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Case Presentation

LIVER CIRRHOSIS

PRESENTATOR

AINUL MARDHIYYAH RAIS

BP.99120007

OPPONENT

HARRY PRIMA SYAPUTRA

BP.97120080

MODERATOR

Prof. Dr. JULIUS, SpPD-KGEH

DEPARTEMENT OF INTERNAL MEDICINE

MEDICAL FACULTY OF ANDALAS UNIVERSITY

PADANG

2003



LIVER CIRRHOSIS

Definition

Liver cirrhosis is a chronic disease which signed by inflammatory process of the liver cell, regeneration and increase fibrous tissue, nodule that disturb the form

liver lobes.

Pathogenesis

If there is a liver cell necrosis which covered a wide area of the liver and that

area will be collapsing. This condition will triggered of collagen tissue. The early

stage that occurs is passive septa which formed by collapsing reticulum and

transform into scar tissue that can connect other portal area or between portal and

central area. The next level parenchyma tissue destruction and inflammation of duct

cell, sinusoid and reticuloendotelial cell in liver. This inflammation will triggered

fibrogenesis that will be active septa. This septa will spread into the parenchyma it

start from portal area. At the same time, this event will also triggered regeneration

process of the liver cell. The regeneration that occurs will disturb the formation scar

tissue. This condition that is continue fibrogenesis, regeneration and liver failure and

the end will formed a liver structure that can be seen liver cirrhosis.

Etiology

1. Viral hepatitis B

2. Alcohol

3. Metabolic disease ex : diabetes mellitus, Wilson disease, Galactosemia

4. Congestive hepatica vein

5. Long term exposure toxins and drug ex metotreksat, INH and metildopa

6. Surgery of intestine in obesity

7. Malnutrition

8. Parasitic infection like Schistosomiasis

9. Malaria



Classification

Based on morphology

1. Micronoduler of cirrhosis

2. Macronoduler of cirrhosis

3. Mix cirrhosis

Clinical Manifestation

1. Compensation

Patient was not have symptom or symptom not clearly, patient feel not fit,

decrease of working ability, decrease of appetite, nausea or vomiting, diarrheaor constipation, loss of weight, fatigue and loss of flesh specially pectoralis

mayor area.

2. Decompensate

There are complication liver failure and portal hypertension with

manifestation liver palm, spider angiomas, collateral vein in abdomen,

jaundice, oedema pretibia and ascites, the urine shows discoloration, blood

disorders, hematemesis and melena from ruptured esophageal varix and

neuralgic disturbances like encephalopathy to coma.

Physical Examination

1. Liver enlargement in early stadium if liver not enlargement, it’s mean bad

prognosis

2. Enlargement of spleen

3. Abdomen : ascites and collateral vein

4. Manifestation extra abdominal : Spider angioma, caput medusa, liver palm,

gynecomastia, atrophy testes (man)



Diagnosis

According Suharyono Soebandiri, 5 from 7 sign below we can make diagnosis

liver cirrhosis :

1. Ascites

2. Splenomegali

3. Varices Bleeding (Hematemesis)

4. Hypo albumin

5. Spider angiomas

6. Liver palm

7. Collateral vein

Complication

1. Liver failure

2. Portal hypertension

3. Hepatorenal syndrome

4. Hepatoma

Treatment

1. Bed rest, high protein diet, fat enough (liver diet III-IV), if encephalopathy

reduce protein (Liver Diet I)

2. Therapy of symptom, like

Diuretic and low salt diet for ascites

Bleeding esophageal : hospitalized

Encephalopathy : correction of precipitation factor

Hepatorenal syndrome : special treatment

3. Liver Cirrhosis known caused

Cirrhosis alcoholic : stopping alcohol

Hemocromatosis : stopping preparat Fe



Prognosis

Based on hepatocellular failure, portal hypertension and there are complication

CASE REPORT

A 61 years old man was admitted to Internal Medicine Department of General

Hospital Dr. M. Djamil Padang at October 27

th

, 2003 with

Chief Complaint

Stomach pain since 1 day ago

Present Illness History

- Stomach pain since 1 day ago, the pain has been felt since 3 months ago and

referred to epigastrium

- Yellow eyes since 2 months ago, but fixed since this 5 days

- Loss of appetite and body weight since this 5 months

- The urine shows like tea since 1 month ago

- Leg swelling since 1 month ago

- Abdominal swelling since 1 month ago and getting bigger

- Nausea (+), Vomiting (-)

- Fever (-), breathless (-)

- Patient has been admitted 3 times

First, 4 months ago in Painan (about 5 days) with vomiting and feces

contained blood. One month later been admitted about 11 days with melena.

