A young alcoholic cirrhotic
June would visit Ram Hari every morning and collect his story bit by bit during the time most of her friends would busy chatting away waiting for Professor Mechanic to come and teach them.
Ram Hari was a 25-year-old man working as a hotel waiter in Bharatpur, Nepal and had come to Kolkata, India searching for a job in a bigger hotel. He landed up in the bed before June however as he had developed a distension of his abdomen while in Kolkata and when he presented to the outpatient department of their medical college a kindly physician admitted him.
That was three years back and ever since he had been depending on the hospital for his food, shelter, and intermittent fluid removal from his abdomen. Most of the hospital staff knew him by name.
He had been a regular drinker since the age of twelve. His mother had abandoned him when he was a 6 year old (his father kept saying she had run away with another man). From the age of 12, he was forced to work as a daily wage earner by his father and was employed in a factory manufacturing country liquor. Since then he started drinking 250 ml of spirits daily and would occasionally consume 2 bottles of 750 ml each.
At the age of 21, he suffered an episode of massive blood vomiting and tarry stools for which he had been admitted to a district hospital in Nepal where he received 6 units of blood transfusion. Soon after discharge from that hospital he resumed drinking for another year until he was readmitted to the same hospital with a fluid filled belly. He has undergone repeated removal of fluid ever since with needles jabbed at various sites over his belly.
He also had a hernia over his umbilicus due to all that fluid in his belly and which burst spontaneously one fine day for which he again had to be admitted for an emergency operation.
June started doing a physical examination on Ram Hari meticulously elucidating the findings as she had often seen Joatmon do.
On general examination Ram Hari was visibly very pale and malnourished, had a prominent scalp infection, and his eyes suggested a mild jaundice. Ram Hari's abdomen provided the maximum number of findings. It was distended with prominent veins and fullness in his flanks, an everted and bulging out umbilicus (as if someone had stuck a top over that portion of his belly). She could hear a continuous to and fro sound over his umbilicus with her stethoscope but couldn’t figure why there was this sound and decided to look it up later in her books if possible.
June could palpate his liver and spleen by dipping her fingers into the organs through his fluid filled belly. She could elicit a vibration of fluid over her palms placed on his belly by tapping at it from a point opposite. It is a sign that goes by the name of 'fluid thrill' possibly given by a thrilled physician first to have discovered it. It confirmed the presence of a lot of fluid in Ram Hari's peritoneal bag covering his intestines.
June took a peek at his file to look up the investigations already done during his hospital stay.
He had a hemoglobin of 5 g/dL, a total leukocyte count of 1800, and markedly reduced platelets on smear suggestive of hypersplenism. His serum bilirubin was 3.6 mg/dL with an unconjugated fraction of 2.4 mg/dL, serum albumin was 2.1 g/dL and globulins were raised at 4.5 g/dL. His HbsAg (Virutex/latex), Anti-HCV (dot blot Assay) and HIV (ELISA) were negative.
Ultrasound abdomen showed an irregular liver surface with portal vein measuring 14 mm apart from free fluid.
