Presentation about case of Chronic Liver disease

1. CLD
• CC; HOPI ( Story )
– onset; progression / regression..
• Leg swelling, Abdominal distension, Pain
• Fatigue, Dyspepsia , Anorexia,
• Wt loss / gain ( thinning of UL/face/ trunk)
• Yellow eyes / urine
• Hemetemesis / Melena ( Purpura )
• Altered sensorium / Sleep rhythm
• Oliguria / Chest pain/ Palpitation/ Orthopnea…

2. • Past – Jaundice, hepatitis, Drugs, Blood Tx; STD; /
known to have HT, DM, IHD.. yrs
• Personal- Alcohol; Smoking; tobacco.. ( qnty/Qlty)
• Summary: Age; gender Habits  Preexisting
illness present problems  hence think of
Chronic Liver disease (compensated/
decompensated) – ?ALD/ Post hepatitis ( viral /
Drug/ toxin),? Portal HTN, ?Ascites; ?SBP; ?Eso
varicies; ?HE

3. • PR ; All PP +; BP; JVP; HJR
• Markers of CLD
– Jaundice;
– parotids,
– fetor hepaticus;
– hair loss,
– spider;
– dupytrines;
– palm erythema;
– clubbing,
– Petiche,
– purpura,
– echimosis
• Flap

8. • Abd distension; Skin; flanks; umbilicus; AAW
vessels
• Tenderness
• Liver & Spleen palpation
• Fluid thrill / Shifting dullness/ Puddles
• Percussion methods of mapping Liver & Spleen
• Hepatic / splenic Rub/ bruit
• Hernial orifices

9. Abdominal examination
 Inspection
 Palpation
 Percussion
 Auscultation

10. Abdominal DISTENSTION
• Obesity (Fat)
• Air or gas (Flatus)
• Ascites (Fluid)
• Pregnancy (Fetus)
• Constipation (Feces)
• Tumor
• Ovarian cyst

11. • Skin - ? Normal / Pigmentations/ Striae /
Veins/ Scars / Bruises

12. Dilated Veins

15. • Palpate deep in all 4 quadrants.
• May use 2 hands
• Press down around 4 cm.
• Start @ right Iliac fossa.
• Feel the ORGANS / MASS..
• Aortic pulsation
Palpation- Deep

16. Normally Palpable structures

17. Abnormalities to palpate for
• ? Enlarged liver
• ? Enlarged gallbladder
• ? Enlarged spleen
• ? Enlarged kidney
• ? Aortic aneurysm
• ? Free Fluid
• ? Mass

18. Palpation - Liver

19. •Feel for entire border, edge,
surface
•Feel & Look for tenderness
•Feel for nodularity
•Feel for pulsatility

21. • Stand on the patient’s right side.
• Start palpating from RIF
• Ask the patient to take a deep breath and gently push
your hand inward and upward trying / anticipating to
feel the liver edge as it comes down during inspiration.
• Gradually move your hand up, inch by inch, repeating
the process until you feel the liver edge or you get to
the costal margin.
Palpation - Liver

22. Spleen

24. Palpation of Spleen
Feel for NOTCH
Border
Surface
Tenderness

25. • Stand on the patient’s right side.
• Place your left hand behind the patient’s Left side under
the 11th and 12th rib area.
• Ask the patient to take a deep breath and gently push your
hand inward and upward  Left upper quadrant, across
UMBALICUS, trying / anticipating to feel the spleen as it
comes down towards RIF during inspiration.
• Gradually move your hand up, inch by inch, repeating the
process until you feel the spleen edge or you get to the left
costal margin.
Palpation- Spleen

26. Percuss the abdomen
• General tymphani
• Liver span
• Splenic dullness
• Renal angle tenderness
• Fluid thrill
• Shifting dullness

27. • Percussion from areas of resonance  dullness.
• Note the points - change of resonance.
• The distance between the two dullness point is
LIVER SPAN.
Percuss- Liver SPAN

30. Spleen- percussion
CASTELLs

31. Nixons

32. Diagnosis:
Decompensated Chronic alcoholic Liver disease , Portal HTN,
Eso varicies, Ascites; ?SBP; HE , Anemia..
( Why )
(how do you confirm your diagnosis?)
(how do you manage this case?)
( What are possible complications ?)

33. –Causes of CLD
–Types of CLD
–Features of PH
–Classification / causes of PH
–Ascites / Transudate/ exudate / SAAG

34. • Causes of
– Hepatomegaly
– Tender Liver
– Nodular Liver
– Hard Liver
– Hepatic Bruit

35. • Causes of Splenomegaly
– Mild/ Moderate / Massive
– Tender spleen
• Hepato- Splenomegaly
• Splenic rub & bruit
• ? Differentiate Spleenomegaly / nephromegaly

36. • ? Ascites
• ? Types
• ? Exudate v/s Transudate
• ? Causes
• ? SAAG /
• High Protein , High SAAG?
• Low Protein , High SAAG ?
• Low Proten, Low SAAG?
• High Protein, Low SAAG?

37. • ? SBP
• ? Monomicrobial non- nutrocytic ascites ?
• ? Poly microbial non- nutrocytic ascites ?
• Culture negative Nutrocytic asites?
• ? Refractory Ascites
• ? Recidivent ascites

38. – ? NCPF
– ? HE
– Rx of UGI bleed
– Complications of HBV / HCV
– Diagnosis of HBV /HCV
– Prevention of HBV /HCV
– Rx of HE
– Compensated v/s decompensated CLD
– Vaccines
– Rx of cirrhotic ascites

39. Long Case
• Detailed case sheet
– Patient information
– Chief complaints
– HOPI
– Past medical / surgical illness
– Drugs on use , Hypersensitivity..
– Family
– Personal
–Summary

40. Vitals
GPE (Head to Toe)
Systemic examination ( all )
Provisional Diagnosis
Differentials
Plan of Investigation ( purpose /anticipated result)
Plan of management
Possible Complications