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 (ACES for PACES Page 290,291)
ª
Dupuytren’s contracture would point to alcohol being implicated in
aetiology (ACES
for PACES Page 298, 306)
¨
Palmar erythema would suggest hepatocellular dysfunction
(ACES for PACES Page 298, 150)
§
Paucity of body hair and gynaecomastia too reflect hepatocellular
failure (ACES for PACES 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
(ACES for PACES Page
302)
ª
Splenomegaly has many causes
(ACES for PACES
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
(ACES for PACES Page
304, 305)
Diagnosis
§
The patient has features of portal hypertension and hepatocellular
failure. Clinically the patient has cirrhosis of the liver.
(ACES for PACES 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.
Revise cirrhosis of the liver KEYS to SUCCESS in
Medicine page 268-273
