A Case Of Per Abdomen Examination

BY:Dr. Tikal Kansara

R2 Medicine D Unit

Bio Data

• Sajjan Devibhai Balai• 50 / F• Hindu• Illitrate• Married• Housewife• Low socio economic status• From Borakheda Village, Ujjain, Madhya Pradesh

CHIEF COMPLAINS

• Abdominal Distention since 19 years• Abdominal Pain since 19 years

Origin, Duration & Progress

• Abdominal Distention since 19 years• Abdominal Pain since 19 years• Yellowish discoloration of urine & sclera 19

years ago• Swelling of both lower limbs since 19 years• Dilated Veins over the abdomen since 15 years• Early Satiety & anorexia since 19 years

• No History s/o:– Malena, Hemetmesis, Bleeding PR, Diarrhoea,

Vomitting– Burning Micturation, Reduced UOP, Hematuria– Cough, Hemoptysis, Fever– Dyspnoea, Chest Pain, Palpitations, Orthopnea,

PND.

• PAST HISTORY:– Hypo pigmented patches over the skin of cheek,

back & soles since childhood• FAMILY HISTORY:– Nothing Significant

• PERSONAL HISTORY:– Nothing Significant

• MENSTRUAL HISTORY:– Menopausal since last 10 years

• OBSTRETIC HISTORY: G4P3A1L3

– G1 – IUFD @ 7 months– G2 – M/24/Home/FTND/Vaccinated– G3 – M/19/Home/FTND/Vaccinated– G4 – M/15/Home/FTND/Vaccinated

HISTORY CONCLUSIONSo, at the end of history we have a 50 y/o F with long standing abdominal distention, discomfort; which have waxing and waning course being partly relieved by medications, & dilated veins over the abdomen most likely we are dealing with a case of ‘Ascites From Portal Hypertension’. The differentials (According to Anatomical Location of Abnormality) would be as follows:

1. Cirrhosis Of Liver1. Hepatitis B & C Infection2. Autoimmune Hepatitis (Late Stage)

2. Portal / Splenic Vein Thrombosis3. Post-Hepatic Obstruction

1. Membranous Webs2. Myeloproliferative Diseases3. Anti-Phospholipid Antibody

Syndrome4. Recurrent Pregnancies5. Hereditary Thrombophilias

GENERAL EXAMINATION

• Patient is conscious, co-operative and well oriented to time, place & person.– VITALS• TPR- N/84/Regular• BP- 104/62 mmHg

– Hypopigmented patches are present in skin of chin, back, foot & distal phalanyx of dorsum of fingers of hands s/o Vitiligo

• No pallor, cyanosis, clubbing, icterus, pedal edema, lymphadenopathy

• No KF Ring visible• Back & Spine Normal• No Signs Of Liver Failure present– No hair loss, parotid enlargement, spider naevi,

dupuytren contracture, palmer erythema.

PER ABDOMEN EXAMINATION

• INSPECTION– Shape of abdomen –

globular– Umbilicus – Shifted

downwards & inverted– Dilated & tortuous

veins present over upper part of the abdomen and upper part of the back.

• ABDOMINAL MOVEMENTS:– Bulges during inspiration

• No Abnormal pulsations are visible• No peristaltic waves visualised• Skin over the abdomen is lax.

• PALPATION:– Superficial Palpation• Temperature: Normal• Non tender abdomen

– Deep Palpation:• Liver – Not Palpable• Spleen – Not Palpable

– Dilated Veins over upper abdomen – Flow from below upwards on milking veins

• PERCUSSION:– Shifting Dullness is present

• AUSCULTATION:– Bowel Sounds audible– No Bruits, No venous hum

OTHER SYSTEM EXAMINATIONS• RESPIRATORY SYSTEM:

– AEBE – No Crepts / Rhonchi

• CARDIOVASCULAR EXAMINATION:– S1;S2 Normal– No Murmur

• CENTRAL NERVOUS SYSTEM EXAMINATION:– HF/CN Normal– Conscious, Cooperative– No Focal Neurological Deficits– Tone Normal; Power 5/5 in all four limbs– PR ↓ / ↓

EXAMINATION CONCLUSIONSo, from history & physical examination we have a 50 y/o F; with chronic abdominal distention & discomfort with dilated veins over front and back of abdomen, which fills from below upwards, without florid signs of liver cell failure. This is most likely a case of ‘Ascites From Portal Hypertension from Obstruction likely at the level of Hepatic Veins &/or Inferior Vena Cava’. At this point, cirrhosis & other differentials seems less likely & post-hepatic obstruction seems probable enough to label it as Budd-Chiari Syndrome.

