Question

Which of the following represents the most likely cause of Mr. G’s abdominal swelling?

a) Hepatomegaly

b) Increased extravascular albumin

c) Portal hyptertension

d) Impaired renal function

Mr. G is a 46-year-old white male with a 16-year history of alcoholism and a 7-year history of alcoholic cirrhosis. In the past month, he has unintentionally gained 15 pounds, and his abdomen has become significantly swollen. Mr. G has had difficulty sleeping, remembering appointments, and has abruptly lost his temper many times this past month. Mr. G's boss sent him home from work last week after noticing odd behavior and witnessing unusual violent behavior at the office. This week, Mr. G has become increasingly lethargic and disoriented. Based on his presentation, Mr. G was admitted to the hospital with abdominal swelling and confusion.

Physical Exam

Mr. G appears restless and is disoriented to person, place, and time. He responds to questions slowly, and his answers are often inappropriate.

Mr. G's skin and sclera have a jaundiced tone, and he has several ecchymoses to the lower extremities.

Lungs clear to auscultation. Abdomen distended, firm, and tender with prominent veins at the umbilicus. Bowel sounds positive in all 4 quadrants. Enlarged liver and spleen (hepatosplenomegaly). Hemorrhoids present. Cranial nerves intact, deep tendon reflexes intact. Slight asterixis observed. Confused and disoriented.

Vital signs: BP 118/70, P 82 and regular, RR 14 and unlabored, T 98.7°F, weight 173 pounds, height 5 ft 8 in, SaO2 97%

Labs: serum ammonia level 250 μg/dL (normal 15-45 μg/d) , serum AST 142 IU/L (normal 10-40 IU/L), ALT 120 IU/L (normal 10-40 IU/L), alkaline phosphatase 224 IU/L (normal 44-147 IU/L), serum total bilirubin 7.3 mg/dL (normal 0.2-1.2 mg/dL), PT 18.2 seconds (normal 11-13.5 seconds), PTT 39.7 seconds (normal 25-35 seconds).

Answer 1

Portal hypertension is the mostly likely cause of abdominal swelling in Mr. G’s case. Portal hypertension can be defined as high blood pressure in the portal vein, which supplies the liver with blood from the intestine and spleen. Portal hypertension may be due to increased blood pressure in the portal blood vessels, or resistance to blood flow through the liver. As a result of the portal hypertension can lead to the growth of new blood vessels (called collaterals) that connect blood flow from the intestine to the general circulation, bypassing the liver. When this occurs, substances that are normally removed by the liver pass into the general circulation. The most common symptom of portal hypertension is ascites.

Mr. G is a very good candidate for the same because all the lab values and his behavioural problems suggest delirium tremens a condition of alcohol toxicities.