100 Cases in Clinical Medicine

Liver

CASE 7: NAUSEA AND WEIGHT LOSS

History

A man of 45 consults his general practitioner (GP) with a 6-month history of reduced
appetite and weight loss, from 78 to 71 kg. During the last 3 months he has had intermit-
tent nausea, especially in the mornings, and in the last 3 months the morning nausea has
been accompanied by vomiting on several occasions. For 1 month he has noted swelling
of his ankles. Despite his weight loss he has recently noticed his trousers getting tighter.
He has had no abdominal pain. He has no relevant past history and knows no family
history as he was adopted. He takes no medication. From the age of 18 he has smoked
5–6 cigarettes daily and drunk 15–20 units of alcohol per week. He has been a chef all his
working life, without exception in fashionable restaurants. He now lives alone as his wife
left him 1 year ago.

Examination

He has plethoric features. There is pitting oedema of his ankles. He appears to have lost
weight from his limbs, but not his trunk. He has nine spider naevi on his upper trunk. His
pulse is normal and the rate is 92/min. His jugular venous pressure (JVP) is not raised and
his blood pressure is 146/84 mmHg. The cardiovascular and respiratory systems are nor-
mal. The abdomen is distended. He has no palpable masses but there is shifting dullness
and a fluid thrill.

Normal

Haemoglobin 12.6 g/dL 13.3–17.7 g/dL

Mean corpuscular volume (MCV) 107 fL 80–99 fL

White cell count 10.2% 109 /L 3.9–10.6% 109 /L

Platelets 321 % 109 /L 150–440% 109 /L

Sodium 131 mmol/L 135–145 mmol/L

Potassium 4.2 mmol/L 3.5–5.0 mmol/L

Urea 2.2 mmol/L 2.5–6.7 mmol/L

Creatinine 101 &mol/L 70–120&mol/L

Calcium 2.44 mmol/L 2.12–2.65 mmol/L

Phosphate 1.2 mmol/L 0.8–1.45 mmol/L

Total protein 48 g/L 60–80 g/L

Albumin 26 g/L 35–50 g/L

Bilirubin 25 mmol/L 3–17 mmol/L

Alanine transaminase 276 IU/L 5–35 IU/L

Gamma-glutamyl transaminase 873 IU/L 11–51 IU/L

Alkaline phosphatase 351 IU/L 30–300 IU/L

Urinalysis: no protein; no blood

INVESTIGATIONS

Questions

• What is the diagnosis?


• How would you manage this patient?