A case of non-B, non-C alcoholic cirrhosis of liver admitted to Yangon General Hospital.

1. Combined Clinic (GI)
BY KYAW KHAN ZAW, KAUNG THET HAN & KYAW SAN LIN
FROM FINAL PART 2, MEDICINE POSTING AT YGH, WARD 1 - 2

2. History Taking
BY KYAW KHAN ZAW, ROLL NO. 17

3. Patient Identification
•Name: UNM
•Age: 46 years
•Race: Burmese
•Region: Buddhist
•Address North Okkalar
•Occupation: Retired engineer
•Marital status: Divorced

4. Admission
•Date of Admission: 13th April, 2015
•Time of Admission: 10 AM
•Ward admitted : YGH, Ward 1 – 2

5. Chief complaint
•Fever off and on x 2 months
•Yellow discoloration of skin & sclera x 2 months
•Abdominal Distension and oedema x one and half month

6. History of present illness

7. Yellow discolorations of skin & sclera
•Noticed by himself while washing his face
•Duration : 2 months
•Onset : Gradual
•Progression: Progressive
•Urine colour : High colour
•Stool colour : Normal

8. For haemolytic jaundice
•No family history of blood diseases/ blood transfusion
•No associated pallor according to the patient

9. For viral hepatitis
•No prodromal symptoms such as anorexia, nausea, vomiting, distaste, rash, joint
and muscle pain.
•No outbreak of VH - A nearby.
•No risk factors for VH – B/C/D such as
oBlood tansfusion,
ounsterile injection,
otatooing,
oear-piercing
osexual promiscuity
•Vaccination (-)

10. For leptospirosis
•No eyeball tenderness
•No abdominal pain, decreased urine output
•No chest pain
•No cough with sputum, haemoptysis
•No muscle and joint pain
•No occupational risk for getting Leptospira infection

11. For Hepatic amoebiasis
•No history of repeated dysentery without proper treatment

12. History of alcohol drinking
•Type : Whisky
•Duration : 2 years
•Amount : 3 – 4 bottles/day

13. For post hepatic jaundice
•No pruritus
•No history of passing worms
•No risk factors for gall stones such as being age over 50, fat,
female gender, being fertile & flatulence

14. Fever
•Duration : 2 months
•Character : Remittent
•Severity : high fever
•No chill and rigor
•Travelling history (+)
•History of TB contact (-)
•Risk factors associated with HIV infection (-)
•Abdominal pain (-)

15. Abdominal distention and Oedema
•Onset : Gradual
•Duration : one and half month
•Site of 1st appearance : Legs
•Progress and rate : Progressive and Gradual
•Severity : Not associated with breathlessness, orthopnoea
•Amount of urine : Normal
•Aggravating Factors : unknown
•Relieving Factors : Diuretics

16. For cardiac oedema
•Dyspnoea (-)
•Orthopnoea (-)
•PND (-)
•Palpitation (-)
•Chest pain (-)

17. For chronic renal disease
•Oliguria (-)
•Puffy face (-)
•Loin pain (-)

18. For nutritional oedema
•Chronic diarrhea (-)
•Vomiting (-)
•Anorexia (-)
•Dysphagia (-)
•Dyspepsia (-)

19. To assess the complications
For Hepatic Encephalopathy
•Disordered sleep rhythm (+)
•Slurring of speech (-)
•Disorientation (-)
•Confusion (-)

20. For portal hypertension
•Abdominal distention (+)
•Haematemesis and melaena (-)
•Bleeding piles (-)

21. For spontaneous bacterial peritonitis
•Fever (+)
•Abdominal pain (-)
For hepatorenal syndrome
•Oliguria (-)

22. System Review
•Respiratory : Cough(-), Sputum(-), Haemoptysis(-),
wheeze(-), Stridor(-)
•CVS : Dysnoea on exertion(-), Cyanosis(-)
•Renal : Normal Urine Output, Normal urine colour
•CNS : Fit(-)

23. Past Medical History
•Hepatitis (+)
•No past history of blood disorder requiring transfusion
•Hypertension (-)
•Diabetes Mellitus (-)
•Ischaemic heart disease (-)
•TB (-)

24. • On March 2015, admitted to North Okkalar General Hospital for 5
days for the similar complaints.
• Went to 2 follow up after discharge from NOGH.
• On 2nd May. admitted to Aung Yadanar Polyclinic.

