A 28 year old male with Gross Ascites

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A 28 year came to OPD with

C/o Abdominal distention since 10 days

       Abdominal discomfort since 10 days

History of Presenting illness 

Patient was apparently asymptomatic 10 days ago then he developed Abdominal discomfort and distention of abdomen for which he visited a primary health care centre near his residence where he was adviced to get an Xray of Abdomen for which he visited our Institution. Abdominal distention was insidious in onset and gradually progressed to current size 

Patient complaints about Abdominal discomfort while talking and also after eating therefore patient is restraining from eating even though he is hungry

No h/o Nausea, Vomiting, Loose stools,  Constipation

No h/o Melena, Hematuria, Burning micturition 


Past History 

No h/o similar complaints in the past

N/k/c/o DM, HTN, Asthma, TB, Epilepsy,  Thyroid disorders, CAD, CVD.

H/o Jaundice 15 years ago

Underwent Appendicectomy 20 years ago

Underwent surgery for Hydrocele 16 years ago

Personal history

Patient is married and has 3 kids

He is daily wage labourer

Appetite is Normal

Diet is Mixed diet

Sleep Inadequate due to abdominal discomfort 

Bowel and bladder movements regular

Addictions - Alcohol consumption since 2 years

Consumes alcohol 2-3 times a week

Occasional toddy drinker

Chews Gutka

Family history 

No similar complaints in the family

General Physical Examination 

Patient was Conscious, Coherent and Cooperative.

Well oriented to time, place and person. 

Moderately built and Undernourished 

No Pallor, Icterus, Cyanosis, Clubbing, Koilonychia, Generalised Lymphadenopathy

Vitals

Temperature - Afebrile 

Pulse - 84 bpm

Respiratory rate - 17 cpm

Blood pressure - 110/70 mmHg

Systemic examination 

CVS - S1,S2 heard

RS - BAE +, Dyspnoea on exertion present 

CNS - No focal neurological deficits

Abdomen

On Inspection 

Abdomen is distended

Umbilicus is central and inverted

Skin is stretched with Dilated veins on sides of the Abdomen 


Appendicectomy scar present 

On Palpation

Soft, Nontender

Liver not palpable 

Spleen not palpable

On Percussion 

Shifting dullness present 

Fluid thrill elicited

Liver span was difficult to percuss due to distended abdomen.

Auscultation  - Bowel sounds present 

Provisional Diagnosis - Ascitis secondary to Chronic aliver disease

Diagnostic ascitic tap reveals Hemorrhagic Ascitis


GastroEnterologist Referral done on 05/01/2024
Advice :
 - MRCP after LVP
 - CA19-9
 - NT tube after MRCP
 - Inj. OCREOTIDE 100mcg SC/TID

Investigations



USG Abdomen and Pelvis
29/12/2023
 - Gross Ascitis
 - Gall bladder wall edema
 - Ectopic left kidney in left iliac fossa
01/01/2024
 - Gross Ascitis
 - Irregular and thickened urinary bladder wall with pappilae into bladder with no vascularity and internal echoes in bladder
 - ?Chronic Cystitis

Ascitic fluid Bacterial C/s report - No growth after 48 hours of aerobic incubation 

Ascitic fluid cytology report
microscopic findings: cytosmear studied shows predominantly lymphocytes, mesothelial cells in a necrotic and hemmorhagic background
No Evidence of atypical cells

Ascitic fluid CBNAAT -  Negative

Ascitic fluid ADA - 22 U/L

CECT Abdomen and Pelvis
 - Severe ascites.
 - Omental thickening
 - Suggest ascites fluid analysis to rule out abdominal Koch's.
 - Normal pancreas.
 - Ectopic left kidney.

Final Diagnosis 
1) HEMORRHAGIC ASCITIS 2° to ?TB, ?Malignancy
2) ECTOPIC KIDNEY

Treatment 

1) IV FLUIDS - RL or DNS 30ml/hour
2)Inj. PAN 40mg PO/OD/BBF
3)Inj. TRAMADOL IV 1 AMP IN 100ml NS BD
4) Syp. ASCORIL 10ml PO/ TID






Comments

  1. My own AETCOM analysis of this patient :

    Attitude leading to failed communication toward patient's

    1) Diagnosis :

    Attitudinal failure to learn how to diagnose his pain abdomen

    There was considerable uncertainty about his abdominal pain and ascites but given the sequence of events, it looked like an inflammatory ascites either secondary to a sealed perforation and secondary peritonitis or even remotely peritoneal tuberculosis

    Instead of trying to seek help from different team members by communicating it to all the stakeholders in time, I just limited my sharing of the patient's problems with very few people and hence failed to arrive at a diagnosis.

    The next step would have been an exploratory laparoscopy to look for sealed perforation with peritoneal biopsy but I failed to realize that as I had limited my communication of this patient with other departmental team members

    Ethics :

    I sent the patient to some other place and forgot totally about him and didn't learn what was done for him finally and as a result I shall repeat the same AETCOM failure again given the same situation of pain abdomen!

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