Ascites

A 47 yr old male presented to op with c/o
Abdominal distention since 15 days
B/l pedal edema upto thigh since 15 days,with a slight decrease on lying down
Not a/w dyspnoea,fever, decreased urine output,Malena  constipation, haematemesis,easy bruisability,
Not a k/c/o dm2 or htn
K/c/o chronic alcoholic since 20yrs consuming 180ml whiskey /day discontinued for the past 2 months due to unavailability of liquor
Not a smoker

Prov diagnosis as per history: alcohol liver disease?cirrhosis(decompendated)

On general examination:
Icterus+
No signs of clubbing
No spidernaevi,palmar erythema,gynecomastia,leukonychia,
 Abdominal examination
Appeared tensly distended with no engorged veins ,umbilicus is flat,no striae
Palpation:organs couldn't be palpable
                   Shifting dullness +(indicating fluid >1000ml)
      Fluid thrill absent
Auscultation: bowel sounds present,no bruits
                      RS:bae+with coarse rt basal crepts
                      CVS: jvp appeared raised in 90 degree sitting position,upto bifurcation of carotid.
             Heart sounds heard in all areas,
              Provisional diagnosis based on examination:
Liver failure due to alcohol intake-h/o alcohol ingestion,ascites
Heart failure-pleural effusion,ascites ,pedal edema, jvp raised
Constrictive pericarditis-hepatojugular reflex -sustained, low voltage complexes on ecg

https://www.ncbi.nlm.nih.gov/books/NBK526097/(input from my colleague)
MELD scoring=16 point
Maddreys discrimination factor=53
(>32 is suggestive of poor prognosis and need for anti inflammatory treatment as per theory that interleukins and tnf alpha mediate tissue destruction)
Diagnostic query?


Usg-showed altered echotexture of the liver and splenomegaly which could not be assessed clinically
Hb=6.8, plt 70,000(h/o bleeding per rectum ? haemorrhoids 20days back)
Stool for occult blood-negative.
Lft interpretation:AST/ALT =Less than one with no fourfold increase in their values as expected
Alb 2.8- suggests chronic pathology as half life of albumin is 21 days , and overload features probably due to hypoalbuminemia.
Which is not -nephrotic syndome/?protein loosing enteropathy - no loss of protein in urine

Expected SAAG- >1.1, with ?ascitic protein evaluation for differentiating cardiac and liver causes

Taught my intern the procedure and the method of evaluation.

Colour- straw,clear.
SAAG-2.5 (high )
Ascitic protein-0.7(suggestive of liver /biliary tract pathology)
With sugar -111, tlc-200, lymphocyte predominance, and cytology negative for malignancy

2d echo- mild TR with mild PAH.

Treatment
Loop diuretics with aldactone
Salt and water restriction
High protein diet
Advice regarding alcohol abstinence....(hopefully will follow up on that)

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