25. Past Surgical History
•No past surgical history.

26. Personal History
•Alcohol drinking (+)
• Smoking (+)
•Betal chewing(+)

27. Drug History
•No known drug allergy.
• No history of taking drug apart from those prescribed by the
hospital.
•There is no history of taking drugs that can cause haemolysis such as
sulphonamides and dapsone.
•No history of taking hepatotoxic drugs such as INH and rafimpicin,
methotrexate, prolonged used of NSAIDs and chlopromazine, etc
•No history of taking indigenous medicine.

28. Family History
No family history of
•Viral hepatits
•Hepatocellular carcinoma
•TB contact

29. Physical Examination
BY KAUNG THET HAN, ROLL NO. 12

30. General Examination
General observation
Age-middle age
Sex-gentleman
Conscious level-well conscious
Comfortable position-lying confortable on the bed
Dyspnoeic-not dyspnoeic
Body Build-average

31. General Examination
Afebrile
Face: bilateral parotid swelling (+), thalassaemic facies (-)
Eye: jaundice (+), Conjunctival haemorrhage (-), anaemia (-),
Kayser Fleischer ring (-), eyeball tenderness (-), xanthelasma (-)
Nose: epistaxis(-)
Mouth: oral thrush (+), fetor hepaticus (-), gum bleeding (-),
angular stomatitis (-), glossitis (-)
Neck: visible pulsations (-), lymph node enlargement (-)

32. General Examination
Hands: Clubbing (-), Leukonychia (+), koilonychia (-),
palmer erythema (+), Dupuytren’s contracture (-), flapping
tremor (-), Bruises (+), pigmentation of palmer creases &
knuckles (-), tattoo marks (-), needle tracks (-)
Legs: Bilateral pitting pedal odema (+), Clubbing (-)
Chest: gynaecomastia (-), axillary hairs are sparse, spider
naevi (+), tattoo marks (-)

33. Abdominal examination (Inspection)
The shape of the abdomen is distended.
The flanks are full.
Umbilicus is flat.
It moves with respiration.
There is no scar, no dilated veins.
No visible mass and peristalsis.
Hernia orifices are intact.

34. Abdominal examination (Palpation)
Light palpation
The abdomen is soft.
Normal temperature.
No tenderness, rigidity, guarding.
No palpable mass.

35. Abdominal examination (Palpation)
Deep Palpation
Liver: size-about 4cm from the right coastal margin,
tenderness(-)
Spleen: is not enlarged
Kidneys are not ballotable.

36. Abdominal examination (Percussion)
Liver dullness is increased up to the right 4th intercostal
space along the mid-clavicular line
Upward enlargement of liver (+)
Splenic dullness is absent
Free fluid: Shifting dullness (+)

37. Abdominal examination (Auscultation)
Bowel sound (+)
Liver Bruit (-)
Splenic Rub (-)

38. Digital Rectal Examination
Rectal varices (-)

39. Bedside Tests
No constructional apraxia

40. System Review
CVS system – no cyanosis, no cardiomegaly, no added
sounds
Respiratory system –no apical crepitations, no bilateral
basal crepitations

41. Provisional diagnosis
Chronic liver disease – cirrhosis of liver most probably due
to alcohol with ascites

42. Investigations &
Treatment
BY KYAW SAN LIN, ROLL NO. 21

43. Investigations

44. Liver Function Test (LFT)
Serum Total Bilirubin 250.7 μmol/L (raised)
Serum Alkaline Phosphatase 113 U/L (normal)

45. Liver Enzymes
ALT 13 U/L (normal)
AST 56 U/L (raised)

46. Total & Differential Protein (T & DP)
Total protein 60 g/L (reduced)
Albumin 23 g/L (reduced)
Globulin 37 g/L (raised)
A:G ratio reversed

47. Coagulation tests
PT (Prothrombin time) 35 sec (prolonged)
(normal control is 12.0 sec)
INR (International Normalized Ratio) 2.83
INR =
Patient PT
Normal mean PT
ISI
ISI = International Sensitivity Index of thromboplastin

