Slide 1

Report
 A 40-year-old male NKCM,but the history of iv
drug abuser for many years presented to the
ER with C/O
 severe abdominal pain associated with fever
since 3 days
 Also history of black or tarry stool (malena) 4
weeks ago
 Also c/o anorexia since 10 days.
• . O/E revealed "track" marks on both arms.
• PALE looks skin
• Distended abdomen
Lab investigations
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Hb 8.1
Tlc 4.0
Plts 80
MCV 102
Ur 35
Cr
0.65
Na 138
K
4.5
Chl 104
Bicarb 22
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PT 28
APTT 42
INR 4
Albumin 2.3
ECG
Normal
CHEST X .RAY
Unremarkable
LFTs
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Bilirubin 2.o
D/billi
2.43
ID /billi 1.5
SGPT
102 (serum glutamic-pyruvic
transaminase, ALT)
• SGOT
128 (serum glutamic-oxaloacetic
transaminase ,AST)
• ALT PHOSPHTASE 102
• GAMMA GT
60
•What is the differential
diagnosis of abdominal
pain????
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Acute gastroentiritis
Intestinal obstruction
Appendicits
Renal stone
Viral hepatitis
Liver abcess
Gastric ulcer
Abdominal TB
Malignancy
Acute pancreatitis
•What is the differential
diagnosis of abdominal
pain with fever????
What is the differential diagnosis of
faver?
• Bleeding from a lesion in the
esophagus,stomach, and duodenum is called
upper GI bleed.
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(i) hematemesis
• (ii) malena,
vomiting of blood
passage of black tarry stool
Causes of upper GI bleed
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Esophagitis
Esophageal varices
Mallor_weiss tear
Gastric ulcer
Duodenal ulcer
Ca stomach
Mallory-Weiss tear
• A Mallory-Weiss tear occurs in the mucus membrane
of the lower part of the esophagus or upper part of the
stomach, near where they join. The tear may bleed.
• Mallory-Weiss tears are usually caused by forceful or
long-term vomiting or coughing. They may also be
caused by epileptic convulsions.
• Any condition that leads to violent and lengthy bouts
of coughing or vomiting can cause these tears.
Bleeding esophageal varices
• Bleeding esophageal varices are enlarged
veins in the walls of the lower part of the
esophagus that bleed. The esophagus is the
tube that connects your throat to your
stomach.
Causes of oesophageal varices
Pre-hepatic
•Portal vein thrombosis.
•Portal vein obstruction - congenital atresia/stenosis.
•Increased portal blood flow - fistula.
•Increased splenic flow.
Intra-hepatic
•Cirrhosis due to various causes, including alcoholic, chronic hepatitis (eg viral
or autoimmune).
•Idiopathic portal hypertension (hepatoportal sclerosis).
•Acute hepatitis (especially alcoholic).
•Schistosomiasis.
•Congenital hepatic fibrosis.
•Myelosclerosis.
Post-hepatic
•Compression (eg from tumour).
•Budd-Chiari syndrome.
•Constrictive pericarditis (and rarely right-sided heart failure).
Oesophageal varices
• WHAT FURTHER
INVESTIGATIONS YOU WILL
ADVISE ON THE BASIS OF
THESE LABS??
• HbsAg
• IF +VE THEN GO FOR PCR OF HBV (DNA)
• Anti HCV . If +ve , then get PCR for HCV
(RNA).
• U/S abdomen . Liver status ,shrinkage,any
• tumor,margins.
• There is no vacanation of HCV due to RNA
genotype
• There is a vacination of HBV due to DNA
genotype
How many types of viral
hepatitis?
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Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E ( PREGNANCY)
Three things for liver function
monitoring
• LFTs (If LFT derrange specialy SGPT it means
liver problem developed)
• PT, APTT, INR (if pt ,aptt,INR incresase it
means acute liver problem)
• Albumin (If Albumin decrease it means with
PT,APTT,INR, increase it means chronic liver
problem)
• PCR OF HCV (RNA) POSITIVE OR
• PCR OF HBV (DNA) POSITIVE
• WITH
• Decompensated liver disease
• Decompensated liver disease means that the
medications and treatments used to treat the
liver is no longer working very well and the liver is
near total failure
• It means only symptomatic treatment
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IVF
IV Antibiotics (if infections develop)
Diuretics (k sparing diuretics Aldactone)
Antipyretic (if fever spike)
Mangement of upper GI Bleed
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IV access
Oxygen
Sedation
Blood transfusion
PPI (proton pump inhibitor)
Octreotide (vasopressin)
surgery
IF PCR OF HCV (RNA) POSITIVE
• WITHOUT DECOMPENSATION
• THEN START INJ
INTERFERON
CAPSULE RIBAVIRIN
WITH
IF PCR OF HBV (DNA) POSITIVE
• WITHOUT DECOMPENSATION
• INTERFERON THERAPHY (interferon
alpha,peginterferon alfa-2b)
• NUCLEOSIDE ANALOGUES (lamivudine tab
zeffix 100mg 1 OD , and adefovir 10mg 1.OD)
Side effects of interferon theraphy
• Thrombocytopenia
• Flu like symptoms

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