DCLD WITH ASCITIS

S.KIRTANA
IV M.B.B.S
DEMOGRAPHIC DETAILS:
53 Y/o (older age groups more prone for chronic hepatitis B/C,
NASH,HCC, alcoholic liver disease. Younger ages- Wilsons, glycogen
storage disorders, hemochromatosis, acute hepatitis, PSC, biliary
atresia)
Male (males- alcoholic liver disease females- autoimmune liver
disease, sle)
Mr. Raman
Sales assistant ( lower socioeconomic status, stressful occupations-
more prone for alcoholism and smoking)
Triplicane
CHIEF COMPLAINTS:
Abdominal distention- 6 months ( feces, fat, fluid, flatus, fetus)
Swelling of legs- 4 months (systemic- hypoproteinemia, right heart
failure, chronic kidney failure, chronic liver failure. Local- vascular
compromise, filariasis, gangrene)
H/O PRESENTING ILLNESS:
Patient was apparently normal 6 months ago after which he started
developing
Abdominal distention:
6 months
Insidious ( seen in dcld, right heart failure, ckd, tb, malignant ascites.
Acute- bowel obstruction, ruptured bowel{pneumoperitoneum},
trauma- {hemoperitoneum})
Progressive
Uniform ( dcld, right heart failure, ckd, hypoproteinemia. Localized-
organomegaly, tumors, loculated ascites)
Swelling of both the legs:
4 months
Insidious
Progressive
Upto mid calf level
Aggravated by prolonged upright posture
Relieved on lying down with legs elevated

H/O pruritus ( deposition of bile salts in the skin)

 No H/O abdominal pain , fever, nausea, vomiting, diarrhea/constipation/hematochezia/worms in stools
(to rule out infections and infestations)
Abdominal pain- acute gastroenteritis, acute hepatitis, peritonitis, rupture of bowel
Fever - acute hepatitis, peritonitis, acute gastroenteritis
Nausea, vomiting- acute hepatitis, hepatic failure, obstructive jaundice, acute gastroenteritis
Steatorrhea- obstructive jaundice, chronic pancreatitis, giardiasis
Worms in stools- ascariasis ( can also affect liver), worms can obstruct intestine causing abdominal
distention.
Dysentery- blood + loose stools- amoebiasis ( can also affect liver- amoebic abscess)
Diarrhoea- >3 times a day, >2oogm stools with altered consistency. Or single passage of liquid/semi solid
stool. Causes: acute gastroenteritis, IBD, IBS, malabsorption
Constipation - < 3 times a week. Causes: hemarrhoids, low fiber diet
Hematochezia- fresh blood in stools due to rectal bleeds
(complications of liver failure)
No H/O loss of appetite, hematemesis, melena, high coloured urine, clay coloured stools
Loss of appetite- acute hepatitis, chronic liver failure, hepatic malignancy, other malignancies,
HIV
Hematemesis- coffee grounds vomitus (brown color due to acid hematin) causes: bleeding
varices (portal hypertension) , bleeding peptic ulcers, Mallory Weiss tears(alcoholism)
Melena- black tarry offensive stool that sticks to the toilet bowl (altered blood) indicative of
upper GI bleed. Causes: same as above
High coloured urine: obstructive jaundice, liver cell failure, drugs like b complex, rifampicin
Clay coloured stools: obstructive jaundice

No H/O confusion, sleep disturbances, altered mental status Hepatic encephalopathy

