A case of ascites

An interesting case of  a 55 year old female with Ascites

                          Submitted by- Simran Dash
                          MBBS-IV | Roll number- 153

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and diagnosis and come up with a treatment plan.

The entire real patient clinical problem is presented in the following link-


My analysis for this patient is as follows-

Age: 55 years

Sex: Female

Occupation: Labourer (does not work now because of  the gradually progressive faigue.)

Chief complaints:
  1. Abdominal distension
  2. Pain abdomen
Analysis of each complaint in detail:

1) Abdominal distension:
  • Onset- Insidious
  • Progression- gradually progressive
  • Duration- 10 days
  • Associated complaints-
    • Dyspnea because of the distension.
  • Type- Generalised
Causes of abdominal distension as given by the mnemonic (8 F's) are:
  • Fat- Obesity (But our patient is malnourished.)
  • Flatus- Gaseous distension
  • Fluid- Ascites, Distended urinary bladder
  • Foetus (not possible in this case as she has attained menopause already.)
  • Faeces- Megacolon
  • Fibroids or Fatal tumour- Splenomegaly 
  • Full bladder
  • Functional- Irritable bowel syndrome
Possible causes in this case could be-
  • Ascites
  • Fatal tumour
2) Pain Abdomen
  • Onset- Insidious
  • Site- In epigastrium and Left Hypochondriac regions
  • Episode- One episode 2 years back
  • Non radiating
  • Character- Dull aching type
  • Aggravated on- Food intake
  • Relieved on- Pain killers (probably an NSAID) and self induced vomiting
Most probable causes for abdominal pain in this case could be:
  • Gastritis
  • Inflammatory Bowel Disease 
  • Gastric ulcer
  • Irritable Bowel Disease (But there is no change in her bowel habits)
3) Other complaints:
  • Early satiety
  • Loss of weight
  • Fatigue
  • Night sweats which were drenching and made her wet 
  • Low grade fever with chills and rigors.
  • Had a history of hematemesis, 1 episode, 50 mL
She has these complaints since the last 3-6 months. She stopped working because of the above complaints.

Past medical and surgical history: Underwent hysterectomy for fibroids.

Personal History:
  •  Appetite - decreased
  •  Sleep- Adequate
  •  Diet- Mixed
  •  Bowel and bladder movements- Regular
  •  No addictions.
  •  Not a known alcoholic or smoker.
From the above complaints, the possible causes could be-
  • Cancer 
  • Abdominal Tuberculosis
  • Gastric ulcer
  • Portal hypertension
To confirm these findings, examination and investigations done are as follows. 

General Examination: The patient was thin built and moderately nourished.

Vitals:

  • P.R. : 72bpm
  • R.R: 18 cpm
  • B.P. : 140/80 mmHg
  • She was afebrile.
Systemic Examination:

 1) Respiratory system:

  • Normal vesicular breath sounds were heard.
  • Trachea is central in position.
2)CVS:
  • S1,S2 were heard.
  • No additional sounds and no murmurs.
3) CNS: No neurological abnormalities were seen.

4) Per abdomen: Patient was examined in both supine and standing position. She was exposed from xiphisternum to pubic symphysis.

        I) Inspection:
  • Abdomen is distended.
  • Umbilicus is everted.
  • Linea nigra was seen.
  • No scars and sinuses were seen.
  • No engorged veins.
      II) Palpation: 
  • She was afebrile.
  • Tenderness was present over epigastric and left hypochondriac regions.
  • No fluid thrill.
  • Girth of the abdomen was 85 cm.
  • Palpable mass felt over the left hypochondraic regions.
  • There was splenomegaly of 16 cm.
     III) Percussion:
  • Shifting dullness is present.
  • Flank fullness is also present.
     IV) Auscultation: Bowel sounds were heard.

From the above findings, I can confirm that this is a case of Ascites. The possible causes for Ascites in this case could be:
  • Portal Hypertension
  • Malignancy
  • Abdominal Tuberculosis
Investigations done:

1) CBP: 
  • Microcytic Hypochromic Anemia
  • Leukopenia
  • Thrombocytopenia
2) CUE: There was albumin in urine.

3) RFT: Normal findings

4) LFT: Elevated Total bilirubin, direct bilirubin and Alkaline phosphate levels.

5) Serology was negative for HIV, HbsAG and HCV.

6) APTT and Prothrombin time findings were normal.

7) INR was normal.

8) Lipid profile: normal.

9) Thyroid profile: normal

10) CRP was negative and ESR was also normal.

11) ECG: Normal sinus rhythm with Flattened T waves.

12) Chest X Ray: Normal

13) USG: 
  • Portal Vein Thrombosis
  • Gross Ascites
  • Moderate splenomegaly
  • Anterior abdominal wall collaterals.
14) Contrast Enhanced CT scan (CECT):
  • Oesophageal varices
  • Caudate lobe hypertrophy
  • Portal Vein Thrombosis
  • Gross Ascites
  • Moderate splenomegaly
  • Anterior abdominal wall collaterals.
15) Ascitic Tap findings:
  • Serum creatinine was normal.
  • ADA was normal
  • Ascitic fluid protein sugar was elevated (177 mg/dl)
  • Ascitic fluid amylase was normal.
  • Ascitic fluid for LDH was less.
16) Serum Amylase was normal.