অধ্যায়-- 61
মাদকজনিত কারণে যকৃত রোগগ্রস্থ যুবক
জুন প্রতিদিন ভোরে রামহরির রোগের ইতিহাস পুঙ্খানুপুঙ্খ ভাবে জানতে আসত। সে সময়টায় জুনের সতীর্থ বন্ধুরা অধ্যাপক মেকানিকের সঙ্গে আড্ডার জন্য অপেক্ষা করত, যিনি তাদেরকে প্রশিক্ষণ দিতে আসত। পঁচিশ বছরের রামহরি নেপালের ভরতপুরের হোটেলে প্রতিক্ষাকারীর কাজে নিযুক্ত ছিল। একটা বড় হোটেলের কাজ পেতে কলকাতায় এসেছিল। তখন মেডিক্যাল কলেজের বহির্বিভাগে দেখাতে এলে, একজন চিকিৎসক তার প্রতি সদয় হয়ে ভর্তি করিয়ে দিয়েছিল। সেটা প্রায় তিন বছর আগেকার কথা। সেই থেকে সে খাওয়া-দাওয়া, আস্তানা, চিকিৎসার জন্য, পেটের জল বের করার জন্য হাসপাতালের উপর নির্ভরশীল ছিল। হাসপাতালের প্রায় সব কর্মচারীদের কাছে বেশ পরিচিত হয়ে উঠেছিল। বারো বছর বয়স থেকেই সে নিয়মিত মদ খেত। ছয় বছর বয়স থেকেই মা নিরুদ্দেশ ছিল। তার বাবা বলত, তার মা নাকি অন্য পুরুষের সঙ্গে পালিয়েছে। বারো বছর বয়স থেকেই তাকে বাবার সঙ্গে দেশি মদের ফ্যাক্টরীতে দিনমজুরের কাজ করতে বাধ্য করা হয়েছিল। তখন থেকেই সে প্রতিদিন 250 মিলি মদ খেতে শুরু করে। কোনও কোনও দিন দুটো 750 মিলি বোতলও সাবার করে দিত। 21 বছর বয়সে মারাত্মক ভাবে তার রক্ত বমি শুরু হয়। সেই সঙ্গে কাল পায়খানা। তাকে নেপালের জেলা সদর হাসপাতালে ভর্তি করা হল। সেখানে তাকে ছয় বোতল রক্ত দেওয়া হয়। হাসপাতাল থেকে ছুটি পেয়ে আরও বছর খানেক ধরে মদ খেতে থাকে, যতদিন না তাকে দ্বিতীয়বার একই হাসপাতালে ফোলা পেটসহ ভর্তি করা হয়। তার পেটে অসংখ্য সূচ ফুটিয়ে বারংবার জল বের করা হয়। পেটে জলের পাশাপাশি তার নাভি অবধি হার্নিয়া ছিল। কোনও একদিন সেটি ফেটে যায়, আবার হাসপাতালে ভর্তি করে অপারেশন করা হল।
জুন তাকে খুঁটিয়ে খুঁটিয়ে শারীরিক পরীক্ষা করছে। ঠিক যেভাবে সে জোটম্যানকে করতে দেখত। সাধারণ পরীক্ষায় রামহরিকে অপুষ্টি রোগগ্রস্থ, ফ্যাকাশে মনে হচ্ছিল। তার মাথার চামড়ায় সংক্রমণ, চোখে মৃদু জনডিস। পেটে অনেক রকম অসঙ্গতি দেখা গেল।শিরা-উপশিরা ফুলে রয়েছে। জুন নাভির উপর স্টেথো ধরে অনবত তোলপাড় শব্দ শুনতে পাচ্ছে, কিছুতেই বুঝতে পারছে না, এত শব্দ কোত্থেকে হচ্ছে। তরলে ভরা পেটের যকৃত, অগ্নাশয়ে আঙুল দিয়ে জোরে চাপ দিচ্ছে, হাতের চেটো বসিয়ে তার উপরে টোকা দিলে জলের নড়াচড়া টের পাচ্ছে। এটা থ্রিল ফ্লুইডের উপসর্গ, যা কিনা কোনও ডাক্তার সেটা প্রথম আবিষ্কার করে নিজে থ্রিলড হয়ে এরকম নামকরণ করেছিল। এ থেকে নিশ্চিত রামহরির পাকস্থলিতে প্রচুর জল জমেছে।
জুন তার মেডিক্যাল নথির ফাইলটি আরেকবার দেখে নিতে তুলে নিল, যা এর আগেও তার হাসপাতালে ভর্তি থাকাকালীন দেখেছিল।
হিমোগ্লোবিন 5 g/dl
লিউকোসাইড কাউন্ট 1800
প্লেটলেট অসম্ভব রকম কমে গেছে। সিরাম বিলিরিউবিন 3.6mg/dl. যেখানে আন-কনজুগেটেড ফ্র্যাকশন 2.4mg/dl. সিরাম অ্যালবুমিন 2.1g/dl. গ্লোবিউলিন বেড়ে 4.5 gm/dl এ দাঁড়িয়েছে। HbsAg( Virutex/latex), anti-HCV(dot blot Assay) এবং HIV(ELISA) নেগেটিভ ছিল। পেটের আলট্রা সাউন্ড থেকে যকৃতের উপরিতল খসখসে পাওয়া গেছে। পোর্টাল ভেইন 14 mm.তে দাঁড়িয়েছে।
Bedside troubleshooting: a systems approach
Prof Mechanic began, " The approach to clinical problems (or challenges), begin almost always in trying to localize it at a component level, be it in the kidneys, heart, brain or liver. Asking where the problem is gives us the morphologic/anatomic diagnosis. The ability to make a diagnosis would therefore depend very much on our knowledge of anatomy, the intricacies of the machine's internal circuitries. None of you should feel uncomfortable looking at the jumble of chips and maze of signaling pathways that one finds on removing the lid off your machines. You have had sufficient time I hope to learn about it in your pre-clinical years. This learning and your knowledge of anatomy is what separate you from a layperson that is more likely to be your patient. It is also important because the human machine takes a long time in its evolutionary sequence to change in structure. So for most part of your medical career you will find many of the other things that you learn today shall change dramatically over the years but your knowledge of structure/anatomy shall not. Even grossly your machine may not appear to change very much in function at a component level. The kidney will continue to produce urine, the liver bile, and the heart shall continue to supply blood and oxygen to all the tissues, microchips that produce energy from your daily bread and the brain shall continue to think perhaps!
