A case of alcoholic liver disease

 A 37 year old male came to the OPD with complaints of jaundice since 3 months, with a history of 7 years alcohol intake 360ml/day.

History of generalised weakness and yellowish discolouration of sclera, skin and urine 3 months back for which he went to a local hospital and on routine examination was found to be having deranged LFT.

Symptomatic treatment was given and the patient was advised to stop alcohol.

He improved symptomatically with treatment and the patient continued to take alcohol.

He again had similar complaints for which he came to our hospital.

History of vomitings since 1 month whenever he consumes alcohol.

No history of pain in abdomen, loose stools, pedal edema, abdominal distension/hematemesis.

3 years back history of similar complaints

No known case of DM, hypertension, asthma, epilepsy, CAD, TB

3 days back he consumed 90 ml alcohol along with food intake.

No significant personal and family history - consuming alcohol since 7-8 years, 3 quarters per day.

GENERAL EXAMINATION:-

Icterus+

No pallor, cyanosis, clubbing, lymphadenopathy, edema

   VITALS-

Temperature 98.4 F

 Pulse rate 74 bpm

 RR 16 cycles per min

 BP 120/70 mmHg

 SPO2 at room AIR - 98%

SYSTEMIC EXAMINATIONJ:-

 CVS S1 & S2+

 RS NVBS+

 Abdomen - scaphoid shaped abdomen, BS+

 CNS - patient was conscious, speech normal

 Cranial nerves, motor system, sensory system - normal

 GCS 15/15

INVESTIGATIONS:-

USG abdomen - Grade 2 fatty liver with altered echo pattern

Few hypoechoic areas in body of pancreas

Gall bladder wall edema with thin layer of pericholecystic fluid - likely acute cholecystitis

Mild ascites

UGIE: Low grade oesophageal varices

3/8/2021 severe PHG

DIAGNOSIS:-

Alcoholic liver disease

Cirrhosis with low grade oesophageal varices, severe PHG

Other investigations done, treatment, advice at discharge and the follow up are shown below:-