GASTROENTEROLOGY MEET

CASE DISCUSSION
MODERATOR : Dr. THIRUMAL HOD GASTROENTEROLOGIST
PRESENTOR : Dr. Vignesh . S
CHIEF COMPLAINTS

• Mr. Tharmathalam , 32 year old male from villupuram , labourer by

occupation , socioeconomic status of lower middle class came with chief
complaints of :

• BLOOD IN VOMITUS X 2 days

History of presenting complaints :
• Patient was apparently normal 2 days back after which he developed blood in
vomitus .

• 2 episodes / day .

• Around half a glass during each episode .

• Non foul smelling

• Color – coffee color

• Contents – food particles with blood .

• Not associated with drug intake

• He also had abdominal pain for 2 days .

• Site – diffuse in nature .

• Insidious in onset , non progressive .

• Intermittent in nature.

• No radiation of pain .

• No aggravating factors

• Relieved on taking medications .

• Associated with malena which was for 3 days .

• 2 episodes / day .

• Foul smelling .

• No H/O abdominal distension.

• No H/O Jaundice .

• No H/O mass per abdomen .

• No H/O epistaxis , gum bleeding , bleeding per rectum .

• No H/O loss of appetite .

• No H/O weight loss.

• No H/O Pruritus .

• No H/O altered sleep pattern .

Past H/O :

• He also had similar complaints in the past 4 years back .

• Patient developed blood in vomitus which was for a day.

• 1 episode / day .

• Had vomitus around half a glass .

• Non foul smelling

• Contents – food particles

• Not associated with drug intake

• He also had abdominal pain which was around 20 days .

• Site – diffuse in nature .

• Insidious in onset , non progressive .

• Intermittent in nature.

• No radiation of pain .

• No aggravating factors

• Relieved on taking medications .

• He also had Jaundice for 15 days .

• Associated with itching .

• Colour of urine and stools was yellow .

• No H/O fever .

• No H/O blood transfusions , tattooing , drug intake

• Was admitted in hospital and was treated for it , after which symptoms got
relieved .
• No h/o any surgeries .

• No h/o drug intake .

• No h/o any abdominal surgeries

• n/k/c/o DM,HTN,TB,asthma
Family h/o
• No similar complaints in the family .
Personal h/o

• Mixed diet .

• Alcoholic for past 5 years .

• 1 quarter whisky / day .

• Last drink - 2 weeks back

• Not a smoker .

• Normal bowel and bladder habits .

Treatment h/o

• He had similar complaints in the past 4 years back and got treated in our
hospital for it and symptoms got relieved .
Summary

• 32 year old male from villupuram , Alcoholic for past 5 years presented
with history of Haematemesis for 2 days , associated with diffuse
abdominal pain for 2 days .

• h/o Malena present .

• He had past h/o Jaundice 4 years back .

• He had similar complaints in the past and was treated for it .

• Probable system involved is GIT – LIVER

Probable diagnosis :

• Decompensated chronic liver disease , cirrhosis with portal hypertension

without evidence of hepatic encephalopathy .

• Etiology – Alcohol .
General examination

• Conscious .

• Oriented to time , place and person .

• PR: 76/min

• BP:100/70 mm hg in right upper limb in supine position

• No pallor,icterus ,cyanosis,clubbing,lymphadenopathy,edema
Signs of liver cell failure
• No signs of liver cell failure present .
ABDOMINAL EXAMINATION
• INSPECTION :
• Shape of the abdomen – scaphoid
• Flanks – free
• Umbilicus – central in position , inverted
• No dilated veins
• No scars , sinuses , scratch marks
• Abdomen moves equally in all directions
• No visible peristalsis
• External genitalia - normal
PALPATION

• No warmth , tenderness

• A non tender swelling palpable in left hypochondrium 2 cm below left

costal margin in mid clavicular line which moves with respiration ,soft in
consistency with a smooth surface and a sharp edge.
• Not bimanually palpable / not ballotable

• Neither could feel the upper border , nor could not insunate the fingers
below the left costal margin

• Probably an ENLARGED SPLEEN

PERCUSSION

• Liver span – 12.5 cm

• TRAUBE SPACE - obliterated

AUSCULTATION

• Bowel sounds present

• No added sounds
Per rectal examination

• Sphincter tone – normal

• Rectum – empty

• No evidence of malena
Other system examination

CVS : S1S2 heard

No murmurs

RS : Normal vesicular breath sounds heard

bilateral air entry equal

no added sounds

CNS: No focal neurological deficit

SUMMARY

• 32 year old male from villupuram , Alcoholic for past 5 years presented
with history of Haematemesis for 2 days , associated with diffuse
abdominal pain for 2 days .

