Table 1 Timeline Table
Dates | Relevant past medical history (symptoms, diagnoses, interventions) | ||
At presentation on 05/06/2013 | Growing lump left upper abdomen since last 15 years Recurrent variceal bleed since last 7 years Epistaxis and ecchymosis since last 3–4 years Diagnosed with – Portal hypertension due to Extrahepatic portal vein obstruction (EHPVO) Earlier managed with - Blood transfusions & EVL | ||
Dates | Summaries from initial & followup visits | Diagnostic testing (with dates) | Interventions |
05/06/2013 | Presented in emergency with hemetemesis & shock On examination- splenomegaly, no sign of liver failure Investigations- UGI endoscopy, Dupplex ultrasound, contrast enhanced computed tomogram, hemogram, liver function tests, coagulation tests, bone marrow examination renal function tests and urine examination Diagnosis- idiopathic EHPVO with acute variceal bleed, portal hypertensive gastropathy, symptomatic hypersplenism & evolving portal biliopathy | Hemogram (05/06/2013)- Hemoglobin 7.1 g/dl, total leucocyte count 1600/cumm, platelet count 45,000/cumm Liver function tests (05/06/2013)- normal Prothrombin time (05/06/2013)- normal Renal function tests (05/06/2013)- normal UGI endoscopy (06/06/2013)- four columns of grade II/III esophageal varices with post EVL ulcers, red colour sign & portal hypertensive gastropathy Protein C, S & antithrombin III levels (06/06/2013)- normal Bone marrow aspiration (06/06/2013)- normal cellularity with no abnormal cells, decreased myeloid erythroid ration (2:1) with normoblastic reaction Urine examination (07/06/2013)- normal Contrast enhanced computed tomogram (07/06/2013)- normal liver, portal vein replaced with large collaterals (portal cavernoma), 23 cm long splenomegaly with 12 mm calibre splenic vein at hilum. Multiple perisplenic, peri gallbladder & peri pancreatic collaterals seen with mild proximal biliary radical dilatation. Left renal vein was retro-aortic in position | Blood transfusions- 05/06/2013 to 07/06/2013- 6 units EVL- 05/06/2013, massive hemetemesis after 24 h Sengstaken-Blackmore tube- 06/06/2013 Condition stabilised Operation- Splenectomy with proximal end to side spleno-renal shunt done on 08/06/2013 |
08/06/2013 to 16/06/2013 | Immediate postoperative outcome- Hemodynamically stable Sengstaken- Blackmore tube removed on 09/06/2013 No rebleed, encephalopathy, ascites | Liver biopsy (08/06/2013)- normal Hemogram (10/06/2013)- haemoglobin 9.3 g/dl, total leucocyte count 10,800/cumm, platelet count 2.1 lakh/cumm Liver function tests (10/06/2013)- normal Urine examination (10/06/2013)- normal UGI endoscopy (14/06/2013)- grade I residual varix, small post EVL ulcers with absence of red color sign & gastropathy | Vaccinated against Streptococcus pneumoniae, Hemophilus influenzae type B & Neisseria meningitides organisms on 16/06/2013 Discharged from hospital on 16/06/2013 Advised for early Physician consultation in case of any infective episode like respiratory infections |
16/10/2013 | History & Clinical examination- Normal No rebleed, encephalopathy, ascites & evidence of hypersplenism | UGI endoscopy (16/10/2013)- normal with no varices Contrast enhanced computed tomogram (16/10/2013)- patent spleno-renal shunt, fewer collaterals around gallbladder and hepatoduodenal ligament with decreased dilatation of intrahepatic biliary radicals. Hemogram (16/10/2013)- normal Liver function tests (16/10/2013)- normal Renal function tests- (16/10/2013)- normal Urine examination (16/10/2013)- normal | Advised for- Normal diet Early Physician consultation in case of any infective episode like respiratory infections |
10/07/2016 | History & Clinical examination- Normal No rebleed, encephalopathy, ascites & evidence of hypersplenism | UGI endoscopy (10/07/2016)- normal Duplex ultrasound (10/07/2016)- patent shunt Hemogram (10/07/2016)- normal Liver function tests (10/07/2016)-normal Renal function tests (10/07/2016)- normal Urine examination (10/07/2016)- normal | Normal diet Advised for early Physician consultation in case of any infective episode like respiratory infections Yearly follow up |