5. Bab III Case Analysis

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CHAPTER III

CASE ANALYSIS

A sixty years old woman admitted to hospital on October 9 th, 2009 with chief

complaint bulging of the abdomen that became even larger since two weeks before

admission.

2 months before admission, the patient complained about bulging of her

abdomen, her bulging abdomen seemed to spread evenly so she found some difficulty

in wearing her outfits. The patient felt uncomfort, heavy, and full of stomach that

caused the decrease in her appetite, there was no constant pain on her abdomen.

There was no nausea, vomiting, or fever. Her body became weak. In addition, both of

her legs were swollen too, but she neither had the swelling eyelids especially when

she woke up in the morning nor itching on her skin.

Because of her bulging abdomen, she sometimes felt shortness of her breath

(dyspnea). Her dyspnea were not caused by her activities, emotional conditions,

weathers, and never produced ngik sound. She still can sleep with one pillow, she

never woke up in the middle of her night-time sleep because of short winded. She

said sometimes she may had dark yellow or brown colored urine, but never passed

black or bloody stools. Theres no others complaint in defecation and urination

habits. She went to the local health care center and took some medicines (she didnt

know name of drugs) but there was no improvement.

2 weeks before admission because of her abdomen seemed even more larger

and tense, she had nausea and vomits, three times, containing all foods and fluids that

she had been consumed that day. There was no blood in her vomit and no

dark/bloody stools. Then, she was hospitalized in Moh. Hoesin Hospital in order to

receive some better treatments.

From physical examination we found: moderate sickness condition, vital sign

within normal limit, nutrition state (in normal condition): IMT= 19,53 kgs/m2

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(normoweight). There were pale of conjungtiva palpebrae (+), palmar erythema (+),

icteric sclera (+), collateral vein (+), ascites (+)..

The bulging of the abdomen in this patient was more specifically due to fluid

accumulation in the peritoneal cavity. Because from physical examination we could

see the bulging seemed to spread evenly in all region of the abdomen (frogs belly),

tender in palpation, and had stony-dull sound. There was no palpable mass or tense

and defans muscular in abdominal wall which is usually because of perforation/

peritonitis .

The ascites because of kidneys diseases was stepped aside because there were

no symptoms and signs being found. The patient were not experienced palpebrae

edema when she woke up in the morning, nausea or vomit, itchs on skin, or any

changed in urination habits (lessen in urines volume or frequency). On the other

hands, fluid accumulation in patient with cardiovascular disorder usually observed at

patients feet and ankle. The dyspnea is more severe, influenced by activities and

better if patient take some rest (dyspnea on effort), orthopnea, paroxysmal nocturnal

dyspnea can occur.

So ascites in this case is more specific due to pathologic process in liver

which is cirrhosis hepatic. Cirrhosis may cause no symptoms for long periods. The

onset of symptoms may be insidious or, less often, abrupt. From anamnesis we knew

that patient complain about felt weakness of her body, losing appetite, nausea, vomit

(non-specific symptoms of compensated cirrhosis) and she had dark-yellow or brown

coloured urine. In advanced cirrhosis, anorexia is usually present and may be

extreme, with associated nausea and occasional vomiting. Abdominal pain may be

present and is related either to hepatic enlargement and stretching of Glisson's capsule

or to the presence of ascites.5

Physical examination, laboratory findings, and abdominal USG are very

important in diagnosing cirrhosis hepatic.4 The stigmata of cirrhosis hepatic including

erythema of palm, collateral vein, ascites, splenomegaly, icterus, and

hypoalbuminemia are fulfilled in this patient. The single best test for diagnosing

cirrhosis is biopsy of the liver. Liver biopsies, however, carry a small risk for serious

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complications, and, therefore, biopsy often is reserved for those patients in whom the

diagnosis of the type of liver disease or the presence of cirrhosis is not clear.

Laboratory findings show anemia (Hb: 8,6 g/dl), trombocitopenia

(175.000/mm3) due to both congestive splenomegaly as well as decreased

thrombopoietin from the liver, hypoalbuminenia (2,1 g/dl): advanced cirrhosis leads

to a reduced level ofalbumin in the blood and reduced blood clotting factors due to

the loss of the liver's ability to produce these proteins.

Bed rest: it is shown to inhibit the neurohomural system (RAAS and SNS)

activated chronically in upright position in cirrhoticpatients that impairs renal blood

perfusion and causes sodiumretention. Bed rest reduces the plasma aldosterone level

and

improves the response to diuretic therapy in cirrhotic patients.

However, bed restis not recommended routinely as it is often unpractical and could cause decubitus

ulcers and muscle atrophyin malnourished cirrhotic patients6.

Management of patients with cirrhosis and ascites. Generally, reduction of

sodium intake is beneficial in patients with ascites. A low-sodiumdiet (60 to 90 mEq

per day, equivalent to approximately 1500to 2000 mg of salt per day) may facilitate

the elimination ofascites and delay the reaccumulation of fluid.7,8

Two different schedules of diuretic treatment are used in cirrhotic patients with

ascites. The most conservative schedule stars with spironolactone 100/mg day. If

there is no response the dose is increased progressively to 200 mg/day and 400

mg/day. Furosemide is added at increasing doses (40, 80, and 160 mg/day) in patients

not responding to 400 mg/day of spironolactone. In this patient we use the second

strategy consists in the simultaneous administration of spironolactone and furosemide

starting with 100 mg/day and 40 mg/day, respectively. If there is no response the

dosages are increased to 200 mg/day and 80 mg/day and to 400 mg/day and 160

mg/day. Respectively there is a general agreement that these are the highest doses of

diuretic to be used in cirrhotics. Weight loss should not go over 0.5 kg/day in the

absence of edema and more than 1 kg/day in edematousstate. 7,8

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http://en.wikipedia.org/wiki/Thrombopoietinhttp://www.medicinenet.com/script/main/art.asp?articlekey=2189http://en.wikipedia.org/wiki/Thrombopoietinhttp://www.medicinenet.com/script/main/art.asp?articlekey=2189


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Clonidine (central agonist beta2 ) is used to decrease blood pressure and usually

used to the resistance hypertension. The small dose of clonidine can used to treat

hypertension without using a diuretic.

All patients with ascites should be evaluated for transplantation, since the

presence of ascites is associated with poor long-term survival (survival rate at five

years, 30 to 40% vs.70 to 80% among patients who have undergone transplantation).7

Fluid retention is the most frequent complication of End Stage of Liver

Disease which is occurring in about 50%of patients within 10 years of the diagnosis

of cirrhosis. It is associated with poor prognosis and 1-year and 5-year survivals of

85% and 56%, respectively.9

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5. Bab III Case Analysis