48 year old trishaw driver came to the hospital with the complaint of tiredness, weakness and vomiting of blood.

He also complains of indigestion after fatty meal. He has a history of taking alcohol for 25 years. On physical examination ---- Thin, Tired-looking, pale, tinge jaundice Dilated veins radiating around the umbilicus, enlarged spleen without enlarged liver, and ascites was noted.

Laboratory investigations: Biochemical Tests Test Albumin Globulin Fibrinogen Total Protein Glucose Bilirubin ALT AST TG

Result 3g/dL 3.2g/dL 0.3g/dL 6.5 g/dL 115 mg/dL 3.7 mg/dL 62 U/L 230 U/L 256 mg/dL

Reference Ranges 3.6 5.2 g/dL 1.9 3.3 g/dL 0.2 0.4 g/dL 6 8 g/dL 80 120 mg/dL <1 mg/dL <50 U/L 10 40 U/L <150 mg/dL

Hematology Test RBC HGB HCT Ferritin MCV PT Result 4.0 million cells/L 10.9 g/dL 40% 18 mg/mL 86 fl 18.5 sec Reference Ranges 4.2 6.2 million cells/L 14 17 g/dL 47% 30 280 mg/mL 87 fl 10 15 sec

Provisional diagnosis for this case is cirrhosis of liver with portal hypertension. What will be the differential diagnosis? Discuss the above results of investigation. What other investigations would you like to do? What is the cause of dilated veins radiating around the umbilicus in this case? Name other sites of porto-caval anastomosis. Discuss the guideline of treatment for this patient. Give the guideline of diet for this patient. What will be the prognosis?

Learning Issue Anatomy - Nine regions of abdomen - Gross anatomy of liver - Histology of normal liver - Histopathology of cirrhosis of liver - Anatomy of portal vein - Porto-caval anastomosis - Clinical features of portal hypertension Physiology - Functions of liver - Explain the physiological basis of anaemia, jaundice, ascities, fat intolerance and prolonged prothrombin time ( ISF formation, clotting factors: principles of the tests, anaemia of chronic disease, fat digestion) Biochemistry - Liver function tests - Metabolic functions of liver - Increased liver enzymes and liver cell damage - Blood coagulation and liver protein synthesis - Balanced diet in patient with liver disease

Clinical correlations Confirmation of clinical diagnosis - Liver function tests - Haematological tests - Ultrasound findings