A 50-year old male presented with 2 months of abdominal distension and lower limb swelling. On examination, icterus, pitting edema, shifting dullness, and splenomegaly were present. Investigations revealed features of chronic liver disease including elevated liver enzymes and hepatitis B surface antigen positivity. Ultrasound and ascitic fluid analysis supported a diagnosis of decompensated chronic liver disease secondary to hepatitis B with ascites. The patient was started on treatment including fluid restriction, diuretics, albumin, antibiotics, and medications for variceal prophylaxis.

1. CLINICAL CASE
PRESENTATION
DEPARTMENT OF MEDICINE
PRESENTED BY- DR.BIJAYALAXMI SWAIN
GUIDED BY-DR.VIVEK VARDHAN

2. PATIENT PARTICULARS
• Name- Kabiraj Bisoi
• Age/Sex-50 Years/Male
• Address- Khurdha ,Odisha
• Occupation- Farmer
• Religion- Hindu
• Marital Status-Married

3. CHIEF COMPLAINTS
• Abdominal distension since 2 months
• B/l lower limb swelling since 2 months

4. HISTORY OF PRESENT ILLNESS
• The patient was apparently alright 2 months back. To start with, he
developed abdominal distension which is insidious in onset, gradually
progressed to flanks full , associated with diffuse abdominal pain.
• Later he developed b/l lower limb swelling since 2 months back which
is gradually progressive, not associated with pain, no redness or
discharge.
• No history of fever, vomiting, cough ,pruritus, dyspnea
,orthopnea,hematemesis or malena, facial puffiness ,burning
micturition, loose stools.

5. PAST HISTORY
• No similar episode in the past
• No h/o hypertension, diabetes mellitus, asthma, tuberculosis, thyroid
disorder, kidney disease.
• No surgical history in the past.

6. PERSONAL HISTORY
• Normal sleep pattern.
• Normal bowel and bladder habits.
• The patient is on mixed Indian diet.
• No h/o addictions.
• Appetite is decreased.
• No h/o of allergies.

7. FAMILY HISTORY
• There is no similar history in the family.
SOCIAL HISTORY
• According to Modified Kuppuswamy scale, he belongs to lower class
family.

8. PHYSICAL EXAMINATION
• The patient was examined in a well lit ,well ventilated room, with
proper consent taken.
• Height- 165cm
• Weight-56 kg
• BMI- 20.6
• Moderately built, well nourished.

9. HEAD TO TOE EXAMINATION
• Hair is dry,
• No parotid enlargement,no gynaecomastia, no scrotal swelling, no
palmar erythema.

10. VITALS
• PULSE- 82 bpm,regular, good volume,normal character,no radio-radial
delay, no radio-femoral delay, arterial wall just palpable, all peripheral
pulses well felt.
• BP- 118/84 mm of Hg in right arm supine position
• RR- 16 cycles/min, thoraco-abdominal
• TEMPERATURE- 97.2 F
• SpO2- 98% on room air

11. GENERAL EXAMINATION
• Pallor absent
• Icterus present
• Cyanosis absent
• Clubbing absent
• Lymphadenopathy absent
• Edema present
• Thyromegaly absent
• JVP not raised

12. SYSTEMIC EXAMINATION- GI SYSTEM
• INSPECTION-
 UPPER GIT- good oral hygiene, normal gum and oral mucosa, no fetor
hepaticus
LOWER GIT-
 Shape of abdomen- appears to be distended
 Distance of xiphi stemi to umbilicus> umbilicus to pubic symphysis
 All quadrants move equally with respiration
 Umbilicus is central ,everted , no discharge
 Skin over the abdomen is healthy and shiny.
 No dilated veins, no spider naevi, no caput medusae.
 No scar marks, no mass, no visible pulsation or peristalsis.

13. • SUPERFICIAL PALPATION-
All inspection findings confirmed
Abdomen is soft, non tender
No local rise of temperature
 No guarding, no rigidity
No palpable mass felt
Abdomen circumference at umbilicus-80 cm

14. • DEEP PALPATION-
Fluid thrill absent
Liver- palpable but not enlarged
Spleen- enlarged
Kidney-not ballotable
All hernial orifices intact

15. • PERCUSSION-
 Shifting dullness present
• AUSCULTATION-
bowel sounds present
No hepatic rub, no bruit

16. • CVS EXAMINATION-
S1,S2 heard with no murmurs
• RESPIRATORY EXAMINATION-
 B/L normal vesicular breath sounds heard with no added sounds.
• CNS EXAMINATION-
 conscious ,oriented to time, place and person.

17. SUMMARY
• A 50 year old male presented with complaints of abdominal
distension and b/l lower limb swelling since 2 months. On
examination, icterus and b/l pitting edema were present, shifting
dullness was present and the spleen was enlarged.

18. DIAGNOSES
• Provisional diagnosis-
Decompensated chronic liver disease( DCLD) with ascites
• Differential diagnosis-
budd chiari syndrome
nephrotic syndrome

19. INVESTIGATIONS
• CBC
Hb-13.6
PCV-41.7
TLC-10.24
TPC-372
• RFT
Urea-28
Creatinine-1.09
• HHH
HBs-Ag= 4730

20. • LFT-
T.Bilirubin-0.54
direct bilirubin-0.23
SGOT-155.3
SGPT-150.1
ALP-201
Albumin-1.36
Globulin-3.13
PT-INR-1.08

21. • USG ABDOMEN- CLD, splenomegaly, moderate ascites, mild omental
thickening
• ASCITIC FLUID CYTOLOGY- T.Cell count= 67cells/cu mm; mesothelial
cells= 55%; lymphocytes=30%; polymorphs=15%
• ASCITIC FLUID PROTEIN- T.Protein=0.3gm/dl ,Albumin =0.2gm/dl
• SAAG- 1.36- 0.2=1.16 gm/dl
• UGIE- s/o Grade II esophageal varices

22. FINAL DIAGNOSIS
• Decompensated chronic liver disease secondary to Hepatitis B with
ascites.

23. TREATMENT
• Fluid restriction (1L/day)
• Therapeutic LVP
• Inj TAXIM 1gm IV TDS
• Inj PAN 40 IV OD B/BF
• Inj H.ALBUCEL 20% 100 ml SLOW IV
• Tab RIFAGUT 550mg BD
• Tab HEPAMERZ 1 TAB OD
• Syp. LACTULOSE 30ml OD
• Inj. ONDEM 8mg IV SOS

24. THANK YOU