case 6

Published on 24/06/2015 by admin

Filed under Internal Medicine

Last modified 24/06/2015

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INTRODUCTION

CASE IN DETAIL

SF’s current problems started with the gradual onset of lower abdominal pain 1 week ago. This was accompanied by abdominal distension. His pain gradually progressed in intensity and became generalised. The pain was dull and constant in nature and he could not identify any precipitating or relieving factors. Associated with these symptoms he developed anorexia and nausea, but did not vomit. This was followed by black, tarry bowel motions, which he first noticed 3 days ago. He presented to the emergency department of the hospital 1 day ago, where he was investigated with multiple blood tests, abdominal ultrasonography and upper gastrointestinal endoscopy. He was significantly anaemic and was transfused with 4 units of packed red cells. He was also commenced on an octreotide infusion and kept nil by mouth. On endoscopic examination he was diagnosed with bleeding varices as well as erosive gastritis. He was treated with banding of the varices and high-dose intravenous omeprazole therapy at 20 mg twice daily. He was also commenced on lactulose 10 mL three times daily for the prevention of hepatic encephalopathy. With this therapy he experienced diarrhoea with liquid motions on average five times a day. He underwent a diagnostic paracentesis and was subsequently commenced on intravenous ceftriaxone 1 g daily. However, he denied any fevers, rigors or drenching sweats.
SF was diagnosed with hepatic cirrhosis 1 year ago when he presented with abdominal distension and haematemesis. He was also noted to be hepatitis C antibody-positive on this presentation. He admitted having had body piercing and tattoos as a possible risk factor but denied any previous blood transfusions or intravenous drug use. Subsequent upper gastrointestinal endoscopy showed oesophageal varices, which were managed with banding. During the same admission he was commenced on a low-salt diet and advised against further alcohol consumption, but he did not comply with either instruction. He was followed up on discharge with four more 3-weekly endoscopic bandings.
Eight months ago he was readmitted with severe abdominal distension, dyspnoea and ascites, which was treated with abdominal paracentesis. He was then commenced on spironolactone 100 mg daily and propranolol 40 mg daily. Subsequently he has presented on three more occasions with tense abdominal distension for paracentesis, and the last episode was 6 weeks ago. He is currently on spironolactone 200 mg daily and frusemide 40 mg daily.
He was diagnosed with a duodenal ulcer 2 years ago when he presented with severe epigastric pain, nausea and vomiting. Diagnosis was made on gastroscopy. He was commenced on ranitidine 150 mg twice daily. Five months ago his symptoms recurred and his general practitioner changed his treatment to omeprazole 20 mg daily. He denies any knowledge of his Helicobacter pylori status and denies ever having been treated for H. pylori.
In summary, his current medications are frusemide, spironolactone, omeprazole, propranolol, lactulose and ceftriaxone.
He denies any allergies.
His family history is significant, with his father dying of bowel carcinoma at the age of 52. His mother is alive at the age of 65 and is well. He has three brothers: the oldest, aged 44, suffers from alcoholic cirrhosis and the second brother, aged 42, was operated on this year for bowel carcinoma; his youngest brother, aged 36, is well.
He lives by himself in a local hotel and has a flight of 10 steps to negotiate to get to his room. He is independent with the activities of daily living. He was married once but he divorced his wife 5 years ago. He has two daughters, aged 10 and 8, both of whom are well and living with his former wife. He rarely sees his daughters, and the last time was 3 years ago. His main social support is a group of friends that he meets in the pub. He does not visit his GP regularly. He spends most of the day in the pub, with his friends.
He worked as a seaman and a waterfront labourer before retiring 5 years ago after a back injury. But he denies any symptoms associated with it currently. He survives on a disability pension and claims it is adequate for his survival.
He smokes approximately one packet of cigarettes a day and has a history of 30 pack-years. He consumes in excess of 100 g alcohol a day in the form of cheap wine or rum. My directed assessment (CAGE questionnaire) confirmed that he is alcohol dependent. He has tried giving up drinking on previous occasions without any success. He has not undergone alcohol detoxification previously. He had his last drink prior to hospitalisation, 1 week ago. He denies any other previous or current recreational drug use.
My nutritional history suggests inadequate nutrition. He usually has his meals at the local fast-food outlet and often neglects his main meals.
He demonstrates very poor insight into his medical and social conditions. He has suffered from depression in the past and has been treated medically. He denies any ongoing vegetative symptoms of depression and is currently not on any antidepressant medication.
He complains of daytime somnolence and nocturnal insomnia.

ON EXAMINATION

SF was drowsy but rousable and cooperative. He appeared cachectic and had mild scleral icterus. He had tattoos on the ventral and dorsal aspects of his thorax and an intravenous cannula in the dorsal aspect of his right hand; the cannula site was not inflamed. He had multiple ecchymoses in the forearms bilaterally and in the forehead.
His pulse rate was 90 beats per minute and respiratory rate 20 per minute. He was afebrile, and his blood pressure was 130/95 mmHg with no postural drop.
His estimated body mass index was 20. His cognitive function was preserved, with a Mini-Mental State score of 28/30.
In the gastrointestinal examination there was no clubbing of the fingers, but there was palmar erythema bilaterally and a Dupuytren’s contracture in the left palm. There was a mild hepatic flap. He had parotidomegaly but no fetor hepaticus. His oral hygiene was poor. There were multiple blistering lesions in the perioral region, some filled with clear fluid and some crusted. There were multiple spider naevi in the upper thorax, both anteriorly and posteriorly. There was gynaecomastia. He had generalised abdominal distension without superficial venous dilatation. There were multiple scars in the left lateral aspect of the abdomen—possible evidence of previous paracentesis. On palpation the abdomen was firm and non-tender. There was firm-to-hard, non-tender hepatomegaly with an irregular edge. The hepatic span was 19 cm along the right anterior clavicular line. His spleen was just tippable in the left upper quadrant. There was a positive fluid thrill and a shifting dullness of 3 cm in the flanks. The kidneys were not ballotable and his bowel sounds were positive and normal.
There was evidence of testicular atrophy, and I would like to confirm this with formal orchidometry.
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