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‘A 54 years old male presented with generalized swelling & weight loss.’
1. ‘A 54 years old male presented with
generalized swelling & weight loss.’
Speaker:
Dr.Farhana Faruque
Indoor Medical Officer, Medicine Unit – II,
SSMC & MH
2. Salient Feature:
Mr. Motiur Rahman, 54 years old, male,
muslim, normotensive, nondiabetic, non
smoker, non alchoholic, businessman, hailing
from Shibganj, Chapainababganj, admits in
this hospital on 21st
December 2017 with the
complaints of generalized swelling of whole
3. Salient Feature(contd.)
body for 04 months, loss of appetite &
weight loss for same duration. Initially
swelling starts at both legs, then it
involves the abdomen & gradually
increasing. Abdominal distension is
associated with discomfort, flatulence &
4. Salient Feature(contd.)
abdominal fullness which usually occurs
after taking meal. There is no history of
breathlessness, cough, facial puffiness &
urine volume is normal. He also complaints
of loss of appetite & significant weight loss
over the last 04 months.
5. Salient Feature(contd.)
He looses about 30 kg during this period. But
there is no history of fever & night sweat.
His bowel moves irregularly 03 to 04 days
apart. Stool is semisolid or sometimes hard
in consistency, not mixed with fresh blood.
He denies any history of jaundice, vomiting,
6. Salient Feature(contd.)
hematemesis, melaena, joint pain, skin rash,
pigmentation. He has history of open
cholecystectomy and appendicectomy 2 years
and 19 years back respectively. He has
history of blood transfusion previously. With
7. Salient Feature(contd.)
consulted with various physicians. Later he
admitted in this hospital on 30th
October 2017
& diagnosed a case of ‘Intestinal Tuberculosis’
in our department. We discharged him with
CAT-I anti TB drug & steroid. After taking
anti TB drug patient was clinically improved
8. Salient Feature(contd.)
about 20 days, then he again develops
ascites & leg oedema simultaneously &
readmits in our unit at 21st
December 2017.
He has no history of IV drug abuse or sharing
of needles. There is no family history of
9. Salient Feature(contd.)
is ill looking, below nutritional status,
mildly anaemic, non icteric, bipedal pitting
oedema was present, pulse-60 beats/minute,
blood pressure- 90/60 mmHg & all other
vital parameters are within normal limit.
On Alimentary system examination
10. Salient Feature(contd.)
oral cavity, tongue and pharynx are
normal. Abdomen is distended, flanks
are full, umbilicus is everted.There are
two scar marks, one in right hypochondrium
other in right iliac region. No visible peristalsis
present. No organomegaly.
11. Salient Feature(contd.)
Both testes are normal. Ascites present
evidenced by shifting dullness. Bowel sound
is present. Bed side heat coagulation test
is negative. Examination of other systems
reveals no abnormalities.
24. Investigations of 1st
admission contd. :
LFT:(30/10/2017)
SGPT 24 U/L
Serum total protein 5.1 g/dl
Serum Albumin 2.7 g/dl
Serum Globulin 2.4 g/dl
Albumin Globulin Ratio 1.12 : 1
25. Investigations of 1st
admission contd. :
LFT:(30/10/2017)
Prothrombin Time :
Control 12 sec.
Patient 18 sec.
INR 1.67
Viral marker:
HBsAg Negative
Anti HCV Negative
27. Investigations of 1st
admission contd. :
Chest X ray P/A view: (31/10/2017):
Normal chest skiagram.
ECG : (31/10/2017):
Normal.
Plain X ray abdomen A/P view:
(31/10/2017):
Suggestive of intestinal obstruction.
28. Investigations of 1st
admission:
CBC : (01/11/2017)
Hb 11.2 gm/dl.
ESR 05 mm in 1st
hour.
WBC count 4800/cumm
Red blood cells 3.58 million/cumm
Platelets 175,000/cumm
33. Investigations of 1st
admission contd. :
USG OF Whole Abdomen:( 01/11/2017):
Liver appears normal in size and parenchymal
echotexture is homogenous. No focal or
diffuse lesion is noted. Intra hepatic biliary
channels are not dilated.
Gall Bladder could not be visualized. Common
bile duct is not dilated.
34. Investigations of 1st
admission contd. :
USG OF Whole Abdomen: (01/11/2017)
Spleen is normal in size with uniform tissue
texture.
Pancreas is normal in size & shape with
uniform tissue texture.