• h/o Malena present .

• He had past h/o Jaundice 4 years back .

• He had similar complaints in the past and was treated for it .

• On examination vitals – stable .

• Abdominal examination showed evidence of splenomegaly

Probable diagnosis

• Portal hypertension – due to non cirrhotic cause .

Causes of non cirrhotic PHTN
Investigations
• Haemoglobin – 14.1 gm/dl

• PCV – 43.9 %

• RBC – 5.6 million / cu mm

• MCV – 77 fl

• MCH – 24.8 pg

• MCHC -32.1 %

• DC – 68 /23 /4/5

• Platelet count – 372 thousands / cu mm

LFT
• T.Bilirubin – 0.7 mg /dl

• D.Bilirubin – 0.2 mg/dl

• SGOT - 38 IU /L

• SGPT – 43 IU /L

• ALP – 141 IU /L

• T.Protein – 8 gm/dl

• S.Albumin – 4.5 gm/dl

• GGT – 29 IU/L
• RBS – 78 mg/dl

• S.Urea - 26 mg /dl

• S.Creatinine – 1 mg /dl

• Urine routine was normal

USG Abdomen

• Chronic thrombosis of portal vein

• Portal hypertension with splenomegaly .

• Multiple haemangiomas of right lobe of liver .

UGI SCOPY :
• Large esophageal varices .
• Portal hypertensive gastropathy .
CT ABDOMEN
• Evidence of portal vein obstruction with collaterals .

• Splenomegaly .

• Suggestive of EHPVO .
CT ABDOMEN
Final diagnosis
• PORTAL HYPERTENSION DUE TO EXTRA HEPATIC PORTAL VEIN
OBSTRUCTION
DISCUSSION – EHPVO
EHPVO

• Extrahepatic portal vein obstruction is a vascular disorder of liver, which

results in obstruction and cavernomatous transformation of portal vein with
or without the involvement of intrahepatic portal vein, splenic vein, or
superior mesenteric vein
PATHOPHYSIOLOGY

• Arterial vasodilation or arterial rescue, which can preserve the liver

function in acute settings, also allows a second mechanism to operate the
venous rescue. Venous rescue allows several collaterals to develop, which
try to bypass portal vein obstruction. This neovascularization or
neoangiogenesis takes around 4–6 weeks and an obstructed portal vein is
replaced by collateral network called cavernoma
• The portal cavernoma bypasses the obstructed portal vein and thus a
thrombosed portal vein turns into a fibrotic cord. The network is seen
around structures near the obstructed portal vein such as the bile duct, gall

bladder, pancreas, gastric antrum, and duodenum.

CLINICAL FEATURES
• Chronic PVT/EHPVO

• With portal hypertension

• Variceal bleed well tolerated

• Splenomegaly moderate
• Hypersplenism.

• Growth retardation in children

• Jaundice, biliopathy, mild hepatic dysfunction.

INVESTIGATIONS

• Liver function test (LFT): Normal

• Endoscopy: Esophageal varices, gastric varices, anorectal varices

• Doppler: PVT and portal vein cavernoma

• CECT and CT angiocollaterals

• Liver biopsy: Normal but not mandatory.

COLOR DOPPLER USG

• Chronic: No color flow in portal vein and hepatopetal signal within the
cavernoma or varices at gall bladder wall and signs of portal hypertension.
Contrast-enhanced CT/MR

Chronic

• Cavernomatus transformation of portal vein with splenomegaly, collaterals,

and/or no opacification of intrahepatic portal vein.
TREATMENT OF CHRONIC EHPVO

• Patients with chronic EHPVO there is no consensus on indication for

anticoagulant therapy, whereas in patients with a persistent prothrombotic
state, anticoagulant therapy can be considered. There is insufficient
evidence in favor of interventional therapy such as TIPS or local
thromobolysis.
TREATMENT OF BLEEDING

• For primary prophylaxis of variceal bleeding, there is insufficient data on whether

beta-blocker or endoscopic therapy should be preferred. For control of acute
variceal bleed, endoscopic therapy is effective. For secondary prophylaxis,
endoscopic therapy is effective and there is preliminary evidence to suggest that
beta-blockers are as effective as EVL.

• Decompressive surgery or interventional radiological treatment should be

considered for patients with failure of endoscopic therapy. Mesenteric left portal
vein bypass (REX Shunt) is preferred in managing bleeding from pediatric
patients with chronic EHPVO if feasible.
• THANK YU