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Monday 10 April 2023
1
Case presentation on ALCOHOLIC LIVER DISEASE with PORTAL HYPERTENSION
Presented by : ABHIMANYU PARASHAR PHARM.D
Monday 10 April 20232
IP no. : 220024
UNIT : medicine 1
AGE : 50 yrs
SEX : male
WEIGHT : 63 Kgs
Monday 10 April 20233
Reasons for admission :c/o : swelling of legs x 1 month (PEDAL
EDEMA) Distention of abdomen x 1 month
(ASCITIS) constipation x 1 month
Monday 10 April 20234
PMHx : Admitted for similar complaints 5
months back Was asymptomatic for 4 months k/c/o hypertension x 6 months was on
tab. Meto-ER (metprolol ) 50 mg Has been diagnosed with GERD and
GASTRITIS on 8/02/2012
Monday 10 April 20235
SHx : Chronic alcoholic x 15 yrs. Smoker x 15 yrs. Left 1 year back No Hx of hematuria , yellow
discoloration , malena and fever
Monday 10 April 20236
Allergies :
NIL KNOWN ALLERGIES
Monday 10 April 20237
FHx :
Not significant
Monday 10 April 20238
DIET : mixed
APPETITE : good
SLEEP : good
BOWEL and BLADDER : normal
Monday 10 April 20239
PROVISIONAL DIAGNOSIS
Liver cirrhosis with decompensation with portal hypertension and essential hypertension
Monday 10 April 202310
Decompensated cirrhosis ? In patients with previously stable
cirrhosis, decompensation may occur due to various causes, such as
constipation infection (of any source) increased alcohol intake medications bleeding from esophageal varices dehydration.
Monday 10 April 202311
Patients with decompensated cirrhosis generally require admission to hospital, with close monitoring of the fluid balance, mental status,
emphasis on adequate nutrition and medical treatment - often with
Diuretics Antibiotics laxatives thiamine occasionally steroids Administration of saline is generally
avoided.
Monday 10 April 202312
DAY NOTES :
Monday 10 April 202313
DAY 1(13/7/2012) BP : 140 / 90 mmHg PULSE : 78 BPM O/E : CNS – conscious oriented PALLOR – present B/L pedal edema no icterus CVS : s1s2 heard R/S : B/L NVBS present PA : distended , dilated veins skin : shiny umbilicus's : everted
Monday 10 April 202314
Scrotal swelling : present
ADV : tapping 1000 ml (paracenteses)
Start tab FUROSEMIDE + SIPRANOLACTONE
U/C , S/E , ECG , no flaps
Monday 10 April 202315
Ascitis with everted umbilicus and dilated veins
Monday 10 April 202316
LAB REPORTS :
Monday 10 April 202317
Hematology Biochemistry Electrolytes Urine analysis
Hb : 8.8 g %
WBC : 8400 cells
DLC : N : 69 E : 5L : 25 M : 1B : 0
PLT : 2.97 LAKHS
ESR : 129 mm/Hr
RBS : 82 mg/dL
UREA : 80 mg/dl
SeCr : 1.1 mg/dl
AST : 38 IU
ALT : 28 IU
ALP : 250 IU (37-320)
BILLIRUBIN :T : 0.66 mg/dlD (BC) : 0.42 mg/dl
Na : 140 mmol/l
Cl : 114 mmol/l
K : 3.9 mmol/l
PUS CELLS : 3
SUGAR : 2 %
RBC : 2-3 cells
ALBUMIN : +++
Monday 10 April 202318
IMP : normocytic normochromic anemia.