Etiology for Budd-Chiari Syndrome at this stage would include:

1. Membranous Webs2. Anti-Phospholipid Antibody Syndrome3. Hereditory Thrombophilias

1. Protein C Deficiency2. Protein S Deficiency3. Factor V Laden Deficiency4. Anti Thrombin III Deficiency

4. Myeloproliferative Diseases5. Recurrent Pregnancies

INVESTIGATIONS• COMPLETE BLOOD COUNT

PARAMETER VALUE NORMAL VALUE

Haemoglobin 12.00 12.0 – 16.0 gm%

Total Counts 6000 4,000 – 11,000 / cumm

Differencials 70 / 28 / 01 / 01

Platelet Count 1.31 lac/ cumm 1.5 – 4.1 lac / cumm

ESR 22 MM 00 – 15 MM

RETICULOCYTE COUNT 0.5 % 0.5 – 2.0 %

PARAMETER VALUE NORMAL VALUE

PCV 32.60 36 – 46 %

MCV 79.00 82 – 92 Fl

MCH 29.20 27 – 32 pg

MCHC 36.80 32 – 35 %

SMEAR STUDY

NORMOCYTIC NORMOCHROMIC RBCs

• Biochemical InvestigationsPARAMETER VALUE NORMAL VALUE

Blood Urea 50 14 – 40 mg/dl

Serum creatinine 0.8 0.1 – 1.2 mg/dl

Bilirubin

Total 1.4 0.1 – 1.2 mg/dl

Direct 0.7 0 – 0.4 mg/dl

Indirect 0.7 0.1 – 0.8 mg/dl

SGPT 20 < 40 U/L

SGOT 42 <37 U/L

ALP 91 28 – 111 IU/L(Adults)

Serum Sodium 136 135 – 145 mmol/L

Serum Potassium 4.5 3.5 – 5.1 mmol/L

Total Protein 8.0 6.0 – 8.0 gm/dl

Serum Albumin 4.8 3.2 – 5.0 gm/dl

PARAMETER VALUE

Chest X-Ray Normal

RBS 122 mg%

ECG Grossly WNL

ASCITIC FLUID ANALYSIS

PARAMETER VALUE NORMAL VALUE

TOTAL CELLS 320 00 – 05 /cumm

DIFFERENCIALS 60 % / 40 %

PROTEIN 3.6

SUGAR 94

• PROTHROMBIN TIME:

• ACTIVATED PARTIAL THROMBOPLASTIN TIME:

PARAMETER VALUE

Prothrombin Time 14.80

Control Time 14.00

INR 1.06

PARAMETER VALUE

PATIENT 30.00

CONTROL 34.00

Ultrasound Abdomen

• LIVER: – Span: 126 mm – Altered with surface irregularity– s/o Cirrhosis

• Spleen: 122 mm Spleenomegaly• Free Fluid: Moderate free fluid in abdomen

ULTRASOUND LIVER SCREENING• Occlusion of terminal IVC• Entire IVC shows reversal of flow• Both iliac veins show flow reversal

• Right hepatic vein patent, dilated & sole outflow channel of the liver

• Left hepatic Vein patent but its ostium is occluded. Flow drains into right hepatic vein through a prominent collateral running over liver surface.

• Spleen is not enlarged. Portal and splenic vein shows normal hepatopetal flow.

CECT Abdomen• Enlarged Caudate lobe and left lobe of liver with surface

nodularity represents Cirrhotic changes.• Multiple homogenously enhancing nodules of varying sizes

in both lobes represents Regenerating Nodules.• Marked narrowing of intrahepatic IVC seen. Middle hepatic

vein not visualised. Right and left hepatic veins visualized. • Intra-hepatic veno-venous collaterals seen. Multiple

abdominal wall, paraspinal and perioesophageal collaterals seen.

• Above findings represent Budd-Chiari Syndrome.

UGI Scopy

1. GRADE II OESOPHAGEAL VARICES PRESENT.

2. CONGESTIVE GASTROPATHY

Viral MarkersPARAMETER VALUE

HIV Non-Reactive

HBsAg Negative

HCV Negative

Other InvestigationsPARAMETER VALUE

SERUM ANA PROFILE NEGATIVE

PARAMETER VALUE NORMAL VALUE

Serum TSH 4.61 0.35 – 5.50

PARAMETER VALUE NORMAL VALUE

Protein C Level 0.66 units/ml 0.55 – 1.11 Units/ml

Protein S Level 0.92 units/ml 0.60 – 1.13 units/ml

Anti Thrombin III Level 0.23 g/L 0.19 – 0.31 g/L

Factor V Laden 4.6 Units/L 2.0 – 10.0 Units/L

THROMBOPHILIC PROFILE