Case Studies 18 : Liver Cirrhosis with Hepatic Encephalopathy.
This is a case of a male patient, aged 46 yrs, diagnosed as a case of Alcoholic Liver Cirrhosis with Hepatic Encephalopathy.
As per the details received from his wife he was a chronic drunkard since 15 yrs and quantity had increased drastically since last 1 yr. Also he was a known case of D.M. & HTN since last 15 yrs. His condition was such that he couldn’t work well at his work place, hence had to take Voluntary retirement.
Thereafter in Nov. 2007, he was observed to have yellowish discoloration of eyes and whole body. When investigated, his bilirubin level was found to be 9 gm%. He tried all sorts of treatment for the same without any relief. He also consulted many specialists, but in vain.
Thereafter patient’s condition further deteriorated with increased ascitis, icterus along with irrelevant talk. So at last was admitted in ICU of a superspeciality hospital. His bilirubin level which was 14 gm% on admission increased to 30 gm% within 17 days of admission inspite of treatment. Because of severe ascitis he underwent ascitic tapping thrice with removal of 5 lit of aspirate; but still had no relief. Along with this he developed bed sores.
After trying for 17 days and considering the bad prognosis, where there were no chances of recovery left, the doctors advised his relatives to take him home.
During this period they happened to come to know about my hospital and came to me for consultation. When patient came, he was in a severe toxic condition. He required support while entering in my consulting room. I observed that he had yellowish discoloration of entire body like the color of turmeric with grossly distended abdomen. There was oedema over the face especially below the eyelids. He sat on the chair with difficulty, leaning backwards and was so prostrated that he was getting breathless while talking. He was looking chilly wearing a monkey cap on his head. Also his wife added that he was not taking food but only milk & fruits since last 4 – 5 months that too in minimum quantities.
Alcoholic Liver Cirrhosis & Hepatic Encephalopathy:
Cirrhosisis a consequence of chronic liver disease characterized by replacement of liver tissue by fibrous scartissue as well as regenerative nodules (lumps that occur as a result of a process in which damaged tissue is regenerated), leading to progressive loss of liver function. Cirrhosis is most commonly caused by alcoholism and hepatitis C, but has many other possible causes.
Cirrhosis is the twelfth leading cause of death by disease, killing about 26,000 people each year. Also, the cost of cirrhosis in terms of human suffering, hospital costs and lost productivity is high.
Ascites(fluid retention in the abdominal cavity) is the most common complication of cirrhosis and is associated with a poor quality of life, increased risk of infection, and a poor long-term outcome. Other potentially life-threatening complications are hepatic encephalopathy (confusion and coma) and bleeding from oesophageal varices. Cirrhosis is generally irreversible once it occurs, and treatment generally focuses on preventing progression and complications. In advanced stages of cirrhosis the only option is liver transplant.
If complications cannot be controlled or when the liver ceases functioning, liver transplantation is necessary.
The prognosis of alcoholic cirrhosis depends on whether the patient can abstain from alcohol; this in turn is related to family support, financial resources and socioeconomic state. Patients who abstain have a five-year survival rate of 60-70%, which falls to 40% in those who continue to drink. Hepatocellular carcinoma occurs in 10% of stable cirrhotics. It is usually fatal in six months.
Hepatic encephalopathy (HE) is a complex, potentially reversible neuropsychiatric condition that occurs as a consequence of acute or chronic liver disease. It is characterized by changes of personality, consciousness, behavior and neuromuscular function. Early features include reversal of sleep pattern, apathy, hypersomnia, irritability and personal neglect. In later stages, delirium, coma and death may occur.
26.01.2008 :
|
BUN |
53.50 mg/dl |
|
Creatinine |
1.60 mg/dl |
|
Total Bilirubin |
28.50 |
|
Direct Bilirubin |
17.90 |
|
Indirect Bilirubin |
10.60 |
|
Alkaline Phosphates |
149.00 U/L |
28.01.2008 : Ultrasound of Abdomen & Pelvis :
Findings are suggestive of :
- Enlarged liver with coarse heterogenous texture and nodular outlines.
- Cirrhotic liver disease.
- Splenomegaly.
- Gross Ascitis.
- Mild Gall Bladder wall thickening with intraluminal sludge noted.
29.01.2008 : Prothrombin Time : 21.3 (Normal 11.6)
04.02.2008 :
|
Creatinine |
1.6 |
|
Total Bilirubin |
30.2 mg/dl |
|
Direct Bilirubin |
16.2 mg/dl |
|
Indirect Bilirubin |
14.0 mg/dL |
|
ALK Phosphates |
130.0 U/L |
04.02.2008 :
Fluid ADA Level : 70.26 IU/L.
(Sample – Ascitic fluid)
His complaints in detail were as follows :
1. Distension & pain in abdomen since 5 months.
- Pain in abdomen (Lt.) hypochondriac region, sometimes (Rt) hypochondriac region.
- Continuous lancinating type of pain along with flatulence.
- Sudden onset and gradual decline.
- Pain radiating to all directions.
< Eating food after. > Lying on painless side.
< Motion. > Sitting with support.
< Lying on painful side.
< Sitting erect.
< Bending forward.
< Cough during.
- Associated with nausea & vomiting occasionally.
2. Severe weakness and prostration since 2 – 3 months.
- Can’t stand for a long time.
- Unable to sit for long.
- Unable to stand up from sitting position and wants support.
- Imbalancing while walking.
< Slight exertion. > Lying down.
3. Loss of appetite since 2 – 3 months.
- Can’t eat food due to distension of abdomen.
- Unable to have solid food but taking liquid e.g. Soups, Milk, Tea with biscuits.