PT/INR : 1.12 PCV : 27.9% (42-52) Total protein : 5 g/dl ( 6-8 ) Albumin : 3 g/dl (3.4-5.0) A/G ratio : 1.5 ( 1.2 – 2.3 )
Monday 10 April 202319
TREATMENT CHART :
Monday 10 April 202320
50/20 mg
50/20 mg
/ furosemide
Monday 10 April 202321
DAY 2 (14/7/2012) BP : 130/90 mm Hg PULSE : 70 BPM O/E CVS : s1s2 heard CNS : conscious oriented RS : B/L NVBS present PA : distended with dilated veins
Monday 10 April 202322
ADV : PT/INR , paracenteses ,
collect ascitic fluid
Monday 10 April 202323
Ascitic fluid report (14/7/2012) 12 ml milky fluid Cell count : 310 Cell types : predominantly
lymphocytes , neutrophils – 15 % Glucose : 121 mg/dl ( 40-70 ) Protein : 10 mg/dl ( 20-45 ) Chloride : 115 mg/dl ( 116-122) LDH : 75 U/L ( 230 – 460 )
Monday 10 April 202324
DAY 3 (15/7/2012) BP : 120 / 80 mm Hg PULSE : 70 O/E : P/A – distended with dilated veins Skin – shiny Umbilicus - everted Abdomen – tensed Girth – 96 cm ADV – peritoneal biopsy and CST
Monday 10 April 202325
Ascitic fluid culture report (15/7/2012)
Gram stain : no cells , no bacteria
AFB not seen
Monday 10 April 202326
DAY 4 (16/7/2012) BP : 130 / 100 mm Hg PULSE : 80 BPM O/E : c/o weakness in proximal muscles CVS - s1s2 heard CNS – Pt. conscious oriented RS – B/L NVBS present P/A – distended with dilated veins ADV - CST
Monday 10 April 202327
DAY 5 (17/7/2012) BP : 120 / 90 mm Hg PULSE : 82 BPM O/E : conscious oriented c/o decreased urine output and
constipation with generalized weakness P/A –distended , free fluid distended ADV - CST
Monday 10 April 202328
DAY 6 (18/7/2012) BP : 128 /80 mm Hg PULSE : 82 BPM O/E : conscious oriented c/o decreased urine output and
constipation with generalized weakness P/A –distended , free fluid distended ADV - CST
Monday 10 April 202329
DAY 7 (19/7/2012) BP : 130 / 80 mm Hg PULSE : 90 BPM O/E : conscious oriented c/o scrotal swelling and mild fever. ADV ascitic tapping
Monday 10 April 202330
DAY 8 (20/7/2012) BP : 128 / 78 mm Hg PULSE : 88 BPM O/E : conscious oriented CVS : s1s2 heard RS : B/L NVBS present Patient was discharged on request
Monday 10 April 202331
PHARMACEUTICAL CARE PLAN (SOAP)
Monday 10 April 202332
SUBJECTIVE EVIDENCE Swelling of legs x 1 month Distention of abdomen others K/C/O liver cirrhosis with portal
hypertension and essential hypertension SHx : alcoholic x 15 yrs
Monday 10 April 202333
OBJECTIVE EVIDENCE Hb : 8.8 g/dl ESR : 120 mm/Hr Urea : 80 mg/dl Decreased total protein and albumin Elevated bilirubin 0.42 mg/dl ( 0 – 0.2 )
Monday 10 April 202334
FINAL DIAGNOSIS
Based on subjective and objective evidence the patients was diagnosed as ALCOHOLIC LIVER DISEASE with PORTAL HYPERTENSION and ESSENTIAL HYPERTENSION
Monday 10 April 202335
cirrhosis Cirrhosis is a consequence of chronic
liver disease characterized by replacement of liver tissue by fibrosis , scar tissue and regenerative nodules (lumps that occur as a result of a process in which damaged tissue is regenerated),leading to loss of liver function
Monday 10 April 202336
In alcoholic cirrhosis, the nodules are usually <3 mm in diameter; this form of cirrhosis is referred to as micronodular
Monday 10 April 202337
Risk Factor Comment
Quantity In men, 40–80 g/d of ethanol produces fatty liver160 g/d for 10–20 years causes hepatitis or cirrhosis. Only 15% of alcoholics develop alcoholic liver disease
Gender Women exhibit increased susceptibility to alcoholic liver disease at amounts >20 g/d; two drinks per day probably safe.
