To john woodward '1 097220 59 year old man past medical history decompensated alcohol related liver disease with ascites only managed with brucosemide 40 mg twice per day and spironolactone 100 mg twice per day previous encephalopathy managed with rifaximin 550 mg twice per day and lactulose 30 mg twice per day previous upper gi bleeding due to hematemesis when he was admitted in march 2025 and he had an ogd at that time demonstrating grade 1 varices without bleeding stigmata as well as portal hypertensive gastropathy in the stomach on the past medical history copd osteoporosis vitamin d deficiency hepatitis c carrier ibs anemia for varices he was having carvedilol but held due to symptomatic hypotension not subsequently restarted cotrimazole started because of risk of spontaneous bacterial peritonitis unadvised to continue most recent liver function test demonstrating bilirubin of 26 but remained normal but with alp of a 143 crp is 7 hemoglobin 105 unstable with normocytosis ct abdomen and pelvis december 22 so yesterday appearance concerning for at least partial small bowel obstruction potentially closed loop suspicious for internal hernia no ct evidence of bowel perforation or ischemia stable appearance of the large anterior abdominal wall hernia containing a loop of uncompromised transverse: apart from increased acidic fluid within background features of liver cirrhosis with increased volume of ascites compared to previous ct from august 2025 filling defect within the left hepatic vein in keeping with thrombus main portal vein appears patent they haven't commented upon whether there's any cavernous transformation he's got perisophageal and upper abdominal varices secondary to portal hypertension again demonstrated mildly enlarged spleen at 13.1 centimeters craniocaudally inr was 1.4 previously but now 1.1 when checked in october but hasn't been checked since his admission with us observations news of 3 pulse of a 113 temperature 36.7 blood pressure a 109 over 77 respiratory rate 16 sats 90% on air so the issues are number 1 is ct evidence of at least partial small bowel obstruction potentially closed loop suspicious for internal hernia and number 2 decompensated alcohol related liver disease decompensated by jaundice with bilirubin of 26 by increased volume of ascites despite diuresis with unclear compliance no evidence of aki no evidence of hepatic encephalopathy an sbp is yet to be excluded coagulopathy is also yet to be investigated issue number 3 is stable long standing anemia with normocytosis which he might benefit from some hematinics but he's not had those since september when the ferritin was 22 next is the potential for hepatic vein thrombus requiring further investigation with ct liver triple phase in order to exclude but potential budd chiari syndrome so discharged 5 days ago from haytor with new it but some of the trouble he was there for having lower abdominal pain since then really to his back surgical review and ed notes he was still drinking alcohol 4 bottles of wine in the last 4 days passing hard rocks when he opened his bowels functionally unable to manage a flight of stairs and juggle around bed current medications lots of being used few doses of iv morphine a few days ago prescribe it out for review spironolactone restarted freeze mother restarted omeprazole and trevo restarted with no lactulose kefuroxime metronidazole antibiotics started on 20 second yes yesterday so on examination abdomen distended with tense grade 3 ascites large ventral abdominal wall hernia which is tense also and full of ascites soft and nontender abdomen no esteryxis very mild pedal edema bilaterally dry tongue chest clear heart sounds normal so the plan is return with ultrasound to consider ultrasound guided drain there's no ir availability today stop oramorph and morphine sulfate start lactulose and rifaximin following drain if renal function is stable to increase spironolactone to hundred and 50 mg bd stop senna