia, hepatic encephalopathy, or progressive electrolyte imbalances.
 Refractory ascites
management
• Continuing sodium restriction

• Discontinuing beta blockers , ACE inhibitors and

NSAIDS.

• Liver transplantation

• Therapeutic paracentesis

• TIPS(Transjugular intrahepatic portosystemic

shunt )
 MELD vs MELD -Na with
exceptions ?

• MODEL FOR END STAGE LIVER DISEASE

• Incorporates serum bilirubin , serum creatinine and

INR for prothrombin time and Indicates three
month mortality risk based on the score .

• Increasing score is associated with increasing

mortality
 MELD-Na
• Serum sodium indicates vasodilatory state in
cirrhosis and predicts waitlist mortality
independent of MELD score.

• Linear increase in mortality by 5 percent for

every m/mol drop of sodium between 125-140.

• Addition of sodium to MELD score increases

transplant priority by 12 percent for waitlist
individuals and hence in 2016 jan organ
procurement and transplantation network
incorporated it .
 Exceptions

Standard MELD exceptions include:

Hepatocellular carcinoma
Hepatopulmonary syndrome
Portopulmonary hypertension
Familial amyloid polyneuropathy
Primary hyperoxaluria
Cystic fibrosis
Hilar cholangiocarcinoma
Hepatic artery thrombosis
 Role of TIPS ?
• Creation of low resistance channel between the hepatic vein
and intrahepatic portion of portal vein

• Absolute contraindications : Heart failure , severe tricuspid

regurgitation , severe pulmonary hypertension,, multiple
hepatic cysts, severe sepsis and unrelieved biliary
obstruction.

• Relative contraindication : Hepatoma especially if central,

obstruction of all hepatic veins , portal vein thrombosis,
severe coagulopathy , thrombocytepenia ( 20,000) .

• Advantage : Buys time for waitlist individuals for liver

transplantation

• Common Limitation : Recurrent hepatic encephalopathy

 Liver transplantation
indications and
contraindications
• INDICATIONS: Acute liver failure , cirrhosis , liver
neoplasms, Liver based metabolic disorders.

• Contraindications:Cardiopulmonary disease , AIDS,

Malignancy outside of liver , hepatocellular
carcinoma with metastasis , intrahepatic
cholangiocarcinoma , hemangiosarcoma, severe
sepsis, Acute liver failure with a sustained
intracranial pressure >50mm/hg or a cerebral
perfusion < 40mmHg.
1.
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