The document discusses a 63-year-old male patient with a history of diabetes, hypertension, and coronary artery disease, who presented with abdominal distension, shortness of breath, and lower limb swelling. Diagnostic evaluations revealed moderate ascites, a liver lesion suggestive of hepatocellular carcinoma, and signs of decompensated cirrhosis possibly due to autoimmune causes. The patient's final diagnosis included portal hypertension with grade 1 esophageal varices and a high SAAG low protein ascitic fluid analysis.

1. Case discussion

2. • 63 yr old male
• Known case of type 2 diabetes mellitus
• Systemic hypertension
• Coronary artery disease
• Resident of coimbatore
• lower middle class

3. Chief complaints
• Abdominal distension x 20 days
• Shortness of breath x 2 weeks
• Lower limb swelling x 2 days

4. History of presenting illness
• Patient was apparently normal 20 days back when he noticed abdominal distension
-insidious onset
-gradually progressive
-generalised
-associated with periumbilical swelling
• He also had exertional shortness of breath not associated with chest pain
palpitations orthopnea ,PND
he developed B/l lower limb swelling since 2 days
-painless
-insidious in onset,
-it started at foot gradually extending above ankles
-pitting type, more in the evening hours.

5. • No h/o fever
• No h/o Pain abdomen
• No h/o Cough
• No h/o jaundice, itching, clay colored stools
• No h/o periorbital swelling,facial puffiness, hematuria
• No h/o hematemesis or melena ,constipation
• No h/o orthopnea ,PND,palpitations
• No h/o CAM intake
• No h/o confusion,drowsiness , altered sensorium.

6. Personal history
• known case of diabetes,hypertension ,CAD on medications
• No addictions
• Sleep cycle normal
• Appetite is good
• Bowel and bladder habits-regular

7. Treatment history
• For the above complaints she was evaluated else where
• USG abdomen showed moderate ascites normal liver and umbilical
hernia
• Prescribed diuretics
• Referred here for further evaluation.

8. Examination
• O/E
• Conscious,oriented to TPP
• pedal edema +
• No icterus,no cyanosis,no clubbing,no lymphadenopathy
• No peripheral stigmata of chronic liver disease
• Temp-Afebrile
• PR:92/min
• BP:140/90 mmHg
• SPO2:98%RA
• P/A:Soft,non tender,FF +,shifting dullness +umbilical hernia +
• RS:B/L AE +
• CVS:S1,S2 +
• CNS:NFND

9. Blood investigations
CBC
HB 9.9/dL
MCV 81
TC 8000
DC N 81%
Platelet 3.45 lakh
INR 1.1
ESR 83mm
LFT
T.BIL 0.3g/dl
Direct 0.1g/dl
Indirect 0.2g/dl
SGOT 28U/L
SGPT 7U/L
ALP 64U/L
GGT 38U/L
T.PROTIEN 7.4g/dl
ALBUMIN 3.3g/dl
GLOBULIN 4.1g /dl
RFT
UREA 22mg/dl
Creatinine 0.6mg/dl
Na 136mEq/L
K 3.7mEq/L
Chloride 104mEq/L
Bicarbonate 21.7mEq/L
I.cal 1.0mmol/L
Peripheral smear: Normocytic normochromic anemia
Alfa feto protein : 1.4IU/mL
Viral serology : Non reactive

10. Ascitic fluid analysis
• low protein high SAAG ascites
• TOTAL COUNT 440cells/cu mm
• Lymphocytes 16%
• Neutrophils 38%
• Albumin 0.76g/dL
• Protein 1.79g/dL
• ADA 1.81U/L
• Ascitic fluid culture was sterile.
• Cytology showed reactive effusion.
-Blood culture Enterococcus
-Urine culture : E.Coli

11. • Liver Profile
• IgGAMA-M2 POSITIVE +++
• Sp100 NEGATIVE
• LKM-1 NEGATIVE
• LC-1 NEGATIVE
• SLA/LP NEGATIVE
• Gp210 POSITIVE ++

12. • ANA PROFILE
• Sm NEGATIVE
• nRNP/Sm NEGATIVE
• AMA - M2 POSITIVE +++
• Rib, P - PROTEIN NEGATIVE
• HISTONES NEGATIVE
• NUCLEOSOMES NEGATIVE
• dsDNA NEGATIVE
• PCNA NEGATIVE
• Ro 52 NEGATIVE
• Jo - 1 NEGATIVE
• CENP B NEGATIVE

13. • ANA IMMUNOFLUORESCENCE[SCREENING DILUTION 1:100] ANA
POSITIVE PATTERN CYTOPLASM RETICULATE++
• Serum IgG Levels 19
• TSH 10.1
• FLP :normal
• Anemia profile low serum iron 11, serum ferritin
• Stool for occult blood negative

14. MRI abdomen
• Liver measures 12.2 cm, appears normal in size and shows heterogeneous
signal intensity.
• A fairly defined small arterial phase enhancing lesion measuring about 9 x 9
mm noted in segment II of liver.
• The lesion shows mild washout in venous and delayed phases.
• The surface of the liver is irregular.
• There is no dilatation of intra / extra hepatic biliary channels.
• Portal vein, splenic vein and superior mesenteric vein appear normal.
• Gallbladder is distended
• Spleen measures 13.4 cm, is enlarged

15. T1 T2

16. • UGI scopy
• Grade 1 esophageal varices
• Lax les grade 2

17. Final diagnosis
• 58yr old female has Decompensated cirrhosis of liver
• Possible autoimmune
• Simplified AIH score 5
-CTP : B MELD : 10
-PORTAL HYPERTENSION
-GRADE 1 ESOPHAGEAL VARICES
-HIGH SAAG LOW PROTEIN ASCITES
-HEPATOCELLULAR CARCINOMA
- BCLC -A