17) SAAG (Serum Ascites Albumin Gradient) : elevated (2.2)

   This indicates transudative ascitic fluid. So we can rule out Malignancy and confirm Portal Hypertension.

"The sensitivity, specificity, positive predictive value and negative predictive value of high gradient and transudative ascites in diagnosing portal hypertension were 943%, 60%, 84.6%, 81.8% and 62.9%, 133%, 91.7% and 50% respectively. High gradient ascites is a sensitive test in the diagnosis of portal hypertension as a cause of ascites. The exudate-transudate approach has severe limitations in the differential diagnosis of ascites."


18) Endoscopy: It confirmed Grade 4 Oesophageal Varices i.e. >4 mm, circular extension around the oesophageal wall; varices almost meet in the middle of the lumen; with or without good mucosal coverage (according to Dagradi classification)

So after the history, examination and investigations, the complete diagnosis in this case would be-

Anatomical diagnosis -  Cirrhosis 

Functional diagnosis- Portal Hypertension

Aetiological diagnosis-
  • Budd Chiari Syndrome 
  • Liver cancer (less likely because there is splenomegaly and transudative SAAG)
Factors favouring the diagnosis of Budd Chiari Syndrome are:-
  • Splenomegaly
  • SAAG > 1.1
  • Caudate lobe hypertrophy 
  • Ascites
  • Portal hypertension 
  • Symptoms of portal hypertension like Oesophageal varices.
  • Abdominal pain 
Complications of Budd Chiari syndrome in this case are:
  • Portal hypertension 
  • Oesophageal varices 
  • Portal vein thrombosis 
  • Splenomegaly
To confirm the diagnosis additional investigations required are:-
  • Doppler ultrasound to confirm Budd Chiari Syndrome by detection of Hepatic vein thrombosis.
  • CBNAAT to rule out Abdominal Tuberculosis.
  • Liver biopsy to rule out Hepatocellular carcinoma.
  • Ascitic fluid can also be sent for culture of Tubercle bacilli.
  • Laparoscopy may reveal peritoneal deposits of TB or malignancy.
  • Percutaneous intrasplenic pressure measurement - increased in portal hypertension 
  • Portal venography by Digital Subtraction Angiography
  • Magnetic Resonance Angiography for Portal Vein.
  • Coagulation profile should also be studied.
  • Alpha fetoprotein levels should be studied to rule out malignancy.

Pooled sensitivities and specificities of Doppler ultrasound were 89% [95% confidence interval (CI), 81-94%, I2 = 24.7%] and 68% (95% CI, 3-99%, I2 = 95.2%), respectively. Regarding CT, the pooled sensitivities and specificities were 89% (95% CI, 77-95%, I2 = 78.6%) and 72% (95% CI, 21-96%, I2 = 91.4%), respectively. The pooled sensitivities and specificities of MRI were 93% (95% CI, 89-96%, I2 = 10.6%) and 55% (95% CI, 5-96%, I2 = 87.6%), respectively. The pooled DOR for Doppler ultrasound, CT, and MRI were 10.19 (95% CI: 1.5, 69.2), 14.57 (95% CI: 1.13, 187.37), and 20.42 (95% CI: 1.78, 234.65), respectively. The higher DOR of MRI than that of Doppler ultrasound and CT shows the better discriminatory power. The area under the curve for MRI was 90.8% compared with 88.4% for CT and 86.6% for Doppler ultrasound.


Treatment received by her: 

A) Pharmacological:
  • Tab. CARVEDILOL 125 mg/po/BD
  • Tab. LASILACTONE 20/50/po/BD
  • Tab. NORFLOX 400 mg/po/BD
  • Tab. PANTOP 40 mg/po/BD
  • Tab. NEUROBION FORTE po/OD
  • Tab. OROFER po/BD
  • Tab. FOLATE 5 mg/po/OD
  • Syrup ZINCOVIT 10mg/po/HS
B) Non pharmacological:
  • Salt and fluid restriction 
  • Gastroenterologist consultation advised
  • Anticoagulant therapy
  • Transjugular Intrahepatic Portosystemic Shunt (TIPS) surgery
  • Oesophageal varices band ligation 
Additional treatment modalities that could be advised in this patient are:


  • Sclerotherapy can prevent bleeding of the oesophageal varices.
“A cumulative meta-analysis of trials of sclerotherapy versus vasoactive drugs clearly shows the consistent effect over time of the superiority of sclerotherapy for control of bleeding (OR 1.384; 95% CI 0.977 to 1.962) and also similar pattern for hospital or 42 day mortality (pooled OR 1.354; 1.032 to 1.777) but the effect is weak.”


References:

1) Davidson’s principles and practice of medicine

2) Harrison’s principles of internal medicine

3) Bedside clinics in medicine by Arup Kumar Kundu











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