Abdominal Discomfort

Clinical Vignette

A 53-year-old man presents with weight loss and abdominal discomfort. Please examine his abdomen.

Positive Findings

  • General: Cachexia, muscle wasting, gynaecomastia, and testicular atrophy.
  • Skin: Excoriations, purpura, spider naevi, and jaundice.
  • Hands: Clubbing, palmar erythema, leuconychia, Dupuytren’s contractures.
  • Face: Icterus, parotid swelling, and pallor.
  • Abdomen: Ascites with shifting dullness, caput medusae, hepatomegaly with a dull edge that is non-tender.

Relevant Negative Findings

  • No tattoos or needle marks suggestive of hepatitis transmission.
  • No signs of hepatic encephalopathy.
  • No signs of cardiac failure (e.g., no elevated jugular venous pressure).
  • No signs of acute infection or superadded sepsis.

What is the most likely diagnosis?

Chronic liver disease (CLD) with hepatomegaly, most likely due to alcoholic liver disease (ALD) or viral hepatitis.

What is your differential diagnosis?

  1. Alcoholic liver disease (ALD) – Common cause, associated with cachexia, gynaecomastia, and Dupuytren's contracture.
  2. Viral hepatitis (HBV, HCV) – Consider tattoos, parenteral drug use, or high-risk sexual history.
  3. Non-alcoholic fatty liver disease (NAFLD) – Often associated with metabolic syndrome or obesity.
  4. Haemochromatosis – Look for slate-grey skin pigmentation, diabetes, and signs of heart failure.
  5. Wilson’s disease – Kayser-Fleischer rings, neuropsychiatric symptoms.
  6. Primary biliary cirrhosis (PBC) – Associated with fatigue, pruritus, and xanthelasma.

How would you investigate this patient?

Blood tests:

  • Liver function tests (LFTs) including bilirubin, albumin, alkaline phosphatase (ALP), and gamma-glutamyl transferase (GGT).
  • Full blood count (FBC) for anaemia, thrombocytopenia (suggests portal hypertension).
  • Coagulation profile (prothrombin time/INR) to assess liver synthetic function.
  • Hepatitis serology (HBV, HCV), autoantibodies (ANA, anti-smooth muscle, antimitochondrial).
  • Ferritin, transferrin saturation (for haemochromatosis), caeruloplasmin (for Wilson’s disease).
  • Alpha-fetoprotein (AFP) to screen for hepatocellular carcinoma.

Imaging:

  • Ultrasound abdomen: To assess liver size, splenomegaly, ascites, and portal vein patency.
  • Doppler ultrasound: To assess blood flow in the hepatic and portal veins.
  • CT abdomen: For further evaluation if malignancy is suspected.

Ascitic fluid analysis (if ascites present):

  • Cell count, protein concentration, culture, and sensitivity for spontaneous bacterial peritonitis.
  • Serum-ascites albumin gradient (SA-AG) to differentiate between cirrhotic and non-cirrhotic causes of ascites.

Liver biopsy (if diagnosis is unclear) to assess the degree of fibrosis and confirm the underlying pathology.

How would you manage this patient?

General measures:

  • Abstinence from alcohol in cases of ALD.
  • Salt restriction for patients with ascites.
  • Vitamin B supplementation and thiamine if alcohol-related liver disease.
  • Diuretics: Spironolactone and furosemide for ascites, aiming for 1 kg/day weight loss.
  • Endoscopic surveillance for varices if portal hypertension is suspected.
  • Nutritional support and dietary advice.

Specific treatments based on the underlying cause:

  • ALD: Abstinence and supportive care.
  • Hepatitis C: Antiviral treatment (e.g., direct-acting antivirals).
  • Wilson’s disease: Chelation therapy with penicillamine or trientine.
  • Haemochromatosis: Regular venesection to maintain ferritin levels below 50 μg/L.
  • Autoimmune hepatitis (AIH): Steroids and azathioprine.
  • Primary biliary cirrhosis (PBC): Ursodeoxycholic acid.

Complications:

  • Treat variceal bleeding with band ligation or sclerotherapy.
  • Manage hepatic encephalopathy with lactulose and rifaximin.
  • Consider transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites.
  • Assess for liver transplantation if decompensated cirrhosis or hepatocellular carcinoma.

Viva Questions

What are the signs of decompensated chronic liver disease (CLD)?

  • Jaundice, asterixis (liver flap), encephalopathy, ascites, hepatic fetor, and coagulopathy (bruising, active bleeding).

What are the precipitating factors for hepatic encephalopathy?

  • Alcohol, infections, gastrointestinal bleeding, constipation, electrolyte imbalances, and sedatives.

How is ascites investigated?

  • Serum-ascites albumin gradient (SA-AG):
    • SA-AG ≥ 11 g/L: Cirrhosis, cardiac failure.
    • SA-AG < 11 g/L: Malignancy, tuberculosis.
  • Neutrophil count > 250 cells/mm³ in ascitic fluid is indicative of spontaneous bacterial peritonitis (SBP).

What are the potential indications for liver transplantation?

  • Cirrhosis with complications (e.g. variceal bleeding, hepatic encephalopathy).
  • Acute liver failure (e.g. from paracetamol toxicity, viral hepatitis).
  • Primary sclerosing cholangitis, primary biliary cirrhosis and hepatocellular carcinoma.

What complications are associated with chronic liver disease?

  • Portal hypertension
    • ascites
    • variceal bleeding
    • hepatorenal syndrome
  • Reduced synthetic function
    • hepatic encephalopathy
    • coagulopathy
  • Hepatocellular carcinoma