Case of Heart failure with cirrhosis of liver

A 69 year old male patient presented with Shortness of breath and dry cough since 4 days.

2 years back he began developing pedal edema which began in the left foot and later involved right foot also. Gradually the edema extended and the entire lower limbs were involved.
Dyspnea progressed from grade 2 to grade 4 (MMRC classification). There is history of orthopnea. There's history of anorexia.

• No H/o chest pain, palpitations, syncopal attacks, dizziness.
• No H/o leg pains, burning micturition, oliguria, fever
• No H/o altered sensorium, constipation nor diarrhoea

Pt is a k/c/o type-2 DM since 26 years. He is on oral hypoglycaemic agents since then.
Pt is a k/c/o hypertension since 15 years. He is on oral antihypertensives.
Patient developed joint pains 25 years back that led to joint deformities of interphalangeal joints. The pains subsided spontaneously.
Pt is not an alcoholic nor a smoker.

On examination :
There's no pallor, icterus, cyanosis, clubbing and lymphadenopathy.
Grade 3 pedal oedema noted.
Deformities of interphalangeal joints were seen bilaterally.

His BP was 150/90 mmHg measured in right arm in sitting position
       Pulse - 80 bpm measured in right hand. Rate, rhythm, volume are normal. Vessel wall is thick.
       Resp.Rate- 28 cpm

Patient had a barrel shaped chest with mild kyphosis.
Patient has abdominal fat which probably is the root cause of Diabetes mellitus and Hypertension

Jugular venous pulse was raised.

Apex beat was palpated in the left 5th intercostal space, 1cm lateral to the mid-clavicular line.
His JVP was measured to be 10cms of H2O. Abdomino-jugular reflux is present.
Heart sounds were normally heard in mitral, tricuspid, aortic and pulmonary areas. There were no
murmurs or rubs.
There are decreased breath sounds in inframammary and infraaxillary areas bilaterally.
On abdominal palpation, hepatomegaly was appreciated and there was tenderness in right hypochondrium.

Following were the investigations done

ECG showing LAD with ?RBBB

Venous Doppler of B/L lower limbs

Chest x-ray PA view

2D ECHO

Complete hemogram

Renal parameters

Serum albumin

Diagnosis:

Right Heart failure with cirrhosis of liver with ? Nephrotic syndrome

Actions taken:

• Patient was put on salt restricted diet
• O2 inhalation at 2L/minute
• Inj. FUROSEMIDE 40mg/ IV/ BD
• Inj. HUMAN ACTRAPID INSULIN according to sliding scale
• Tab. CARVEDILOL 3.125mg/ BD
• Tab. RIFAXIMIN 550mg/ BD
• Tab. ONDANSETRON 4mg/ IV/ TiD 30min before meals
• Tab. ASPIRIN 75mg / H/s
• Tab. ATORVASTATIN 40mg/ H/s
• Syp. LACTULOSE 15ml / H/s

Problem list and interventions:

1) Patient's shortness of breath subsided with O2 inhalation

2) His pedal edema subsided, but incompletely with FUROSEMIDE injections

3) RIFAXIMIN and LACTULOSE were given to prevent Hepatic encephalopathy

4) CARVEDILOL to reduce blood pressure. It came down to 130/90 mmHg.

5) ASPIRIN to prevent systemic emboli and thromboembolism

6) ATORVASTATIN for atherosclerosis

7) Patient is still complaining of dry cough but with reduced severity.

8) Coarse inspiratory crepitations heard in Right lung fields on auscultation. 

Latest Chest X-ray is below

B/L pleural effusion with ?mild pulmonary edema

To conclude, the patient's general condition has improved and he is still recovering.


After about 10 days of hospital stay, patient has recovered and edema has subsided considerably.