Examination: Abdominal Swelling: Liver Cirrhosis

Casebank Combined
1

Who are you:
You are an FY2 in GP surgery.

Who the patient is:
Tom Henderson, 55 years old, has some concerns.

Other information
None

Special Note
None

What you should do:
Take focused history, do the relevant examination, and address the patient’s concerns.

Approach

  • GRIPS
  • OA (aka ODIPARA) for Abdomen Swelling
    D: When did you first notice the swelling?
    P: 3-4 months ago.
    D: When you say abdominal swelling, do mean feeling bloated?
    D: Is it there all the time or it comes and goes?
    D: Is the swelling getting worse?
    D: Is there anything that makes it worse? Does food make it worse?
    D: Is there anything that makes it better? brings down the swelling?

Differential Diagnosis

  • Heart failure - SOB at night? How many pillows do you use? Swelling of leg that’s worse by the end of the day? Any palpitation? Any heart problem?
  • Liver failure - Alcohol History, Any jaundice? Any liver problem?
  • Colonic cancer- Any weight loss? Any change in bowel habits? Any constipation or diarrhoea?
  • Renal failure- Any kidney problems? Anyone in your family with kidney problems?
  • Malignancy- systemic review
  • Ovarian cancer- any lower abdominal discomfort? any bleeding from down there (PV)? any family history ovarian cancer?
  • IBS - any food cause bloating, diarrhoea and abdominal discomfort
  • Celiac disease- gluten associated abdominal discomfort
  • Chronic urinary retention- any urinary problem? nocturia? urinary frequency? urgency? dribbling?

PMAFTOSA

  • P: I drink 4 pints or cans of beer daily.

ICE

Psychosocial impact

Examination

  • Observation
  • Abdominal examination: Abdomen Mannikin in room, Findings: Ascites (demonstrate: flank and shifting dullness), enlarged liver
  • Respiratory examination: Normal
  • Cardiovascular: Normal
  • External genitalia: Normal
  • Lower limb examination: Normal
  • PR examination: smooth enlarged prostate
  • Urine dipstick: Normal
  • ECG: Normal

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Diagnosis

From what you have told me so far, you’re drinking 4 pints of beer daily, 1 pint or cans is 2.5 Units, ie 10 units a day and 70 units a week, which is way above the recommended amount, ie less than 14 units per week. And over years as you have been drinking for sometime, it can cause liver damage. Therefore, I’m suspecting it’s a Liver Cirrhosis, which is as a result of regular alcohol you have been taking.

Management

  1. Reduce alcohol intake and if possible complete stop drinking alcohol
  2. Today we’re going to do:
    • Routine blood test
    • arrange a USG of the liver
  3. We’ll refer you to a gastroenterologist, they’ll:
    • go through the results of the test that we’ll do today
    • and may also perform specialist investigation
      Needle paracentesis: they take some fluid from your tummy for further investigation
      Liver biopsy: to find the exact cause.
  4. If its confirmed that you’ve liver cirrhosis, usually they’ll treat you with:
    1. Lactulose: some laxative called lactulose, to prevent toxic substance being absorbed in your body and going to your brain, it’s a complication of liver cirrhosis.
    2. Spironolactone: to remove fluid in your tummy.

Alcohol Units

  • Wine: 1 glass = 3 units, 1 bottle 3 glasses, A bottle of wine = 9 units
  • Beer: 1 pint = 2.5 units
  • Spirit, Whisky, Brandy, Vodka, Rum, Gin, Tonic: 1 shot = 1 unit, 1 shot is 25 ml, 1 bottle = 30 units, Half a bottle = 15 units
  • Recommended amount < 14 units per week.
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