October bimonthly exam

 

1-With the history of chronic alcoholism 

 - (AST/ALT ratio=1.24)- indicates alcoholic liver disease

Usg suggestive of altered ecotexture with hepatosplenomegaly -- indicates cirrhosis 

A) Pathogenesis of ascites in cirrhosis : 

-Due to portal hypertension 

- salt and water retention 

Activation of hepatic stellate cells - fibrosis,increased hepatic resistance ,decreased nitric oxide production leading to intrahepatic vasoconstriction 

Increase in systemic nitric oxide ,Tumor necrosis factor ,VEGF --- splanchnic vasodilation -pooling of blood - hypovolemia-- activation of RAAS 

B)decreased synthetic activity - hypoalbuminemia (alb-1.4) 

Decrease in oncotic pressure - leading to fluid accumulation in peritoneal space causing-Ascites 

2- hypoalbuminemia - causing pedal edema . Chronic pedal edema causing skin changes 

Patient gives history of self treatment of blebs under unsterile conditions - that could be leading to recurrent cellulitis 

3- Astrexis and constructional apraxia indicates hepatic Encephalopathy - 

As he didn’t pass stools- there could be accumulation of Ammonia. It crosses blood brain barrier and leads to delirium .

According to sonic classification of HE- patient is in overt hepatic encephalopathy 

Treatment primarily includes eliminating ppt factors like bleeding , infection, hypokalemia , medications, dehydration 

Non absorbable materials like lactulose - these are first line agents 

Antibiotics are considered as second line . Rifaximin is approved for treatment of chronic HE and reduction in risk of recurrence of overt HE in pts with advanced liver disease 

2 Case : 

1- Direct hyperbilirubinemia without raised liver enzymes ,and a recent history of drug intake (ATT ) 

2- investigational findings that support diagnosis of pulmonary tuberculosis are - sputum positive ,and CT chest showing fibrocavitatory lesion in right lower lobe 

3-  Chronic alcoholism since 35 years ,along with decreased appetite , malnutrition ,super added pulmonary tuberculosis .

Ascites could be due to cirrhosis causing portal hypertension ,salt and water retention .Also contributed by malnutrition and superadded infection.

3 case: 

With the history and investigations - patients has glomerular injury causing protienuria .

Ascites and pedal edema are likely due to Hypoalbuminemia .

Renal biopsy would help in knowing the cause  of nephrotic syndrome .

2- 

https://www.google.com/url?sa=t&source=web&rct=j&url=https://academic.oup.com/ndt/article-pdf/11/1/12/5281324/11-1-12.pdf&ved=2ahUKEwii1_P88absAhV77HMBHQ7mBcsQFjAAegQIARAB&usg=AOvVaw2E_VM26MJTNDs_KeDwrP6E&cshid=1602225598156

I quote from this reference : 

Further argument on renal   biopsy is  that  we  lack  adequate  therapy  for  each  type of  renal  disease  and  that  the  'informational  content' of  renal  biopsies  is  judged  by  the  physician's  opinion on  treatment  and  prognosis  and  often  not  on  the  basis of  randomized  controlled  studies.  An  important example  of  this  point  is  the  management  of  adults  with a  nephrotic  syndrome  due  to  a  focal  segmental  glomerulosclerosis.  We  have  reported  that  the  nephrotic syndrome  in  patients  with  the  glomerular  tip  variant of  FSGS  and  also  what  we  have  called  early  classical focal  glomerulosclerosis  does  respond  to  steroids  and immunosuppressants  and  that  with  this  treatment  progression  to  renal  failure  is  reduced  [14].  It  is  argued that  even  though  in  these  patients  a  renal  biopsy changed  management,  in  the  absence  of  randomized controlled  studies  of  sufficient  power  to  indicate  the effectiveness  of  the  proposed  treatment,  then  the  biopsy would  in  itself  have  been  useless.