Ascitis

 A 29 year old female from presented to us to opd on a wheel chair with complaints of

     

                         chest pain 

                 abdominal distension  since 1 month.

History of present illness:

 Patient was apparently asymptomatic one month back then she developed chest pain on the left side stabbing type non radiating since one month and abdominal distension gradual in onset progressive in nature since 1 month associated with shortness of breath grade 2 to 3

No history of pedal edema, palpitations , orthopnea and PND

No history of constipation, Nausea , vomitings or diarrhoea

No history of fever , weight loss, cough

No history of  hematemesis, melena, or yellowish discoloration of eyes.

Going back to her history: 
She got married in  2015 and 
Concieved  in the month of ? May 2016
Bleeding PV after two months of pregnancy for which she had been to hospital and was told about abortion for which Dilatation and curratage was done.
2017: september she concieved again and  her 1 st and 2 nd trimester were uneventfull.
Edd was in the month of  june 2018
She had been to doctor on 1st of june and usg turned out to be normal 
Then she had been to doctor again on june 11 th as she had tightening of abdomen for which USG was done and was told as IUD as there was no fetal heart rate.
And then  normal vaginal delivery was for bringing out iud .

2019 : February they had been to doctor in view of not concieving for which she underwent investigations and her 
PLBS  ? 210  and was started on OHA.
She was on OHA for 1 month.
2020May : LMP : 17/5/2021 she concieved for 3 rd time 
And was again on OHA ( for 20 days)in the month of july and from august she was on 

Inj Equisilin (NPH (70)/regular (30)/sc

And when she had been on 24 th january to doctor as there was abdominal distension causing difficulty in sleeping and moving so she underwent usg showing polyhydromnios.
And she was operted ( Cesaerean section) at 7:00 pm ivo fetal bradycardia.
Baby cried immediatly after birth 
Baby weight (boy) : 3200 grams.
And she was discharged on 28th january 2021
Her sugars were normal so after delivery she was not on any hypoglycemic agents.
 

Since March 2021 c/o left sided chest pain stabbing type with abdominal distension  with loss of appetite .

Past history: Patient is a diabetic since 3 years 

No history of hypertension, Tuberculosis, HIV , malignancy, thyroid disorders.

Personal history: Patient takes mixed diet, bowel bladder normal 

Non alcoholic and smoker.

No significant family history




surgery referral was done in the view of need for peritoneal  biopsy. 



Advice:plan for diagnostic laparoscopy + proceed to peritoneal or omental biopsy
Report: multiple paracentesis was done with 500 ml draining out each time.
IT WAS A REFRACTORY ASCITES. 

17/03/2020:
one unit of PRBC was transfused in view of blood loss during operation and was started on antibiotics post operatively.
                      INJ.TAXIM /BD
                      INJ.METROGYL/TID
                      INJ.AMIKACIN/BD
                      INJ.PCM/TID
                      INJ.PAN/OD
          


Peritoneal biopsy and Omental biopsy:

                  Microscopy- sections studied from peritoneal biopsy shows chronic inflammatory cell infiltrate in the fibrocollagenous tissue.

                                         sections studied shows lobules of mature adipocytes with area showing chronic inflammatory cell infiltrate comprising of lymphocytes, epithelioid cells and plasma cells.occasional neutrophilic infiltrate seen.Fewmultinucleated gaint cells seen.

                  Impression- peritoneum- features suggestive of chronic peritonitis.
                                        omentum- features suggestive of granulomatous omentitis.

A drain was placed for 5 days after surgery

20/03/2020:                
                          In the view of above biopsy report patient was initiated on ATT with 3 drugs FDC according to body wt on 20/03/2020 and tab- prednisolone 30mg OD on 20/03/2020.

patient complaints of left hypochondric pain and a review ultrasound and chest x-ray was done. 
  USG report- Mild to moderate ascitics- echogenic fluid. Rtkidney irregular calycial dilatation noted.
chest x-ray report- Mild to moderate plureral effusion on left side for which 
 Thoracocentasis  was done.

Pleural fluid analysis: sugar-246mg/dl


                                       protein-6.1gm/dl

Pleural fluid analysis : exudative
Ascitic fluid analysis : SAAG : 0.5 
    Non portal hypertensive gastropathy
   DIfferentials. ? TB
                        ? Peritoneal carcinomatosis
                     ? Pancreatitis


GENERAL EXAMINATION
Patient is conscious coherent and cooperative 
Built : moderately 
Nourishment : moderate 
aFebrile
Pallor present 
No Icterus Cyanosis Clubbing 
Pedal edema  and lymphadenopathy

VITAL SIGNS
 
PULSE:  97 bp regular 
 
BLOOD PRESSURE: 100/70 mm hg supine position right arm
 
RESPIRATORY RATE : 24 cpm 
 
TEMPERATURE: 98.4 F measured in the Axilla
 
 
SYSTEMIC EXAMINATION







 
 
ABDOMEN:
INSPECTION:
1. Shape – distended-uniform
2. Flanks – full
3. Umbilicus – central in Position, Shape-everted (transverse slit)
4. Skin – stretched ,striae present 
5. No Dilated veins 

 
PALPATION:
Soft , tenderness diffuse all over the abdomen . No organomegaly
 
PERCUSSION:
Shifting dullness present 
 
AUSCULTATION:
1. Bowel sounds heard 
 
CARDIOVASCULAR SYSTEM:
S1, S2, heard with no murmurs
 
EXAMINATION OF RESPIRATORY SYSTEM: NVBS hears.
 
