CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION WITH PORTAL VEIN THROMBOSIS WITH RETROVIRAL DISEASE
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A 30 year old female came to OPD with C/O B/L lower limbs and abdominal swelling since 3 years.
History of presenting illness:
Patient was apparently asymptomatic 3 years back then she developed bilateral lower limb swellings which were inscidious in onset, started at lower limbs and then ascended to abdomen, later she went to local scan and taken USG and there according to scan report, said as stones in gall bladder and swelling of liver(no reports) and then she used medication (lasix and protein powder) and then edema relieved subsequently after using medications for 2 months and then now, after two and half years, developed gradually and inscidious swelling of both lower limbs and abdomen. One episode of blood vomiting on 28/04/2022.
History of past illness:
-No H/O HTN, DM
-usage of lasix 2 years ago
-No H/O thyroid, TB, asthma
-H/O accident and fall and abrasion to left eyebrow when she was 10 years old.
-H/O blood transfusion at 10 years.
Personal history:
Patients husband diagnosed with HIV 6 years back and husband's brother also HIV positive.
General examination:
Patient is conscious, coherent and cooperative.
BP-110/80mmHg
PR-86bpm
RR-18cpm
Temp-98.5F
SpO2- 98% @ RA
Edema of lower limbs and abdomen
Clubbing present
No pallor/icterus/cyanosis/lymphadenopathy
Systemic examination:
CVS- S1 S2 present
RS- BAE+, NVBS
CNS- NAD
P/A-
Inspection- Abdomen distended, visible veins present, umbilicus flat , flanks full, umbilical hernia present
Palpation- mild spleenomegaly, mild hepatomegaly
Percussion- fluid thrill present
Auscultation- bowel sounds present
PROVISIONAL DIAGNOSIS-
CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION WITH PORTAL VEIN THROMBOSIS WITH RETROVIRAL DISEASE.
INVESTIGATIONS:
Ascitic fluid-Appearance-clear, yellowish
TC-75cells
DC-90% lymphocytes
10%polymorphs
CD 4 COUNTS- 370 CELLS
29/04/2022
Hb-7gm/dl
TLC- 7600
PLT- 1.95
01/05/2022
02/05/2022
04/05/2022
Na+- 134
K+- 4.1
Cl-101
Ascitic fluid cytology
Clear, colorless
TC-280 cells
DC- polymorphs 80%, lymphocytes 10%, mesothelial cells 10%
RBC -NIL
TREATMENT
1.T. Lasix 40mg po/tid
2.T ALDACTONE 50mg po /od
3.Syrup . Lactulose 10ml/po/tid
4. T. Propranolol 10mg/po/bd
5. T. Rifagut 550mg/bd
6. T. Ciprofloxacin 500 mg bd
7. Inj. Monocef 2gm/iv/bd
8. Salt and fluid restriction
9. 2-4 egg whites/day
S - patient becoming drowsy in day time, shortness of breath, decreased vision in both eyes since yesterday evening. Dark coloured stools.
O - excess day sleep, bp 120/70, pr 78, spo2 96 on RA. No Tremors, passing dark coloured stools. Though no significant hb drop ( 7 @admission now 6.7 ). CD4 - 397. Ascitic fluid ADA 5.4
A - ?grade 1 hepatic encephalopathy with Malena and RVD+ on dtl
P - enema twice daily. Propronalol 10mg.
In 1988, the International Ascites Club divided refractory ascites into two categories: type 1, or diuretic-resistant ascites, which is defined as the inability to mobilize ascites fluid despite intensive medical therapy and salt restriction diet for at least 1 week; and type 2, or diuretic-intractable ascites, which is characterized by the recurrence of ascites secondary to the development of diuretic-induced complications, which prevents the use of the maximal dose of diuretics.
initial fractional excretion of sodium (FeNa) greater than 0.2% may predict the development of refractory ascites in patients receiving diuretic therapy
recent studies have revealed that individual patients with normal hepatic function, plasma sodium levels, and refractory ascites who undergo TIPS can significantly improve transplant-free survival when compared to patients who receive large-volume paracentesis (P=.035).7 Furthermore, high levels of plasma renin, norepinephrine, and hypotension are markers of poor prognosis.31
TIPS is a noninvasive method used to treat refractory ascites. This procedure decreases portosystemic pressure by creating a shunt between the hepatic vein and the portal vein, relieving intra-abdominal pressure and improving renal function. Consequently, RAAS activity decreases, improving urinary sodium excretion.3,15,54 The success rate associated with TIPS is between 75% and 90%, depending upon the local expertise.29,55
Recurrence of ascites is known to occur in patients with refractory ascites after TIPS placement. However, TIPS patients have a lower recurrence rate than those undergoing paracentesis.54 The rate of recurrence for TIPS was shown to be 42% compared to 89% for large-volume paracentesis (P<.0001) in a study.7 Furthermore, a recent study revealed that individual patients with normal hepatic function, plasma sodium levels, and refractory ascites undergoing TIPS placement can significantly improve transplant-free survival when compared to large-volume paracentesis (P=.035). A significant increase in survival rate was also demonstrated (P=.009).7 Finally, TIPS is shown to improve hydrothorax in 60–70% of patients.2
The contraindications for TIPS include portal vein thrombosis, hepatic encephalopathy, an INR greater than 2, presence of SBP, age older than 60, ejection fraction less than 55%, and a Child-Pugh score (used for assessing prognosis of cirrhosis) greater than 12.29,30
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