The next case for today is a 62 year old male, who initially presented three years ago with diarrhoea and vomiting. Examination showed splenomegaly and ascites, with multiple distended surface veins, particularly on the upper chest and lower part of the neck. Investigations showed a pancytopaenia with a reactive appearance on bone marrow biopsy.

An abdominal ultrasound a year later confirmed hepatic cirrhosis with a very large spleen and abnormal liver function tests. No evidence for alcohol abuse was found, and serology for Hepatitis B and C was negative, as were auto antibodies, alphafetoprotein, alpha-1-antitrypsin and caeruloplasmin levels were normal. A liver biopsy was ruled out; his INR was 2.2.

He was again admitted in March of the same year with a 2 day history of colicky abodominal pain associated with increasing ascites and jaundice. Liver function at this time was markedly abnormal with a bilirubin of 257, INR 2.4, Albumin 23.

Clinical signs were of hepatic encephalopathy with marked ascites. Several litres of fluid were drained and a culture isolated Pseudomonas sp. He was treated with antibiotics but continued to deteriorate and also developed renal failure due to hepatorenal syndrome.

Unfortunately, he died 6 days after admission.