4. Bed sores since 1 month.
Location: Buttocks and thighs.
1. H/o Tonsillectomy in childhood.
2. # Knee joint 10 yrs before due to accident on bike. (Side ?)
3. Injury to hand # of Interphalangeal joint of (Rt) thumb & index finger 2 yrs before.
4. Tapping – ascitis thrice, in last 15 days.
Mother : Rheumatism, HTN.
Father : HTN.
Habit : Alcohol (Wine) since 15 yrs Regular. Increased since 1 yr. Tobacco since 20 yrs. (1 pack/day)
Diet : Mixed.
Appetite : Decreased since 2-3 months.
Desire : Pungent++ / Spicy++ / Mutton++ / Milk / Oily Food / Cold Drinks / Ice-Cream.
Aversion: Sweet.
Eyes : Spects for distant & near vision. Yellowish discoloration of sclera.
Nose : Cold & Coryza occasionally. Watering from nose.
< Change of weather.
Mouth : Profuse salivation.
Tongue : White thin coating on tongue, moist.
Thirst : L.Q.S.I. in past. But due to distension of abdomen doesn’t drink water, but basically thirsty.
Teeth : Brownish coating over teeth.
Chest : Breathlessness since 5-6 months occ.
< Physical exertion. > Rest.
< Walking.
< Motion.
Perspiration: Profuse on face, forehead.
< On slightest movement.
Bowel : Unsatisfactory, soft stool. 2-3/day, 1-2/night.
Bladder : 4-5/day. 1-2/night, dark yellow colour.
Skin : Yellowish discoloration over body.
Sleep : Disturbed & unrefreshing sleep. Lying on alternate sides. Covering up to head.
Dreams : Of daily routine. But in past, he had horrible dreams like tree is falling on him.
Thermal : Previously HOT but now TOWARDS CHILLY & motion < Chilliness.
Since the patient was in a delirious state, most of the following information was provided by his wife and other relatives.
1. When asked about his childhood
The patient was born and brought up in poor financial conditions. They were 2 brothers & a sister and patient was 3rd amongst them. Patient had to work hard since childhood due to poor financial condition. He could complete his 11th std. but could not study further in spite of the desire to do so.
By nature, patient was very short tempered and irritable and also very talkative.
2. What about his nature now ?
Wife said that even now patient is extremely short tempered and irritable and also uses abusive language when angry. Everything should happen according to his wish and thinks that whatever he says is always right. He usually expresses his anger only at home. There have been episodes when he had hit me & my children. His behaviour outside is very different. He gets angry if too much expenditure is done by me or children. He requires all things to be kept in proper places or else gets very angry. All our family members and relatives fear him for his temper and his extremely straight-forward behavior.
In spite of being the younger most in the family, he is the one who takes various decisions and looks after all the transactions.
He was very good at his work place; well known for his perfect work and his seniors would also consult him for opinions. He was the one who would motivate his colleagues when they became depressed. Still I don’t understand that how did he end up getting so addicted to alcohol.
He is a very restless person, never sits idle, and doesn’t like domination in any way. Previously he would like travelling and taking part in social activities. Earlier he had many friends and use to like being with them, but now it has all reduced since last 10 yrs. According to me, his alcohol habit is due to his bad friend circle.
3. Tell me about your relationship with family members?
I was married in 1987 and since then I always had conflicts with my wife. My son doesn’t like my habit of consuming alcohol. At times if I scold him in front of others, then he back answers at me. I feel insulted and get angry with him.
Wife added, he has a very good relation with his father and mother and weeps when talking with them since the illness started.
4. Tell me about any tensions & worries you have?
As such I don’t have any worries at present; but earlier when I was working, there were many tensions due to increased workload as the manpower was low. Besides this, I had some conflicts with one of my colleague 5-6 months before leaving the job.
- Short tempered.
- Anger on contradiction.
- Dictatorial.
- Desire company.
- Towards Chilly.
- Abdomen distention.
- Great weakness and prostration.
- Loss of appetite.
- Thirsty patient.
- Motion < Chilliness.
- > Lying down.
- Desire : Pungent / Spicy / Mutton / Milk / Oily / Cold Drinks / Ice-Cream.
- Alcohol & Tobacco desire.
Looking at his critical condition I advised immediate admission. His appetite improved within 3-4 days of treatment which he had lost since 5-6 months.
His weakness gradually reduced, he was able to sit and move a little. His bilirubin level which was 30.2 on admission got reduced to 12.1 on 13.02.2008 just on the second day of admission. I was extremely happy on his recovery as it was a risky case.
Day by day he showed gradual improvement in his general condition. Yellowishness of the skin, sclera, and urine reduced.
His complaint of distended abdomen & pain due to ascitis also reduced. His further routine investigations also showed improvements.
After a month, at the time of discharge, his total Bilirubin level was 4.8, SGPT : 25, SGOT : 50.
He could walk on his own and also ascend & descend stairs. His distended abdomen got reduced and the contour became completely normal (without any ascitic tapping). His wife & family members were extremely happy as it was like a rebirth for them.
His investigations from time of admission up to now are as follows .
|
Date |
BUL |
Sr. Creatinine |
S. Bilirubin |
SGPT
|
SGOT
|
|
13.02.2008 |
46 |
1.1 |
12 |
108 |
196 |
|
22.02.2008 |
|
|
6.1 |
75 |
122 |
|
01.03.2008 |
|
|
4.6 |
35 |
48 |
|
10.03.2008 |
|
|
4.7 |
42 |
44 |
|
18.03.2008 |
|
|
4.8 |
25 |
50 |