Step by step clinical diagnosis

A 54-year-old woman Para 5 was admitted to the hospital because of increasing abdominal enlargment. She felt well until a year ago, when abdominal distention gradually developed. In abdominal ultrasongraphy a coarse, echogenic liver and ascites was detected, the spleen was enlarged and other intraabdominal organs were normal. Abdominal paraeentesis was performed. Serum-aseites albumin gradient was greater than 1.1 gr/dl [high serum-ascites albumin gradient]. Laboratory-tests for evaluating the etiology of cirrhosis revealed: HBs Ag: Neg, HBc Ab: Neg, Hcv Ab: Neg, Anti HBs: Pos. ASMA [anti smooth muscle antibody]: Neg ANCA [anti neutrophilic cytoplasmic antibody]: Neg ANA [anti nuclear antibody]: Neg AMA [anti mitochondria! Antibody]: Neg SPEP [serum protein electrophoresis]: Normal range The patient had no history of hepatotoxic drug usage. In upper GI endoscopy two columns grade II varicose veins were seen. Based on the history and para clinic evaluation cryptogenic cirrhosis was the most probable diagnosis. The patient underwent medical therapy with furosemide and spironolactone, and in regular follow up amount of ascites was under control. A month ago the amount of ascites increased and several therapeutic paraeentesis were performed. Ascites analysis showed high serum-ascite albumin gradient and negative cytology for malignancy. Ultrasonography reported multiple focuses on peritoneal surface with seeding like appearance, cirrhotic liver, enlarged spleen and massive ascites, normal kidneys and uterus and ovaries.Tumour markers measurement revealed: CEA= 0.3 [Normal range= 0-5 ng/ml] alpha FP= 0.4 [Normal range= 0-10 lU/ml]CA 125- 244 [Normal range- 0-35 lU/ml] Abdominal and pelvic CT scan didn't show any tumoural lesion and no paraaortic lymphadenopathy. Trans vaginal sonography reported normal uterus and ovaries. Further tumour marker analysis revealed: Elevated serum level of CA 125 to 414 lU/ml CA 15 - 3 = 27 [normal = up to 40 lU/ml] CA 19 - 9 = 25 [normal = up to 40 lU/ml]. A week later level of CA 125 decreased to 262. Therefore we obtained fluctuating level of CA 125, normal CT scan and normal level of other tumour markers. We found in papers from other countries in the same situation that they performed laparotomy but they found nothing except cirrhosis [1]. In some articles CA 125 presented as a marker of ascites in patients with liver cirrhosis [2]. Some authors suggested that quantification of CA 125 in peritoneal fluid [PCA125] and serum [SCA125] can differentiate between cancer cases and non cancer disease, and they found that ratio of PCA125 to SCA125 [P/S CA125] was significantly lower in non cancer patients than that in cancer ones. [If the ratio is upper than five the risk of malignancy increased] [3]. We quantified CA125 level simultaneously in peritoneal fluid and serum: PCA125 - 210, SCA125 = 250, P/S CA125 - 0.84. The ratio of 0.84 was predictive of a benign disease. In an overview to our patient, we had one sonography that reported seeding like appearance in peritoneal surface, but in CT scan no lesion was detected. Fluctuating level [increase - decrease] of CA125 and low P/S ratio, normal level of other tumour markers, made us to come to the final step of laparoscopic examination and biopsy to determine whether it is malignant or benign. In laparoscopic examination no cancerous lesion or fibrin deposit or tuberculosis granoluma with normal omentum and cirrhotic liver detected. Multiple biopsies were taken from peritoan beside liver which reported normal [no: 159104]. We came to this conclusion that in cirrhotic patient with ascites the elevated level of CA125 with normal level of other tumour markers and low P/S ratio and no malignant finding in imaging is suggestive of a benign process, as described in other articles. More studies on this matter should be performed in order to prevent the unnecessary laparatomies

[Complications and patency rate of portosystemic shunts in chronic liver diseases]

Cirrhosis is the most important etiology of portal hypertension worldwide. Even with improvements in noninvasive therapies, portosystemic shunts still remain one of the most important approaches after failure in medical treatment. Transjugular Intrahepatic Portosystemic shunt and liver transplantation are alternatively used in other countries. Evaluation of complications and patency rates can be a great help in choosing the best technique in patients. The aim of this study was to evaluate patency rate and complications of portosystemic shunts in patients with chronic hepatic diseases. In this cross sectional study, from summer 2000 to spring 2004, carried out at General and Vascular Surgery Departments 19 patients with portal hypertension underwent surgery. Patients with portosystemic shunts were followed up for at least one year after surgery, considering blood flow in anastomosis, using color Doppler ultrasonography and symptoms such as gastro intestinal bleeding, hepatic encephalopathy and etc. Data were analyzed using SPSS version 13 and descriptive statistics. Male to female ratio was 1:1.7. Portosystemic shunt was performed for 16 patients [2 distal splenorenal, 10 central splenorenal, 2 portocaval, 2 mesocaval] and 3 underwent splenectomy. Of patients 2 complicated with pneumonia after a week, and 2 with encephalopathy. After at least one year, 66.6% of shunts were patent, 8% were closed and in 25.4% doppler ultra sonography could not localize the shunt. One patient died under surgery. There was no death at the end of the first year; but during a 6 years follow up, 6 mortalities occurred. The major etiology of portal hypertension in these patients was cirrhosis secondary to hepatitis B. This finding is due to the cultural and religious differences with other countries. There was no relationship between pneumonia and splenectomy [p= 0.45]. Also, no significant difference observed between pre and post surgery encephalopathy [p =0.14]. Mortality rate did not depend on pre [p= 0.09] and post [p= 0.11] surgery encephalopathy. Survival rate of patients was 94.7% after one year and 73.7% after 2 years, demonstrating better results in comparison with other similar studies

[Step by step diagnosis]

A 25 - years- old man was admitted to the hospital because of fever, chills and jaundice after return from Pakistan . On physical examination he had fever [40°C] and BP of 120/70, respiratory rate and pulse rate were 24 and 100 respectively. Heart sounds were normal and there wasn't any pathologic sound in lungs. The sclera was icteric yet there wasn't any signs of anemia _and no adenopathy was found. In abdomen, hepatosplenomegaly was present and right upper quadrant had tenderness on examination, however, there wasn't ascitis and collateral circulation. Laboratory tests performed and revealed leukopenia [3500] and thrombocytopenia [70000] but no anemia, increased liver function tests and bilirubin, though normal PT and PTT. Wright, 2 ME, widal was negative. Sonography of abdomen revealed hepatosplenomegaly, still other findings were normal. Because of high fever blood culture performed and parenteral antibiotic started. For bicytopenia and increased liver function tests, bone marrow aspiration and additional tests, also, carriedout. Markers of viral hepatitis [HAV. HBV. HCV. CMV HBV.HSV] and autoimmune hepatitis were negative and BMA was normal. After five days of admission when the patient was on parenteral ceftriaxone and did not have any fever and felt much better, the result of blood culture reported as salmonella typhi. As a result in patients with fever, jaundice and hepatosplenomegaly it is essential to consider typhoid fever, although the widal test is negative