Previous Illness History



- Yellow disease (-)

- DM (-)

Family Illness

None of his family members got the same illness

Social and Economic Background

He’s working as a farmer

Physical ExaminationVital Sign : General appearance : moderately ill

Consciousness : compos mentis cooperative

Pulse rate : 60 x / min

Respiration Rate : 18 x / min

Blood Pressure : 120/70 mmHg

Body Temperature : 37’C

Body weight : 52,5 kg

Body height : 167 cm

Cyanosis : -

Edema : + (pretibia)

Jaundice : +

Stomach circumference : 85 cm

Skin : Jaundice

Lymph Node : not enlargement

Head : Eye : conjunctiva anemic, sclera icteric

Ear, nose and mouth no disturbance

Neck : No enlargement of lymph nodes and thyroid gland

JVP : 5 + 2 cmH2O



Chest : normochest, spider angioma (+)

- Lung : I : Symmetric movement, thoraco abdominal respiration type

P : Fremitus both were the same

P : Sonor, left and right were the same

A : Vesicular Normal, Ronchi (-), Wheezing (-)

- Heart : I : Ictus was visible

P : Ictus was palpable 1 finger medial at LMCS V ICS

P : left border : 1 finger medial at LMCS V ICSupper border : II ICS

A : Regular rhythm, murmur (-), M1>M2, P2>A2

- Abdomen : I : abdomen was swollen

P : Liver was palpable 3 finger below costal arch flat, blunt, flat,

pain pressure (+)

Spleen : S1

Ballotement (-)

P : Shifting dullness (+)

A : Normal peristaltic sound

Back : Symmetric, Pressure pain (-) and knock pain (-)

Extremity Right Left

Physiological reflex + +

Pathological reflex - -

Smooth sensibility + +

Rough sensibility + +

Edema + +

Liver palm + +

Laboratory Finding



Blood : Hb : 7,1 gr%

Leukocyte : 6100/mm3

Na : 143 Eq/L

K : 4,2 Eq/L

Cl : 97 Eq/L

Blood glucose concentration : 113 mg%

Ureum : 59 mg%

Urine : Sediment L : 1-2/LPB

E : -Crystal : -

Epitel gepeng : -

Protein : +

Reduction : -

Bilirubin : ++

Urobilin : +

Feces : Yellow, mucous +, blood –

Diagnosis

Liver cirrhosis decompensate

Differential Diagnosis

- liver cirrhosis post necrotic

- liver cirrhosis portal

- hepatoma

- Active Hepatitis Chronic

Treatment



- Bed rest

- Liver diet II

- Blood transfusion

- IVFD Aminofuscin : Triofuscin = I : II

- NTR

- Hepatoprotector

- Spironolacton

- Urdafalk

- Aspilet

- Aminoleban oral

Suggested examination

- Routine blood, urine, feces test

- Albumin/globulin

- Liver function

- Bilirubin

- Hepatitis marker

- USG

- Gastroscopy

- Ureum creatinin

- EKG

Follow up

October 28th, 2003

A/ : stomach pain +

Decreased of appetite

Urine shows like tea

PE/ : General appearance : moderately ill

Consciousness : composmentis cooperative







Eye : Conjunctiva anemic, sclera icteric

JVP : 5 + 2 cmH2O

Abdomen : liver was palpable 3 finger below costal arch

flat,

Spleen : S1

Lab/ : Total cholesterol : 135 mg%

HDL : 72 mg%LDL : 36 mg%

Triglyceride : 134 mg%

Ureic acid : 7,4 mg%

Total Protein : 7,4 gr%

Albumin : 2,9 gr%

Globulin : 4,5 gr%

Total Bilirubin : 29,86 gr%

Indirect : 11,46 gr%

Direct : 18,4 gr%

SGOT : 328 u/L

SGPT : 87 u/L

Alkali Phosphate : 825 u/L

HbsAg : + (positive)

Urine

Protein : -

Reduction : -

Leukocyte : 2-3/LPB

Erythrocyte : -

Cylinder : -



Crystal : -

Epitel Gepeng : +

Bilirubin : ++

Urobilin : +

WD/ : Stq

Th/ : continue

Follow up

October 29th, 2003

A/ : stomach pain (+)


Nausea (–), Vomiting (–)Urine shows like tea







Eye : Conjunctiva anemic, sclera ikteric

JVP : 5 + 2 cmH2O


flat,

Spleen : S1

LAB/ : USG : liver cirrhosis and hepatoma

WD/ : Stq

TH/ : Continue

Follow up October 30th, 2003



A/ : stomach pain (+)


Nausea (–), Vomiting (–)

Urine shows like tea




Respiration Rate : 24 x / minBlood Pressure : 140/70 mmHg


Eye : Conjunctiva anemic, sclera ikteric

JVP : 5 + 2 cmH2O


flat,

Spleen : S1

Stomach circumference : 86 cm

LAB/ : -

WD/ : Stq

TH/ : Continue



DISCUSSION

Based on anamnesis, physical examination and laboratory finding we found

data to conclude diagnosis to the patient. From anamnesis we found Stomach pain

referred to epigastrium, yellow eyes, the urine shows like tea, leg swelling abdominal

swelling, patient has been admitted 3 times with vomiting and feces contained blood.From physical examination we got conjunctiva anemic and sclera icteric, jaundice,

edema, liver was palpable 3 finger below costal arch flat, pain pressure, spleen S1,

spider angioma, liver palm. The data from laboratory routine we got anemic,

bilirubinuria and from suggested examination showed liver disturbance that

increased SGOT/SGPT, alkali phosphate and bilirubin serum, decreased albumin and

positive hepatitis marker. From USG showed liver cirrhosis and hepatoma.

So the diagnosis this case is liver cirrhosis decompensate and we gave treatment Bed

rest, Liver diet II, Blood transfusion, IVFD Aminofuscin : Triofuscin = I : II, NTR,

Hepatoprotector, Spironolacton, Urdafalk, Aspilet and Aminoleban oral

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