52/female brought to casualty in drowsy state with c/o progressively increasing jaundice since 2 months for which they were taking some ayurvedic medicines from a quack.  pt is non alcoholic, no h/o blood transfusion, fever, no h/o significant weight loss.  o/e- drowsy, pulse- 110/min, BP- 90/60. spo2 98% on air. icterus, pallor and pedal edema present.  P/A- liver palpable 4 cms and free fluid present.  within 1 hour of admission she started with profuse malena and hematemesis.  Ix showed Hb (6.8), TLC (10,300), Plt (4.17L), Total Bil (18), direct (10) indirect (8), OT/PT (265/121), Albumin (3.5),Globulin (3.1), serum ammonia 250, HBSAg, HCV negative, INR (1.8), Urea (46), creat (1.9), Na (145), K (2.9).  Diagnostic Ascitic tap was done and report attached (ADA and cytology awaited). USG and CT abdomen attached.  could it be malignancy?  can obstructive jaundice present directly at this terminal stage? patient had no h/o abdominal pains before and had no h/o gall stones.  Budd Chiari?

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Interesting case ! In my opnion this is an Acute on Chronic liver failure , and etiology may ne Autoimmune hepatitis, PSC, Cryptogenic, Wilsons or NASH... Only point agaisnt the scenario of decompansated liver disease is the central and peripheral IHBR dilatation.. So if we consider Corrhosis then HCC can be the cause or if we consider PSC them cholangio ca or ca gall bladder could be the cause...Anyways at this point please do triphasic contrast CT or MRI abdomen for clarification of the scenario...

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This is not budd chiari,but chronic decompensated liver disease - cirrhosis with portal hypertension with hepatic encephalopathy & portal biliopathy and the imaging confirms that. There is a component of cholangitis. Etiology could be cryptogenic liver disease with drug induced liver injury as superadded insult. She needs ICU care, anti encephalopathic measures, IV antibiotics and plan for an ERCP + biliary stenting. Once stabilised, she needs to be listed for a liver transplant which will be the only cure,but technically difficult.

Can spleen has normal morphology echotexchure, and size in case of portal HTN due to cirrosis?
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रोगी की किडनी व यकृत में विकृति है। चिकित्सा संबंधी योग,,, यकृतदारि लौह 4 रत्ती शहद के साथ सुबह शाम सेवन कराएं, मूत्रल कषाय, पाषाणभेद मकोय पंचांग शाहतरा कासनी बीज गोखरू छोटा गुडुची वरुण छाल पूनर्नवा जड़ का काढ़ा बनाकर उसमें 2 ग्राम स्वेत परपटी डालकर सुबह शाम सेवन कराएं जलोदरारि रस 2 वटी सुबह दें कुमारियासव 25 ग्राम सुबह-शाम खाने के बाद दें योग परिक्षित है पिछले 40 वर्ष से प्रयोग कर रहा हूं।

Malena and hematemesis -- Esophageal variceal bleed. Get AlphaFP-rule out malignancy, and further Liver panel reports Immunoglobulins, ANA, Endoscopy with band ligation can be considered as life saving with transfusions Meds-- Udiliv, terlipressin, tranexa, antibiotics, Pantoprazole infusion, lactulose,octreotide PET CT may be required

thank you doctor
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It is intrahepatic biliary obstruction with renal involvement, mostly hepatocellular carcinoma,or secondaries liver, needs management in IMCU with protocol in hepatic cell failure, needs pet scan and CA markers

Its case of liver metastasis causing osbstructive jaundice with renal failure with hepatolenticular failure with coagulation dyscrasia malena.Ayurvedic treatment could have worsened the jaundice.Treatment is symptomatic, supportive at this stage with further investigations to confirm diagnosis

just an off beat reply.. the liver enzymes OT/PT and ALP has a link.. if there is a disproportional high values of ALP compared to the rise in OT/PT, it indicates CBD obstruction...

ALP was quite within normal range. thank you doctor
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Case of liver metastasis with intrahepatic biliary obstruction withrenal involvement

Acute hepatic failure...Due to ayurvedic drugs... Start octreotide and NAC Rule out autoimmune hepatitis and Wilson's disease..

thank you doctor
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