48. Full Blood Count
Haemoglobin concentration 7.1 g/dl (anaemia)
Haematocrit 19.4% (low)
MCV 72.4 fL (microcytic)
MCH 26.5 pg (normal)
MCHC 36.6 g/dL (normal)

49. Full Blood Count
Total WBC Count 19.15 x 103/μL (Leucocytosis)
Neutrophil count 13.47 x 103/μL (neutrophilia)
Neutrophil % 70.3% (normal)
Lymphocyte count 3.25 x 103/μL (normal)
Lymphocyte % 17% (reduced)

50. Full Blood Count
Monocyte count 1.76 x 103 /μL (monocytosis)
Monocyte % 9.2% (normal)
Eosinophil count 0.57 x 103 /μL (eosinophilia)
Eosinophil % 3.0% (normal)
Basophil count 0.10 x 103 /μL (normal)
Basophil % 0.5% (normal)

51. Full Blood Count
Platelet count 183 x 109/L (normal)

52. Blood Film Examination
RBC: Hypochromic microcytic with anisopoikilocytosis
WBC: Neutrophil leucocytosis
Platelet: Adequate

53. Serum Urea, Creatinine & Electrolytes
Urea 4.1 mmol/L (normal)
Creatinine 90 μmol/L (normal)
Na+ 129 mmol/L (hyponatraemia)
K+ 4.02 mmol/L (normal)
Cl- 100.6 mmol/L (normal)
Bicarbonate 20.3 mmol/L (reduced)

54. Urine RE
Specific gravity 1.010
pH 7
Leucocyte negative
Nitrite negative
Protein negative

55. Urine RE
Glucose negative
Ketone negative
Urobilinogen normal
Bilirubin negative
Blood negative

56. Other tests
ESR 60mm after 1st hour (raised)
HBsAg negative
Anti HCV negative
RBS 131 mg/dl
CXR (PA) cardiomegaly
ECG NAD
OGD scopy planned to do next week

57. Child – Pugh Classification
Serum Bilirubin >50 μmol/L 3
Albumin <28 g/L 3
PT >6 sec longer than normal 3
Ascites mild 2
Encephalopathy none 1
Total Score 12 = Child’s C
1st year survival 42%
5th year survival 20%
Refer to Davidson’s Principles & Practice of Medicine
22nd Ed. Pg. 944 for the full scoring system.

58. Maddrey’s discriminant function (DF)
DF = [ 4.6 x Increase in PT (sec) ] + Bilirubin (mg/dL)
DF = 111
> 32 implies severe liver disease with a poor prognosis.

59. Definitive Diagnosis
Chronic liver disease – cirrhosis of liver most probably due
to alcohol with ascites

60. Treatment

61. Abstinence of alcohol
cornerstone of therapy for patients with alcoholic liver
disease

62. Treatment of Ascites
Bed rest in supine position
Salt, water restriction
PO Spironolactone (Aldactone®) 4 tablets od
IV Furosemide (Lasix®) 40 mg 12 hrly

63. Treatment of Coagulopathy
Infusion of FFP 1 units daily for 3 days
IV Vitamin K 1 ampoule od

64. Prophylaxis of Hepatic Encephalopathy
PO Rifaximin (Hepaxime®) 1 tablet bd

65. Treatment of Spontaneous Bacterial
Peritonitis (SBP)
IV Metronidazole 500 mg 8 hrly
IV levofloxacin 500 mg od
IV Piperacillin/tazobactem 4.5 g 8 hrly

66. Supportive Treatment
IVI dextrose water + Pabrinex® 1 pair
PO DL – Methionine, choline & vitamins (Neutrosec®) 1
tablet bd
PO Arginine 1 tablet bd
PO Protec® tablet 1 bd
PO Live Up® 1 tablet od
PO Hepacel® 1 tablet bd

67. Supportive Treatment
PO Thiamine (Bevit®) 1 tablet bd
PO slow K 2 tablets tds
PO Ursodeoxycholic acid (Udihep®) 1 bd

68. Expert Opinion & Management
Shown to Liver Medical Unit, YSH

69. Thank you very much for listening!!! Any questions???