This view of the brain was not always there in the past and we have held on to it for quite some time now. However at a deeper microcosmic level the stories may change. This is because, (Quoting Blake) "The Microscope knows not of this nor the telescope:they alter the ratio of the spectators Organs but leave objects untouched."
Apart from identifying which component is malfunctioning we have to also answer the question of why it is malfunctioning. If a machine points out or displays chest pain on its LCD screen we can speculate the source to lie in the coronary pipes which may be blocked and not supplying enough oxygen to the central pump, or it could even be something wrong with the aortic valves in the pump, again impeding circulation through the coronary pipes. We can also speculate that it may be due to a host of other system components like the food pipes or lungs or even the muscles or bones of the chest and very often these possibilities would be narrowed by weighing clues offered in the symptoms, the onset, duration, course and exact site of the pain. Assuming that we have narrowed down the problem site to the pipes supplying the heart (fashionably called the coronary arteries) we have to wonder next why, what is happening there? The commonest story in circulation at present to explain blockage of these pipes is the story of atherosclerosis. The story of immigrant lipid moieties settling down in the endothelium, constantly under attack from inflammatory mediators until one fine day the plaque like community fissures and cracks up resulting in a blocked pipe. This is a problem of the present global community, violence and strife everywhere. Our diagnosis generally ends here after unearthing the site and cause of the problem.
Summarizing livers and rivers within
Prof Mechanic continued, "To summarize then, we have a 25-
year-old system with a bloated belly, past blood vomits and
altered behavior. This point’s to the liver and its pipes under high
pressure as the anatomic location of this problem. This is what we
would label as its anatomic diagnosis. Now the exact cause for
injury to the liver is also quite clear. Ten years of uninterrupted
high dose alcohol consumption, like spilling coffee everyday on
your notebook that finds its way into the hard disc. On examining
this machine we find prominent veins over his belly a marker of all
those displaced liver rivers. And just look at those beautiful red
spiders, Wow! Look at that haul on his back! Look how they
blanch off and disappear when I press this glass on his skin and
reappear when I remove the pressure. Also if you remove his
underwear and examine his genitals you shall find both his testes
small like that of a kid. There is hardly any secondary sexual
characteristics in this 25-year-old you would expect, axillary, pubic
hair...hardly any? The spiders-dilated small arterioles, small
testes, lack of sexuality is all because of an excess of the female
hormone, estrogen in his blood…That estrogen which couldn't be
utilized by his ailing liver.
The class looked at Professor Mechanic mesmerized by his deft
handling of this 25-year-old young machine arriving so very easily
at a diagnosis both morphologic as well as etiologic.
