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Respiratory compromise relieved by laparotomy
  1. Anu Balia,
  2. David A Walkerb,
  3. John P Iredalea,
  4. Colin D Johnsonc
  1. aSouthampton University Hospital, Southampton, UK, bIntensive Care Unit, Queen Alexandra Hospital, Portsmouth, UK, cUniversity Department of Surgery, Southampton University Hospital, Southampton, UK
  1. Dr J P Iredale, University Department of Medicine, Mail point 811, Southampton University Hospital, Tremona Road, Southampton SO16 6YD, UK (e-mail:jpi{at}soton.ac.uk)

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A 40 year old woman presented with a four month history of lethargy, reduced appetite, diarrhoea, and weight loss. In addition she complained of shortness of breath on exertion. Her alcohol intake was high with consumption in excess of 28 units of alcohol per day. Eighteen months previously she had been investigated at another hospital for epigastric pain and had been found to have a pancreatic pseudocyst of 3 cm in diameter and she was advised to stop drinking alcohol. There was no other past medical history of note. Examination at first presentation revealed the presence of spider naevi with an enlarged liver, extending some 7 cm below the costal margin, with marked ascites, raised serum amylase and liver enzymes: alkaline phosphatase 362 IU/l, alanine aminotransferase 24 IU/l, amylase 118 IU/l, and γ-glutamyltransferase 835 IU/l. The provisional clinical diagnosis made was advanced alcoholic liver disease with cirrhosis. An outpatient chest radiograph and abdominal ultrasound were arranged and a follow up appointment made for one month.

After the ultrasound, urgent admission was arranged. She had developed symptoms of breathlessness that were sufficiently severe that walking to the bathroom precipitated dyspnoea. On examination she had a displaced cardiac apex beat, a third heart sound, reduced breath sounds at both lung bases, and a mass in the right upper quadrant of her abdomen. Her biochemistry tests were repeated: alkaline phosphatase 464 IU/l; alanine aminotransferase 12 IU/l, amylase 446 IU/l, and γ-glutamyltransferase 186 IU/l. Chest radiographs at admission are shown in figs 1A and B.

Figure 1

Chest radiographs: anteroposterior (A) and lateral (B) views.

Questions

(1)
What does the chest radiograph show and what would be your next investigation?
(2)
What is the diagnosis and how would you manage this patient?

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