WEST HAVEN CRITERIA
 No H/O oliguria, puffiness of face, frothy urine, increased frequency, hematuria or dysuria
(For renal failure causing abdominal distention)
Oliguria- renal failure
Puffiness of face- nephrotic syndrome, chronic renal failure
Frothy urine- proteinuria, causes: nephrotic syndrome, nephritis.
(bence jones proteinuria- multiple myeloma, amyloidosis)
Hematuria- glomerulonephritis, renal calculi
Dysuria- uti, calculi
No H/O chest pain, breathlessness, palpitations, syncope (for cvs causes of abdominal
distention. Rvf presents with ascites, tender hepatomegaly and elevated jvp)
No H/O cough with sputum, evening rise of temperature, night sweats (rule out tuberculous
etiology)
PAST H/O:
No previous similar complaints (recurrent/resistant ascites,
unmotivated patient who has not quit drinking)
Not a K/C/O DM (immunocompromise- increased risk of
spontaneous infection of ascitic fluid, hepatitis B/C, diabetic
nephropathy) , HT ( hypertensive nephropathy) , IHD (IHD at 50 years
would suggest associated hyperlipidemic states which can cause
NASH) , TB (tuberculous ascites, intestinal tb- obstruction, tb of liver,
immunocompromise) , asthma (beta blockers contraindicated) ,
epilepsy ( hepatotoxic antiepileptic medication)
No previous surgeries/ blood transfusions ( hepatitis B/C, HIV)
PERSONAL H/O:
Consumption of alcohol for last 33 years- 180 ml/day whiskey ( risk
factor for cirrhosis. Safe limit- 21 units per week in males, 14 in
females. 1 unit= 30 ml whiskey)
Not a smoker
No H/O iv drug abuse, tattooing, exposure to STDs (hepatitis b/c HIV)
Takes mixed diet (food borne hepatitis- a, e. lack of hygiene-
amoebiasis, ascariasis, other infestations)
Normal sleep habits (altered in hepatic encephalopathy)
Normal bowel and bladder habits
SUMMARY:
A 53 Y/o man, an alcoholic for the last 33 years came with the
complaints of abdominal distention for the last 6 months and swelling
of both legs for the last 4 months with no other complaints
The system involved is the abdomen.
GENERAL EXAMINATION:
Conscious (altered in hepatic encephalopathy)
Oriented to time place and person altered in hepatic encephalopathy
Moderately built and nourished obese- NASH, poorly built/nourished- malabsorption, malignancy, dcld,
tb, chronic inflammatory conditions
Icteric check in upper palpebral conjunctiva, palate, underside of tongue, palms and soles. Under
natural light. Icterus is seen when bilirubin levels are >3mg/dl
Grade 3 pan-digital clubbing (grade 3- parrot beaking, causes: chronic liver failure, ibd, hepatoma other
causes: suppurative lung diseases, cyanotic heart diseases)
Bilateral pitting pedal edema extending upto the mid calf level (bilateral – ivc compression by
abdominal mass/distention, heart failure, kidney failure. Unilateral- lymphatic obstruction, vascular
compromise, filariasis. Pitting- fluid retention states, non pitting- filariasis, myxoedema)
NO pallor, cyanosis, generalized significant lymphadenopathy
Pallor- chronic liver failure, chronic inflammatory states, chronic kidney failure, nutritional
Lymphadenopathy- tb hiv malignancy lymphomas
VITALS:
Pulse: 80/min, regular, normal volume and character, felt in all
peripheral pulses rapid pulse seen in sepsis, bacterial peritonitis
BP: 120/80 mm Hg peritonitis may present with shock and
hypotension
Temp: 98.4 F increased in peritonitis
RR: 18/min, thoracoabdominal type ascites prevents
abdominothoracic respiration
JVP: not elevated elevated in right heart failure
MARKERS OF LIVER CELL FAILURE:
Alopecia increased estrogen More than 5 spider nevi
Medial madarosis increased estrogen Gynecomastia increased estrogen
Xanthalasma- dyslipidemia Sparse body hair increased estrogen
Icterus deposition of bile pigments in the sclera Abdominal distention ascites
Bitot spots- vit a deficiency hernia
Sch- hypocoagulability Sparse pubic hair increased estrogen
Parotid enlargement Testicular atrophy
Fetor hepaticus- mercaptans Pedal edema ivc obstruction, hypoproteinemia
Palmar erythema
Duputryn contracture
Excoriation marks over limbs deposition of bile salts in
the skin
Asterxis/flapping tremors
EXAMINATION OF ABDOMEN:
After obtaining informed consent patient was exposed from xiphisternum to mid thigh
On inspection in supine and upright postures:
Abdomen is uniformly distended (local distension seen in organomegaly, tumor mass, loculated ascites)
Flanks are full (indicates >1L fluid in abdomen)
Umbilicus is in midline and horizontally slitted (horizontal slitting is seen in ascites)
All quadrants move equally with respiration (local inflammation and peritoneal irritation may lead to guarding and
absence of respiratory movements in one or more quadrants)
No visible pulsations/peristalsis (visible peristalsis is seen in early stage of bowel/gastric obstruction, visible
pulsations are seen in abdominal aorta aneurysm, highly vascular tumors close to the surface)
No scars, sinuses, dilated veins (scars- previous surgeries, previous ascitic fluid tapping sinuses- tuberculosis
dilated veins- portal hypertension, svc obstruction, ivc obstruction. Better seen than felt, after milking direction of
blood flow indicates if svc (filling up to down) or ivc (filling down to up) veins are affected. CAPUT MEDUSA –
dilated veins leading away from umbilicus)
On raising the head, divarication of recti is seen (chronic abdominal distention weakens recti, weak recti increase
chance of herniation)
Hernial orifices are free (raised intraabdominal pressure due to ascites can cause hernias)
Pubic hair is sparse (excess estrogens in liver failure)
External genitalia is normal and penis is in midline
On palpation:
No warmth/tenderness (warm/tender- acute condition, infection, trauma, inflammation)
Inspectory findings are confirmed
Liver - not palpable (cirrhotic liver is shrunken. Normal span- 10-12 cm)
Spleen – not palpable (splenomegaly seen in portal ht)
Measurements: Abdomen girth- 120 cm (important to know baseline to assess response to treatment)
spinoumbilical distance- 23 cm on both sides (in case of ovarian or other lateral tumors
spinoumbilical distance is increased ipsilaterally)
xiphisternum to umbilicus- 27 cm
umbilicus to pubic symphysis- 18 cm ( xiphi to umbilicus > umbilicus to symphysis
implies that the pathology causing the distention is abdominal and not pelvic)
No palpable inguinal/supraclavicular nodes (lt supraclavicular node enlarged in abdominal
malignancies- Virchow node, troiser sign)
On percussion:
Shifting dullness is present (1-1.5L fluid necessary to elicit. >2L fluid thrill, <500ml puddle sign)
Shifting dullness- percuss from midline down towards the axilla till point of dullness is reached, without removing the
hand make the patient to turn onto the opposite side. After few seconds percuss at the same spot. Resonant note is
heard due to shifting of the fluid to the opposite side and bowel floating up
Fluid thrill- stand at foot end, make an assistant place his hand firmly over the midline of abdomen, with one hand
tap on the flanks, with the other hand feel for thrill on the opposite flank
Puddles sign- patient is put in knee elbow position and auscultopercussion is done near the umbilicus
Liver dullness felt at 5th ics
Liver span 7 cm
Traube space resonant (no splenomegaly)
On auscultation:
Normal bowel sounds heard
No bruits/rubs
OTHER SYSTEMS:
RS: trachea in midline, normal vesicular breath sounds over all lung
fields, no added sounds, no evidence of pleural effusion (ascites can
lead to pleural effusion, tb can cause ascites)
CVS: S1 S2 heard no added sounds or murmurs (rule out right heart
failure as a cause)
CNS: no focal neurological deficit (cns examination is important to
rule out hepatic encephalopathy)
SUMMARY:
A 53 y/o male alcoholic for the past 35 years who came with the
complaints of abdominal distention for the last 6 months and swelling
of legs for the past 4 months on general examination was conscious,
oriented, icteric, with bilateral pitting pedal edema upto mid calf level,
grade 3 pandigital clubbing and markers of liver cell failure, on
examination of the abdomen it was found to be uniformly distended
with flanks full and girth was 120cm, umbilicus was in midline and
horizontally slitted, liver was not palpable, on percussion shifting
dullness was elicited.
DIAGNOSIS:
A CASE OF CHRONIC DECOMPENSATED LIVER DISEASE WITH ASCITES
AND NO OTHER COMPLICATIONS (decompensated- liver cell failure
signs seen. Ascites seen)