Both Kidneys are normal in size & shape.
Parenchymal echotexture is normal.
Pelvicaliceal systems of both kidneys are not
dilated. No stone or mass lesion is noted.
35. Investigations of 1st
admission contd. :
USG OF Whole Abdomen:( 01/11/2017):
Urinary Bladder is well filled and well outlined.
No stone or intravesical lesion is seen.
Prostate is normal in size with uniform
echotexture.
There is moderate ascites.
No enlarge lymph nodes seen in any
areas of abdomen.
36. Investigations of 1st
admission contd. :
USG OF Whole Abdomen:( 01/11/2017):
Comment:
1. Moderate ascites.
2. No abdominal lymphadenopathy at
present.
37. Investigations of 1st
admission contd. :
Ascitic fluid study: (02/11/2017)
Quantity 05ml
Colour Straw
Appearance Clear
Ascitic fluid for ADA 15.8 U/L
Ascitic fluid for Sugar 7.2 mmol/L
Ascitic fluid for Protein 2.3 gm/dl
38. Investigations of 1st
admission contd. :
Ascitic fluid study: (02/11/2017)
Wet film RBC 3-4 /hpf
Total count 160 cells/cumm
Differential count:
Lymphocyte 80%
Polymorphs 20%
Staining:
Z.N. Stain - AFB not found
Gram’s Stain – Microorganism not found
39. Investigations of 1st
admission contd. :
Upper G. I. tract endoscopy :( 02/11/2017):
Normal Upper GIT at endoscopy.
Colonoscopy : (06/11/2017):
(Seen upto caecum)
Small haemorrhoides otherwise normal colon
at colonoscopy.
45. Investigations of 2nd
admission contd. :
USG OF Whole Abdomen:( 21/12/2017):
Left lobe of liver is small in size, measure
about 13mm in transverse diameter and
parenchymal echotexture is homogenous. No
focal or diffuse lesion is noted. Intra hepatic
biliary channels are not dilated. Common bile
duct is not dilated. CBD measures 3.6 mm in
diameter.
Gall Bladder could not be visualized.
46. Investigations of 2nd
admission contd. :
USG OF Whole Abdomen: (21/12/2017)
Spleen is normal in size & uniform tissue texture.
Pancreas is not well visualized due to excess
bowel gas & huge ascites.
Both Kidneys are normal in size, shape, position
with higher cortical echogenecity. Bipolar length
of right kidney is 81mm & left kidney is 82mm.
47. Investigations of 2nd
admission contd. :
USG OF Whole Abdomen:( 21/12/2017):
Pelvicaliceal systems of both kidneys are not
dilated. No stone or mass lesion is noted.
Para-aortic lymph node could not be
visualized due to excess bowel gas.
48. Investigations of 2nd
admission contd. :
USG OF Whole Abdomen:( 21/12/2017):
Prostate is normal in size with uniform
echotexture.
There is huge ascites at present.
Abdomen is full of bowel gas.
49. Investigations of 2nd
admission contd. :
USG OF Whole Abdomen:( 21/12/2017):
Comment:
1. Huge ascites.
2. Atrophied left lobe of liver.
3. Consistent with CKD.
4. Excess bowel gas.
50. Investigations of 2nd
admission :
CBC : (22/12/2017)
Hb 10.4 gm/dl.
ESR 05 mm in 1st
hour.
WBC count 5700 /cumm
Red blood cells 3.21 million/cumm
Platelets 165,000/cumm
62. Consultation with surgery department :
After discussion in medicine grand round
confirmed diagnosis could not be established.
So the decision was that to consultation with
surgery department and transfer the patient
to surgery department for diagnostic
laparoscopy.
63. Exploratory laparotomy was done under
G/A in Surgery Department on 14/03/2018.
OT Findings:
-Huge ascites present.
-Liver adherent to diaphragm.
-Peritoneal adhesion in previous
cholecystectomy scar.
64. Ascitic fluid study: (14/03/2018)
Quantity 50ml
Colour Pale yellow
Appearance Clear
Ascitic fluid for ADA 18.60 U/L
Ascitic fluid for Sugar --- mmol/L
Ascitic fluid for Protein --- gm/dl
65. Ascitic fluid study: (14/03/2018)
Wet film RBC 2090 /hpf
Total count 30 cells/cumm
Differential count:
Lymphocyte 98%
Polymorphs 02%
Staining:
Z.N. Stain - AFB not found
Gram’s Stain – Microorganism not found
