Name: gao guo chi, male 57years old

Businessman
Chief complaint: vomiting blood and
black stools for 1 month,
consciousness not clear for 20 days

HPI
The patient has had multiple
episodes of hematemesis and
melena for 1 month and impaired
consciousness since 20 days. The
patient was previously admitted for a
TIPS procedure due to portal
hypertension accompanied with
esophageal varices, which was
successfully performed on
2015.11.19.

 20 days ago, whilst the patient

continued having hematemesis and
melena, also developed altered
consciousness, he was taken to the
emergency department and was
given l-ornithine, for which the level
of consciousness was improved

 2 days later, he had the same

episodes, and was thus admitted to
the GI internal medicine department
of the First Affiliated hospital under a
diagnosis of hepatic encephalopathy
due to decompensated cirrhosis and
esophageal varices

Past medical history

He had a partial cholecystectomy due
to gallstones done 4 years ago
He has had diabetes mellitus since 3
years, for which he is taking insulin
(good control)
Liver cirrhosis was diagnosed 2 years
ago and was treated for 2 times

 He denies any history of

hypertension, hepatitis virus
infection, TB infection or other
diseases of infectious etiologies
Except from those stated above, he
is not currently on any long term
medication

Allergy hx
The patient denies any allergy to
food or medication

Social history
Alcohol history: yes
40 year history of drinking baijiu, 1
lb/day
stopped 2 years ago
Smoking: no

Physical exam
T:36.1 P:120/min BP:150/67
RR:20
CNS is normal
Skin is normal ( no jaundice)
HEENT is normal
Chest and lungs are normal
Cardiac exam reveals sinus
tachycardia P:120, all other
modalities are normal

 Abdomen: abdomen is soft,

abdominal superficial veins are
normal, there is no observable
peristaltic wave, no tenderness, no
rebound tenderness, palpation did
not detect any mass, the liver&
spleen borders are not palpable, gall
bladder not palpable, no percussive
tenderness over the liver and kidney
areas, no shifting dullness

 Auscultation of bowel sounds is 46/min

No vascular bruits were heard on
auscultation

Specific appearance
No palmar erythema, no spider
naevi, no capillary distention, no
fetor hepaticus

RBC

Special exam
Gastroscopy:
25cm distal to the opening of the
esophagus, 4 enlarged veins can be
observed, with the largest one
measuring 1.2cm
The mucosa is erythematous
The pyloric sphincter is round and
opens/closes smoothly

Special exams
2015/11/17 CT: liver cirrhosis,
splenomegaly, post-surgical portal
vein changes, 2 small left renal cysts,
low amount of pleural effusion
bilaterally
2015/11/18 gastroscopy: type 3
esophageal varices 25 cm distal to
the opening of the esophagus
2015/12/06: blood ammonia 93
mol/L (9-30)

Diagnostic info
Middle aged man
3 years history of cirrhosis
2011-8-25 partial cholecystectomy and
removal of gallstones
2012-10-(25-31) received treatment for
cirrhosis twice
2015-11-19 TIPS procedure
Hematemesis and melena for 1 month
Consciousness not clear for 20 days

 Why did he have altered

consciousness?

 What are your diagnoses?

 What is the next step in treatment of

this disease?

 What are the types of cirrhosis? How

to differentiate between them?

 What are the treatment options for

this patient?