Monday 10 April 202338
Diagnostic criteria Signs and symptoms Asymptomatic Hepatomegaly, splenomegaly Pruritus, jaundice, palmar erythema,
spider angiomata, hyperpigmentation Gynecomastia, reduced libido Ascites, edema, pleural effusion, and
respiratory difficulties Malaise, anorexia, and weight Encephalopathy
Monday 10 April 202339
Laboratory tests Hypoalbuminemia Elevated prothrombin time Thrombocytopenia Elevated alkaline phosphatase Elevated aspartate transaminase (AST), alanine transaminase (ALT) γ-glutamyl transpeptidase (GGT) Elevated billirubin
Monday 10 April 202340
Monday 10 April 202341
Child-Pugh Classification
Score 1 2 3
Bilirubin (mg/dL)
1–2 2–3 >3
Albumin (mg/dL)
>3.5 2.8–3.5 <2.8
Ascites None Mild Moderate
Encephalopathy (grade)
None 1 and 2 3 and 4
Prothrombin time (seconds prolonged)
1–4 4–6 >6
Grade A, < 7 points; grade B, 7–9 points; grade C, 10–15 points.
Monday 10 April 202342
MAYO ESLD (MELD)
MELD score =
0.957 × Loge(creatinine mg/dL) + 0.378
× Loge(bilirubin mg/dL) +1.120 × Loge(INR) + 0.643
Monday 10 April 202343
MELD score calculation takes into account a patient’s :
serum creatinine, bilirubin, international normalized ratio (INR),
etiology of liver disease, omitting the more subjective reports of ascites and encephalopathy used in the Child-Pugh system.
Monday 10 April 202344
GOALS OF TREATMENT Assess the risk for variceal
bleeding and begin pharmacologic prophylaxis where indicated, reserving endoscopic therapy for high-risk patients or acute bleeding episodes
The patient should be evaluated for clinical signs of ascites and managed with pharmacologic treatment (e.g., diuretics) and paracenteses.
Monday 10 April 202345
Prevention of complications, achieving adequate lowering of portal pressure with medical therapy using beta-adrenergic blocker therapy, or supporting abstinence from alcohol.
Careful monitoring for spontaneous bacterial peritonitis should be employed in patients with ascites who undergo acute deterioration
Frequent monitoring for signs of hepato-renal syndrome, pulmonary insufficiency, and endocrine dysfunction is necessary
Monday 10 April 202346
Hepatic encephalopathy is a common complication of cirrhosis and requires clinical vigilance and treatment with dietary restriction, elimination of central nervous system depressants, and therapy to lower ammonia levels
prevent symptoms and maintain reasonable QOL
To provide adequate nutritional support
Monday 10 April 202347
TREATMENT OPTIONS Patient specific : for portal hypertension
Propranalolnadolol
for Ascites: aldosterone antagonists (spiranolactone)loop diuretics
Monday 10 April 202348
ADJUVENT THERAPY
Ursodeoxycholic acid Multivitamin supplements pantoprazole
Monday 10 April 202349
GOALS ACHIEVED Paracenteses was started on day 1(1000
ml fluid was removed ) and patient was feeling relived from his abdominal distention
Patient was feeling better by day 8 and was discharged on request.
Monday 10 April 202350
PROBLEMS IDENTIFIED Untreated indication : ANEMIA PT/INR was not repeated Patient was not started on antibiotics as
a prophylaxis for spontaneous bacterial peritonitis
Patient was not started on syrup lactulose even though patient was on high risk to develop encephalopathy
Monday 10 April 202351
MONITORING PARAMETERS Liver function test BLOOD SUGAR Blood Pressure Electrolytes (Na and K) body weight prothrombin time Complete hemogram USG Abdomen
Monday 10 April 202352
PATIENT COUNSELLING
Monday 10 April 202353
About the disease Non curable disease.
Risk factor
Signs and symptoms
Monday 10 April 202354
About medication
Name and purpose
Dose and frequency
Medication adherence
Possible adverse effects
Missed dose
Monday 10 April 202355
About life style modification
Stop taking alcohol
Smoking cessation
Nutritious diet
Monday 10 April 2023
56
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