Case 33 Gastroenterology

Cirrhosis with a murmur

Work it one clue at a time. The diagnosis stays hidden until you reveal it.

Clue 1

A middle-aged woman with a year-long history of Laennec’s cirrhosis (EtOH-related) comes under your care.

Sure enough she has signs of liver disease on exam.

Clue 2

What else do you notice in the above video? The EJ is engorged. This is an unexpected finding in a patient with cirrhosis, where you would expect to see extravascular hypervolemia (eg, pitting edema, ascites) but not intravascular hypervolemia. Let’s take a closer look.

Clue 3

Intravascular volume is markedly elevated.

Let’s take a listen to the heart: (best to use headphones or good computer speakers.)

Clue 4

What you’re hearing is a booming gallop. Our patient is so tachycardic it’s tough to distinguish between an S3 and an S4. However, the phonocardiogram can help.

Clue 5

Our patient has an S4 gallop.

Let’s look back at ascitic fluid results since the diagnosis of Laennec’s cirrhosis was made. SAAG >1.1, consistent with a portal hypertensive process.

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