EXAMINATION OF CNS : NFND

Investigations: 

Ascitic fluid amylase - 15
Ascitic fluid protein- 4.1

                       Sugar- 147
Ascitic fluid LDH- 431
Serology - negative
LFT- TB-0.82,DB-0.20, AST-31,alt- 59,alp-228,
Tp- 5.6, alb-2.2, a/g ratio - 0.66
Fbs-166
Rbs-215
Sr.albumin-2.2
Ascitic albumin-1.7
Saag-0.5
Rft- urea-11,creat-0.7,uric acid - 6.6,ca-8.4,p-5.2, sodium - 138, k-3.9,cl-100
Sr.protein -5.5
Cue-color-reddish
Alb-2+, sugars - nil, pus-10-12,epi cells-3-4, RBC-5-6,others- budding yeast cells present

USG ABDOMEN: gross ascites

Hemogram: hb-9.6, tlc-6700,pcv-28.6, plt-4.38

03/04/2020:

E S R # 80 mm/ 1 st hour

HEMOGRAM

HAEMOGLOBIN # 10.0 gm/dl 

TOTAL COUNT 5,700 cells/cumm NEUTROPHILS 80 % 

LYMPHOCYTES # 15 % 

EOSINOPHILS 02 % 

MONOCYTES 03 % 

BASOPHILS 00 % 

PCV # 35.4 vol % 

M C V # 72.7 fl

M C H # 20.5 pg

M C H C # 28.2 % RDW-CV # 20.2 % 

RDW-SD 48.8 fl

RBC COUNT # 4.87 millions/cumm

PLATELET COUNT 4.60 lakhs/cu.mm SMEAR

RBC Normocytic hypochromic anemia Light Microscopy

WBC With in normal limits Light Microscopy

PLATELETS Adequate in number and distribution Light Microscopy

HEMOPARASITES No hemoparasites seen Light Microscopy

IMPRESSION Normocytic hypochromic anemia

LFT

Total Bilurubin 0.62 mg/dl 

Direct Bilurubin # 0.22 mg/dl 

SGOT(AST) 20 IU/L 

SGPT(ALT) 22 IU/L 

ALKALINE

PHOSPHATE

# 232 IU/L 

TOTAL PROTEINS # 6.0 gm/dl 

ALBUMIN # 2.0 gm/dl 

A/G RATIO 0.52

04/04/2020:

C-Reactive Protein -Negative mg/dl

09/04/2020:

HEMOGRAM

HAEMOGLOBIN # 10.5 gm/dl 

TOTAL COUNT 5,200 cells/cumm NEUTROPHILS 80 % 

LYMPHOCYTES # 16 % 

EOSINOPHILS 02 % 

MONOCYTES 02 % BASOPHILS 00 % PCV # 35.1 vol % 

M C V # 72.9 fl M C H # 21.8 pg

M C H C # 29.9 % 

RDW-CV # 20.8 % 

RDW-SD 49.3 fl

RBC COUNT # 4.81 millions/cumm

PLATELET COUNT 3.22 lakhs/cu.mm 

SMEAR

RBC Microcytic Hypochromic Light Microscopy

WBC With in normal limits Light Microscopy

PLATELETS Adequate in number and distribution Light Microscopy

HEMOPARASITES No hemoparasites seen Light Microscopy

IMPRESSION Microcytic Hypochromic

LFT

Total Bilurubin 0.56 mg/dl Direct Bilurubin # 0.24 mg/dl SGOT(AST) 17 IU/L SGPT(ALT) 13 IU/L ALKALINE

PHOSPHATE

# 203 IU/L TOTAL PROTEINS 7.2 gm/dl ALBUMIN # 2.91 gm/dl 

A/G RATIO 0.68

RFT

UREA # 10 mg/dl 

CREATININE 0.6 mg/dl 

URIC ACID # 8.7 mg/dl DHBS

CALCIUM 9.6 mg/dl 

PHOSPHOROUS 3.9 mg/dl 

SODIUM 139 mEq/L

POTASSIUM 4.0 mEq/L

CHLORIDE 101 mEq/L

CELL COUNT PLEURAL FLUID

VOIUME 3 ML 

COLOUR Pale Yellow

APPEARANCE Turbid

TOTAL COUNT 50 Cells/cumm

DIFFERENTIAL COUNT

NEUTROPHILS 0% 

LYMPHOCYTES 100% R B C Nil

OTHERS Nil

LDH

LDH 269 IU/L

PLEURAL (SUGAR, PROTEIN)

SUGAR # 246 mg/dl

PROTIEN 6.1 g/dl .

SERUM PROTEIN

SERUM PROTEIN 7.8 g/dl .

Treatment given :
Tab.pcm 650mg qid
Tab.pan 40mg od
Inj.diclofenac im sos  
Due course patient developed arthralgia due to pyrizinamide (ATT) due to hyperuricemia so eventually allopurinol was added and subjectively patient is feelimg better and now presently is arthralgia is it enthesitis due to the same etiology causimg pleuritis serositis is not know.

After 6 months of ATT she was subjectively feeling better and objectively there was no ascites