Summary 16

Ms. KB, a 44-year-old Malay housewife, non-alcoholic, was diagnosed with Child Pugh B liver cirrhosis secondary to hepatitis C three years ago. She presented with progressive abdominal distention for 5 days, followed by fever and loose stool for 3 days.

Question: What would be your suspicion of cause of the fever and loose stools at this point? What would be your suspicion of the increasing abdominal distension here?

On the day of admission, she experienced breathlessness and generalize abdominal pain for 1 day.

Question: What will you suspect as the cause of the breathlessness and abdominal pain at this point?

There was no symptom suggestive of heart failure or kidney failure.

Question: Why is it incorrect to say "There was no symptom suggestive of heart failure"?

She has 3 previous hospitalizations due to upper gastrointestinal bleed secondary to ruptured oesophageal varices with 3 bandings done.

Upon admission, patient was conscious but lethargic. She appeared to be pale, breathless and in pain.

Question: What will you suspect at this point?

Respiratory rate was 24 breath/minute and temperature was 37.3C. Other vital parameters were within normal range. On examination, there was stigmata of chronic liver disease such as leukonychia, palmar erythema and loss of axillary hair. Abdominal examination revealed a uniformly tensed and distended abdomen with positive shifting dullness and fluid thrill. No tenderness was elicited. The lower border of the liver was not palpable due the tense distended abdomen.

Laboratory investigation showed microcytic hypochromic anaemia. Leukocytosis with predominant neutrophils and raised ESR were suggestive of bacterial infection.

Question: What will you suspect as the cause of the anemia?

Abdominal X-ray excluded bowel perforation.

Question: Why was abdominal perforation considered as a possibility?

Based on high clinical suspicion of spontaneous bacterial peritonitis on top of presence of risk factors, she was treated with IV Ceftriaxone 2g STAT. Peritoneal tapping was done after administration of antibiotic. She was replaced with 200ml of IV 20% human albumin. A total of 3.7L of straw coloured ascitic fluid was drained and showed undifferentiated packed cells with no organisms or acid-fast bacilli (AFB). Alpha-Fetoprotein level was low (3.4 IU/ml), not suggestive of malignancy. CT thorax, abdomen & pelvis showed gross ascites with oesophageal varices, strongly suggesting liver cirrhosis with portal hypertension. No hepatic lesion suggestive of hepatocellular malignancy.

Question: What was the reason for the "high clinical suspicion of spontaneous bacterial peritonitis"? Explain the significance of this finding: "showed undifferentiated packed cells with no organisms or acid-fast bacilli". What malignancy is unlikely when alfa fetoprotein is low?

Patient’s condition subsequently improved and was discharged after 5 days of hospitalization with her old medication, which T. Ciprofloxacin 750mg OD, T. Furosemide (Lasix) 40mg BD, T. Spironolactone 50mg ON, Slow K 600mg OD, T. propranolol 20mg BD, syrup lactulose 15ml OD and T. Pantoprazole 40mg OD. She was planned for repeat OGDS in 1 month to review her oesophageal varices and given follow-up at surgical outpatient department in 2 months.

Question: Did the patient improve because of the paracentesis or because of the antibiotics? What do you think about the dose of Spironolactone? What potentially dangerous drug-drug interaction do you see in her prescription at discharge?

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