CASE7

NAUSEA AND WEIGHTLOSS

恶心与体重下降

History

A man of 45 consults his general practitioner (GP) with a 6-month history of reduced appetite and weight loss, from 78 to 71kg. During the last 3 months he has had intermittent nausea, especially in the mornings, and in the last 3 months the morning nausea has been accompanied by vomiting（伴随有呕吐） on several occasions. For 1 month he has noted swelling of his ankles（踝关节浮肿）. 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（多血质）. There is pitting oedema（水肿，也可以写作edema） of his ankles. He appears to have lost weight from his limbs（四肢）, but not his trunk（躯干）. He has nine spider naevi（蜘蛛痣，naevi是naevus的复数） on his upper trunk. His pulse is normal and the rate is 92/min. His jugular venous pressure (JVP颈静脉压) is not raised and his blood pressure is 146/84mmHg. The cardiovascular and respiratory systems are normal. The abdomen is distended. He has no palpable masses（可触及的包块） but there is shifting dullness（移动性浊音，通常见于腹水，量在1000ml以上） and a fluid thrill（液波震颤，通常见于大量腹水，量在3000-4000ml以上）.

INVESTIGATIONS

Urinalysis: no protein; no blood

This man has abnormal liver function（肝功能异常） tests which indicate hepatic failure（肝衰竭/肝功能不全）; the hypoproteinaemia（低蛋白血症） has caused the ascites（腹水） and ankle swelling. The number of spider naevi is more than the accepted normal of three. The cause is likely to be alcohol as it is a common cause of this problem, he is at increased risk through his work in the catering business（饮酒商务）. His symptoms of morning nausea and vomiting are typical, and this would account for his cushingoid appearance（库兴样表现） (alcohol increases adrenocorticotrophic hormone (ACTH) secretion) and the macrocytsis on the blood film (due to dietary folate deficiency（叶酸缺乏） and a direct toxic action on the bone marrow（骨髓） by alcohol). However his alcohol intake is too low to be consistent with the diagnosis of alcoholic liver disease（酒精性肝病）. When the provisional diagnosis is discussed with him though, he eventually admits that his alcohol intake has been at least 40–50 units per week for the last 20 years and has increased further during the last year after his marriage had ended, the reason for this being his drinking.
The slight reductions in the sodium and urea reflect a chronic reduced intake of salt and protein; the rise in bilirubin is insufficient to cause jaundice.
Further investigations are the measurement of hepatitis viral serology（肝炎病毒血清学检测）, which was negative（阴性，阳性为positive）, and an ultrasound of the abdomen. This showed a slight reduction in liver size, and an increase in splenic length of 2–3cm. There was no evidence of a hepatoma（-oma结尾的为xxx瘤，如carcinoma肿瘤，所以这里是肝细胞瘤或称肝癌）. These findings indicate that portal hypertension（门静脉高压，通常指的是肝门静脉高压） has developed. A liver biopsy（肝脏活检）, performed to confirm the diagnosis, assess the degree of histological damage and exclude other pathology,showed changes of cirrhosis（肝硬化，sclerosis是硬化病）.
The crucial aim in management is to impress upon the patient the necessity to stop drinking alcohol, in view of the degree of liver damage, the presumed portal hypertension and the risk of oesophageal varices（食管静脉曲张） and bleeding（（破裂之后）出血）, and to effect this by his attending an alcohol addiction unit. In the short term he should also improve his diet to increase his protein intake. Diuretics（利尿剂） could be used to reduce his oedema, but it should be remembered that they could cause postural hypotension（体位性低血压） more easily against this background.
His attendance at the addiction unit was fitful, he continued to drink heavily and he died 3 years later as a result of a second bleed from oesophageal varices.