"But then...June thought, is getting the diagnosis the central
process of clinical medicine?" The 5 edition of the oxford handbook of clinical medicine that she
carried about in her apron most often to the wards also raised the
same question and in its own answer submitted, “The central
process in medicine are: The relief of symptoms, the providing of
reassurance or other prognostic information and the lending of a
sympathetic ear, all seriously lacking June thought in professor
Mechanic who always seemed to be in a hurry doing procedures,
giving lectures and advice too often without much listening. He
was more like a tree swaying gregariously in a storm shaking off
all the birds that dared not build nests on his shoulders. Prof Jo
never seemed to be in a hurry, which made you wish you could be
with him always.
61
Discussing the Whole
June emailed Ram Hari’s story to Joatmon particularly because
she was convinced there must be another level of diagnosis for
him apart from the fact that he had cirrhosis of liver (Prof
mechanic’s morphologic diagnosis) due to alcohol (His etiologic
diagnosis).
Dear June, Thanks a lot for this. There is this other dimension of
a patient’s diagnosis which you have sensed and we in holistic
medicine feel is so often neglected by professor mechanic’s
hardware school. It’s the social diagnosis that lifts this machine
from the hospital bed and places him in a wider community
perspective. That is why a hospital physician who never practices
in the community can hardly ever connect to his patients beyond
the mechanical approach, barring exceptions. I would like you to
prepare a report of this case because it’s important that we tell the
world that cirrhosis with all its complications due to alcohol can
even occur at this age possibly related to poverty, child labor and
easy access to alcohol and we need to keep our eyes open for
this cohort of young alcoholics. Give me the complete clinical
summary of this case and I shall prepare the discussion. Jo
June browsed through the discussion prepared by Jo. It must
have been hard to collect the references sitting in his cave in the jungle but then he had friends in better places that would have
mailed the references to him. This patient highlights the social
problems posing substantial challenges to health care in the third
World. Child labor was forced upon him at an early age and he
took up alcohol early also because of easy access to liquor.
Inspite of legislative enactments prohibiting employment of
children below the age of 14 years (section 14; Civil rights act,
2012, Nepal), the 1981 census, Nepal, showed that 4.5 million or
60% of the child population in 10 to 14 age group of Nepal is
economically active1
. The sale or offering of alcoholic drinks to
persons below 18 years of age is illegal according to legal
restrictions on production, sale, and consumption of alcoholic
beverages in Nepal2
. However, alcohol use has been quite
prevalent in Nepal since time immemorial. Social tolerance to
alcohol use is quite high and mostly alcohol has not been taken
seriously either by the Government or by any social organization.
Production, sale, and consumption of alcohol are ever on the
increase and it could be taken as the number one problem drug in
the country3
. These factors contributed to the early onset of heavy
drinking in our index case and he developed cirrhosis at the age of
21 years. His dependence on alcohol was such that he didn’t stop
drinking even after the first episode of blood vomiting and tarry
stools. Continued drinking for another year made his social and
financial supports give away.
Following this he was converted into a total dependant on the
hospital partly for his regular abdominal fluid removal and partly
for 2 square meals a day, effectively falling into the vicious cycle
of poverty and social-physical debility. The so called Developed
countries such as United States have dealt with their alcohol
problem with periodic enforcement of strict prohibition like the one,
which lasted from 1920-23, and the incidence of alcoholic cirrhosis
reached an all time low. The death rate from the condition fell to
half its 1907 peak and did not start to increase again until the
amendment was repealed4
. The time is ripe for Nepal to embrace
strict enforcement of its prohibition laws.
References
Children and Women of Nepal, a situation analysis, UNICEF
Nepal Publications 1992.
Madira Niyamharu (2033) Nepal Niyam Sangraha, Khanda4. (KA)
2040, Ministry of law and justice, HMG/Nepal, pg 132-8.
Shrestha NM. Alcohol and drug abuse in Nepal. British J of
Addiction 1992; 87: 1241-8.
Musto DF. Alcohol in American History. Sc American 1996; 274
(4): 64-9.
Image source : https://rhea9895.blogspot.com/2021/12/47-years-old-male-patient-with-reduced.html?m=1
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