A 45 years old man consults his general practitioner (GP) with a 6-month history of reduced appetite
and a weight loss, from 78 to 71 kg. 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 on several occasions. For 1 month he has noted swelling of his ankles. 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. There is pitting oedema of his ankles. He appears to have lost weight from his limbs, but not his trunk. He has nine spider naevi on his upper trunk.
His pulse is normal, and the rate is 92/min. His jugular venous pressure (JVP) is not raised, and his blood pressure is 146/84 mmHg.
The cardiovascular and respiratory systems are normal.
The abdomen is distended. He has no palpable masses, but there is shifting dullness and a fluid thrill
Investigations:
Haemoglobin = 12.6 g/dL (normal = 13.3–17.7 g/dL)
White cell count = 10.2 × 109/L (normal = 3.9–10.6 × 109/L)
Platelets = 121 × 109/L (normal = 150–440 × 109/L)
Sodium = 131 mmol/L (normal = 135–145 mmol/L)
Potassium = 4.2 mmol/L(normal = 3.5–5.0 mmol/L)
Urea = 2.2 mmol/L (normal = 2.5–6.7 mmol/L)
Creatinine = 101 μmol/L (normal = 70–120 μmol/L)
Total protein = 48 g/L (normal = 60–80 g/L)
Albumin = 26 g/L (normal = 35–50 g/L)
Bilirubin = 25 mmol/L (normal = 3–17 mmol/L)
Alanine transaminase = 276 IU/L (normal = 5–35 IU/L)
Gamma-glutamyl transaminase = 873 IU/L (normal = 11–51 IU/L)
Alkaline phosphatase = 351 IU/L (normal = 30–300 IU/L)
International normalised ratio (INR) = 1.4 (normal = 0.9–1.2)
Urinalysis: no protein; no blood
• What is the diagnosis?
• How would you manage this patient?
