Abdomen 2

Abdomen 2

(In this sheet, I will focus on differences between this case and the one in sheet 1)

4 c/o

Abdominal distension one week duration

4 HPI

The condition started 10 years ago by an attack of hematemesis ,preceeded by nausea and vomiting. The blood was dark red in colour, containing food particles, not associated with loss of consciousness, the patient was admitted to Zagazig university hospital where resuscitation was done by fluids and blood transfusion and endoscpoy was done to stop  bleeding ,the attack was followed by melena for several days.

The patient was followed up by regular scleotherapy.  

The patient remained symptom free till one week ago when he re-experienced gradual onset, progressive course of abdominal distension associated with bilateral pitting painless lower limb oedema reaching the mid leg level.  

No history of abdominal swellings, abdominal pain, other upper or lower GIT symptoms, hepatobiliary or urogenital symptoms, no constitutional symptoms.

No symptoms of other system affection.

4 General exam

4 Overview__

-          Temperature : 37

-          Blood pressure 110/70

-          Pulse : regular pulse, 75 /minute, average volume, no special characters, vessel wall is not felt, equal on both sides with intact peripheral pulsations

-          The patient is fully conscious, well oriented for time place and persons, average mood and memory, the patient is co-operative with average intelligence, the patient looks ill, under built, tinge of  jaundice, no pallor or cyanosis.

4 H&N__

-          wasting of temporalis,masseter and pterygoid muscles. No parotid enlargement, no fine silky hair, no fetor hepaticus, the skin shows no spider naevi or paper money appearance

-          Neck veins are congested not pulsating

4 Extremities__

-          Mild bilateral pitting painless oedema L.L reaching mid leg level.

-          Wasting of muscles.

-          No clubbing, no leuchonychia, no capillary pulsations and no flappy tremors.

-          The skin shows no spider naevi, no palmer erythema, no paper money appearance, no S.C haemorrhage .

4 Local exam :

4 Inspection__

The abdomen moves freely with respiration, generalized abdominal distension, there is no localized bulge, no dilated veins, regarding the skin: there is no scars, no stria no scratch marks, no  sc haemorrhage, no pigmentation, no oedema in anterior abdominal wall with normal skin elasticity, there is left oblique inguinal hernia and gynecomastia. There is wide subcostal angle confirmed by thumb test, no epigastric pulsation, no visible peristalsis. There is divarication of recti. Regarding the umbilicus, it is shifted downwards everted and transverse in shape no hernia no discharge. The skin shows no dilated veins no nodules no scars, pigmentation or ulcers, there is feminine distribution of suprapubic hair with normal genitalia, regarding the back no deformity, no swelling, no scars.

4 Palpation__

By superficial palpation:

No swellings, no rigidity, no tenderness, no hyperesthesia .

By deep  palpation

-          The liver is not palpable

-          The spleen is firm in consistency ,rounded notched border,it is felt 4 fingers below the left costal margin (or it is huge in size) with smooth surface, it is not tender or pitted (to be differentiated from other masses in the left hypochondrium and left lumber specially left kidney).

             Otherwise, there is  no other palpable abdominal organs.  

4 Percussion__

-          Upper border of liver is in the 5^th intercostals space in the right midclavicular line  detected by heavy percussion

-          There is dullness detected 4 fingers below the left costal margin detected by light percussion and continuous with traub's area dullness.

-          There is moderate  ascites detected by shifting dullness .

    

4 Auscultation__

There is audible intestinal sound, no vascular sounds no hepatic or splenic rubs no sucussion splash, no puddle's sign. the liver is not  detected below the right costal margin by scratch test.  

4 Investigation

-          Urine and stool analysis for viable bilharzial ova

-          Blood for CBC(anemia),LFT, serological tests of bilharziasis, hepatitis markers

-          Ascetic fluid analysis for ………..

-          ECG for bilharzial corpulmonale

-          Barium studies for …….

-          Ultrasonography  for ………

-          Endoscopies upper and lower for ………….

4 Treatment

-          Stop any hepatotoxic drugs

-          Treatment of hemtemesis in between attacks (band ligation better than sclerotherapy, TIPS can be tried)

-          Treatment of ascites ……

4 Diagnosis :

A case of splenomegaly for D.D most probably mixed bilharzial cirrhosis, there is some signs of LCF and previous attacks of bleeding with no complications.

Or A case of splenomegaly for D.D most probably mixed bilharzial cirrhosis, there is vascular and cellular decompensation with no complications .

 

NB

• splenomegaly  from local exam and sonar
• mixed bilharzial cirrhosis from history, urine and stool analysis,hepatitis markers and serological tests for bilharzia (rectal snip is much better)
• cellular decompensation from of symptoms and signs of LCF and LFTs
• vascular decompensation from signs of portal hypertension (splenomegaly, portal venography and manometry are much better) and bleding.
• Not Complicated as there is no evidence of spontaneous bacterial peritonitis, malignancy or hypersplensim (see how to detect each one in B.H theoretical notes).