Cirrhosis-irreversible chronic injury to the liver parenchyma with

extensive fibrosis and regenerative nodule formation
Complications-
ascites- abdominal distention, pedal edema, sbp, protein loss
portal hypertension- splenomegaly, bleeding varices,
hepatic encephalopathy- confusion, delirium, asterixis, coma
INVESTIGATIONS: (GENERAL)
CBC (hb levels for anemia, tc/dc for infections- neutrophilia in acute bacterial
infections, lymphocytosis in tb, esr elevated in inflammatory conditions)
Blood urea sugar creatinine electrolytes
Urine albumin sugar cytology
ECG
Chest X ray
Lipid profile (nash)
Viral markers (hep b/c)
Covid rtpcr
INVESTIGATIONS: (SPECIFIC)
USG abdomen (ascites, organomegaly, portal vein)
Doppler of portal veins
CT abdomen
MRI abdomen
LFT (bt,ct, clotting factor assays, albumin:globulin ratio inverted, serum albumin
reduced, ast, alt elevated, ggt specific for alcoholic cirrhosis, alp elevated in
obstructive jaundice, serum bilirubin (conj and unconj) elevated)
Ascitic fluid analysis (ascitic fluid- gross- color, turbidity, blood staining.
Biochemistry- albumin, ldh, saag- >1.1 in portal Ht, <1.1 in non portal ht causes, ada.
Cytology- gram stain, afb, culture sensitivity, malignant cells)
Upper GI Endoscopy (bleeding varices)
Liver biopsy (confirmatory, if cause is unclear)
INVESTIGATION: (special)
Autoimmune hepatitis- anca, ana, ra, tests for sle
Parasites- stool examination
Wilsons- serum cu, urine cu, serum ceruloplasmin
hemochromatosis- serum fe, ferritin, hemosiderin in tissues
Storage disorders – liver or tissue biopsies
TREATMENT:
Bed rest
Abstinence from alcohol
Ascites- salt and fluid restriction, diuretics, paracentesis with salt free albumin infusion
(massive tapping >3L not advocated due to risk of rebound ascites and hypotension.large
volume Tapping always in conjunction with albumin transfusion)
Varices- resuscitate, blood transfusion if required, ryles tube insertion, vasopressin,
somatostatin, balloon tamponade with sengstaken Blakemore tube, propranolol to prevent
recurrence,sclerotherapy or banding of varices, TIPSS (bypasses portal circulation,
anticipated side effect- hepatic encephalopathy)
HE- protein restricted diet, lacutulose,rifaximin, LOLA to sterilize gut, ensure calorie, fluid
and electrolyte requirements met by diet, zn supplements
Bleeding tendency- inj.vitK
End stage- liver transplantation (motivated patient after 6mo abstinence from alcohol)