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Congestive Hepatopathy Case Presentation PowerPoint Presentation

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Published on : Oct 28, 2018 | Views : 2381 | Downloads : 1

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Slide 1-

Case presentation Presented by : Dr.Hamad A.lAblani , IM R2 Supervised by : Dr.Abdullah Madani ( Consultant Hepatologist )
Slide 2-

Chief Complaint Abdominal pain Vomiting Yellowish discoloration of 7 days skin & sclera
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History of presenting symptoms 28 years old Saudi gentleman known case of Bronchial asthma , Came with history of mild to moderate epigastric and right upper quadrant pain started 7 days ago , started suddenly with dull in nature , not radiated , associated with vomiting ( one to two times per day with food contents ) and yellowish discoloration of skin and sclera with dark urine , not related to a specific time with no relieving or exacerbating factors ( not related to foods ) .
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Systemic Review NO Hx of heartburn sensation , loss of appetite . NO HX of Diarrhea or constipation . No HX of dysphagia or hematemesis . NO HX of abdominal distension . No HX of fever , night sweating , or weight loss . NO HX of raw milk ingestion . NO HX of contact with sick people or recent travel NO HX of SOB , chest pain , orthopnoea ,PND , palpitations , syncope or LL oedema . NO HX of easy bruising or ecchymosis . No HX of skin rash or pigmentation or joints pain . NO HX of polyuria, dysuria or GU symptoms
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Past medical & surgical History He had history of recurrent shortness of breath on&off with cough since 8 months , and he went to primary care physician and he diagnose him as BA and start him on salbutamol PRN . No previous surgeries No pervious hospital admissions No history of blood transfusion Vaccination history uncelar .
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Drugs history Salbutamol inhaler PRN Paracetamol 500mg per-oral Q8h PRN
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Family History 3 sister , 4 brothers . Two of his brothers had dilated cardiomyopathy . No history of similar presentation in the family ( abdominal pain , jaundice ) No history of malignancy in the family .
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Social History Military Single , lives in Riyadh Not smoker , Not alcoholic . No history of drug abuse or using herbal meds . No history of recent travel No history of Contact with animals or sick patients . Allergic History Not known to have any allergies from food or drugs .
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Summary 28 years old Saudi gentleman known case of Bronchial asthma , Came with history of mild to moderate epigastric and right upper quadrant pain started 7 days ago , started suddenly with dull in nature , not radiated , associated with vomiting and yellowish discoloration of skin and sclera with dark urine , not related to a specific time with no relieving or exacerbating factors ( not related to foods ) .
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Examination
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General Examination General Conscious, alert, oriented to T/P/P. connected to IV line Not on respiratory distress Looks jaundiced , not pale or cyanosed . Vitals T : 36.2 BP: 110/88 mmHg SITTING , 106/85 STANDING HR: 73 RR : 26 O2 sat: 97% on RA BMI : 22
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HEENT: yellowish discoloration of sclera ( jaundice ) No lymph nods enlargement No mouth ulcers No distended neck veins Hands: No clubbing No Leukonychia No Palmar erythema or deformity
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Abdominal Exam Inspection - Normal abdominal contour - Inverted umbilicus, no visible hernia, or dilated veins , masses or Striae , no surgical scars , No visible peristalsis with normal hair distribution . Palpation Soft , lax . Mild tenderness at epigastric and right hypochondrial areas .
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No hepatosplenomegaly . Kidneys were not palpable No palpable masses , No Fluid thrill . No inguinal or axillary lymph node enlargement . Percussion No Shifting dullness . Liver span in 12 cm at midclavicular line Auscultation +ve bowel sounds , no bruits PR Examination : Unremarkable
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Cardiovascular Exam Inspection: No scars , No visible pulsation . Normal JVP. No chest wall abnormalities Palpation - Apex beat at left 6th intercostal space, mid clavicular line . - No parasternal heave or palpable thrills . Auscultation S1 +S2 + 0 No pericardial rub, no added sounds or murmurs
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Chest Exam Inspection Patient setting in 45 degree , exposed from waist up No nasal canula . Not using accessory muscle . No scars , prominent veins or deformity. Symmetrical chest movement . Palpation Trachea is central . Equal chest expansion , front and back . Tactile vocal fremitus not increased or decreased
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CONT. – Chest exam Percussion Resonant bilaterally Auscultation Normal vesicular breathing with equal bilateral intensity of breath sounds with no added sound Neurological examination : Intact with normal power and tone
Slide 18-

Investigations
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CBC U&E LFTs Coagulation Profile
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US abdomen Liver , gall bladder, pancreas , spleen are unremarkable . - No fluid collection seen .
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EGD GERD grade B , WITH mild antral gastritis .
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On the third day of admission , Pt. started to have shortness of breath , tachypnea , tachycardia , with desaturation . ICU team was contacted . - Cardiac enzymes , full septic screens were done . - CXR showing CARDIOMEGALY . - Bed side TT-ECHO showing : Left ventricle is severely dilated , with severe global hypokinesia of LV , severe TR + MR EF : 20 %
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Congestive Hepatopathy
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Hepatic congestion can result from any cause of right-sided heart failure, including constrictive pericarditis, mitral stenosis, tricuspid regurgitation, cor pulmonale, and cardiomyopathy . Hepatic congestion should be suspected in patients with clinical and laboratory features suggestive of congestive heart failure or other cardiac condition associated with elevated central venous pressure .
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In addition to a careful history (especially for risk factors for liver disease and medications that might contribute to hepatic injury) and a physical examination, a reasonable evaluation might include serologic testing for viral hepatitis, hemochromatosis, Wilson disease (especially in a younger person), alpha-1 antitrypsin deficiency, celiac disease, autoimmune hepatitis, thyroid dysfunction, a right upper quadrant ultrasound with Doppler studies of the portal and hepatic veins and hepatic artery, ECG, and a cardiac ultrasound.
Slide 28-

The cornerstone of management is treatment of the underlying heart disease. Care should be given to avoid excess diuresis, which could impair hepatic perfusion. Patients who require warfarin anticoagulation for their cardiac condition should be monitored closely, since patients with congestive hepatopathy are at increased risk for excessive anticoagulation. Uptodate
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Thank you