ALD with portal htn

Monday 10 April 2023

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Case presentation on ALCOHOLIC LIVER DISEASE with PORTAL HYPERTENSION

Presented by : ABHIMANYU PARASHAR PHARM.D


IP no. : 220024

UNIT : medicine 1

AGE : 50 yrs

SEX : male

WEIGHT : 63 Kgs


Reasons for admission :c/o : swelling of legs x 1 month (PEDAL

EDEMA) Distention of abdomen x 1 month

(ASCITIS) constipation x 1 month


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


SHx : Chronic alcoholic x 15 yrs. Smoker x 15 yrs. Left 1 year back No Hx of hematuria , yellow

discoloration , malena and fever


Allergies :

NIL KNOWN ALLERGIES


FHx :

Not significant


DIET : mixed

APPETITE : good

SLEEP : good

BOWEL and BLADDER : normal


PROVISIONAL DIAGNOSIS

Liver cirrhosis with decompensation with portal hypertension and essential hypertension


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.


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.


DAY NOTES :


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


Scrotal swelling : present

ADV : tapping 1000 ml (paracenteses)

Start tab FUROSEMIDE + SIPRANOLACTONE

U/C , S/E , ECG , no flaps


Ascitis with everted umbilicus and dilated veins


LAB REPORTS :


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 : +++


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 )


TREATMENT CHART :


50/20 mg

50/20 mg

/ furosemide


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


ADV : PT/INR , paracenteses ,

collect ascitic fluid


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 )


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


Ascitic fluid culture report (15/7/2012)

Gram stain : no cells , no bacteria

AFB not seen


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


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


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


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


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


PHARMACEUTICAL CARE PLAN (SOAP)


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


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 )


FINAL DIAGNOSIS

Based on subjective and objective evidence the patients was diagnosed as ALCOHOLIC LIVER DISEASE with PORTAL HYPERTENSION and ESSENTIAL HYPERTENSION


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


In alcoholic cirrhosis, the nodules are usually <3 mm in diameter; this form of cirrhosis is referred to as micronodular


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.


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


Laboratory tests Hypoalbuminemia Elevated prothrombin time Thrombocytopenia Elevated alkaline phosphatase Elevated aspartate transaminase (AST), alanine transaminase (ALT) γ-glutamyl transpeptidase (GGT) Elevated billirubin



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.


MAYO ESLD (MELD)

MELD score =

0.957 × Loge(creatinine mg/dL) + 0.378

× Loge(bilirubin mg/dL) +1.120 × Loge(INR) + 0.643


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.


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.


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


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


TREATMENT OPTIONS Patient specific : for portal hypertension

Propranalolnadolol

for Ascites: aldosterone antagonists (spiranolactone)loop diuretics


ADJUVENT THERAPY

Ursodeoxycholic acid Multivitamin supplements pantoprazole


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.


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


MONITORING PARAMETERS Liver function test BLOOD SUGAR Blood Pressure Electrolytes (Na and K) body weight prothrombin time Complete hemogram USG Abdomen


PATIENT COUNSELLING


About the disease Non curable disease.

Risk factor

Signs and symptoms


About medication

Name and purpose

Dose and frequency

Medication adherence

Possible adverse effects

Missed dose


About life style modification

Stop taking alcohol

Smoking cessation

Nutritious diet


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Health & Medicine

ALD with portal htn