Description
The patient was an elderly man who was lying comfortably in
bed. He was tall but underweight.
He had no icterus, he was not pale there was no parotid
enlargement.
On examination of his hands there was Dupuytren’s
contractures in his left hand and there was palmar erythema.
He had no spider naevi but there was paucity of body hair
and he had gynaecomastia.
His abdomen was not distended. There were prominent veins
over the anterior abdominal wall; the flow of blood within these vessels was
away from the umbilicus. His liver was not enlarged, the spleen was palpable 3
fingerbreadths below the costal margin it was firm. No other lumps were
palpable; there was no free fluid within the peritoneal cavity. A venous hum was
heard between the umbilicus and the right costal margin.
Analysis
♥
The fact that the patient is underweight would indicate chronic
illness (Page 290,291)
ª
Dupuytren’s contracture would point to alcohol being implicated in
aetiology (Page 298, 306)
¨
Palmar erythema would suggest hepatocellular dysfunction
(Page 298, 150)
§
Paucity of body hair and gynaecomastia too reflect hepatocellular
failure (Page 299, 300, 352)
♥
Distended veins over the anterior abdominal wall in the context of
features of hepatocellular failure suggest the patient has portal hypertension
(Page 302)
ª
Splenomegaly has many causes (Page 304,
389). However, in the context of features of hepatocellular failure
and portal hypertension, the most likely cause is portal hypertension.
¨
The venous hum confirms that the patient has portal hypertension
(Page 304, 305)
Diagnosis
§
The patient has features of portal hypertension and hepatocellular
failure. Clinically the patient has cirrhosis of the liver.
(Page 305)
♥
This has many causes
ª
Clinically the only pointer is Dupuytren’s contracture
¨
However, this is inadequate to confidently state that this is the
aetiology.
§
The patient will need further investigation in the form of a liver
screen, imaging, and if all else fails this patient may require a liver biopsy.
