A 55 yr old female with abdominal distension, epigastric pain and weight loss

The complete case can be found in the link

https://ruchithareddy007.blogspot.com/2020/06/e-log-of-p-ruchithareddy.html?m=1


possible differential diagnoses

chronic left hypocondriac pain

small bowel causes
Crohn’s disease,
irritable bowel xyndrome (IBS),
mesenteric ischemia, and
mesenteric adenitis
large bowel causes
mesenteric ischemia
colitis
splenic causes
splenomegaly secondary to neoplasms,
lymphoma,
portal vein thrombosis,
Gaucher’s disease,
portal hypertension,
endocarditis.
pancreatic causes
chronic pancreatitis,
pancreatic abscesses
cysts
malignancy
renal
pyelonephritis
perinephric abscess

"Symptoms such as weight loss and appetite change suggest more chronic problems such as Crohn’s, mesenteric ischemia, or malignancy."

an episode of  haemetemesis suggests

esophageal varices
stomach or esohageal cancer
peptic ulcer disease
mallory weese syndrome
vascular malformations

most likely diagnosis and why?

various eteologies of portal hypertenson is more likely because of characteristic abdominal distension and hemetemesis due to dilated portocaval anastomosis at esophagus causing esophageal varices.

What investigation will you like to order at this point of time? And why?

Complete blood count (leukocytosis for infection, thrombocytopenia for platelet sequestration, hemoglobin/hematocrit – blood loss anemia or hemolysis)

Basic metabolic profile (renal insufficiency, BUN:Creat ratio may help differentiate volume status), electrolyte abnormalities

Liver function test

elevated protein gap suggesting HIV, hepatitis, or multiple myeloma;

hyperbilirubinemia suggesting possible pancreatohepatobiliary obstruction;

elevated transaminases suggesting parenchymal injury or biliary obstruction;

liver synthetic function when considering causes of splenomegaly)

Lactic acid (mesenteric ischemia secondary to vascular or toxic [cocaine] causes)

Lactate dehydrogenase (LDH) (pancreatitis, mesenteric ischemia)

Amylase (mesenteric ischemia, pancreatitis)

Lipase (pancreatitis)

Blood alcohol level, fasting lipid profile, fecal fat studies (acute and chronic pancreatitis)

Stool studies – fecal leukocytes, ova and parasites, gram stain and culture, Clostridium difficile

Anti-saccharomyces antibody (Crohn’s disease)

Fecal calprotectin level (inflammatory bowel disease)

Imaging:

  • Total abdominal ultrasound with Doppler imaging (gallstone pancreatitis, nephrolithiasis with hydronephrosis, splenic masses, splenic vein thrombosis, perinephric abscess, portal vein thrombosis)

  • Computed tomography (CT) scan with kidney stone protocol (nephrolithiasis)

  • CT Abdomen/ Pelvis (pancreatitis, pancreatic abscess, perinephric abscess, pyelonephritis, obstruction, diverticulitis)

  • Barium contrast enema (Crohn’s disease, volvulus)

  • MRA or CT Angiogram or Mesenteric Angiography (mesenteric ischemia)

  • Abdominal X-Ray (obstruction, Crohn’s disease, nephrolithiasis, colitis)

  • CXR flat and upright (perforated lumen with free intraperitoneal air)

  • MRCP/ ERCP +/- EUS (pancreatitis, pancreatic abscess/cyst, pancreatic malignancy)

  • Colonoscopy – (Crohn’s disease, colitis, diverticulosis)

Other Tests: Intra-abdominal pressure/bladder pressure (if concerned for abdominal compartment syndrome secondary to pancreatitis or peritonitis)

reference: https://www.cancertherapyadvisor.com/home/decision-support-in-medicine/hospital-medicine/left-upper-quadrant-abdominal-pain/


Based on this new information, what could be the diagnosis?

primary portal vein thrombosis

Management

"Treatment is otherwise based on anticoagulation, although there are no randomised data that demonstrate efficacy."
reference: Davidson principles and practice of medicine 23rd edition pg.898.

Anticoagulation with low molicular weight heaprin and vitamin k antagonists is medical theraapy and TIPPS as an interventional therapy



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