CASE PRESENTATION ON ALCOHOLIC LIVER DISEASES - PowerPoint Presentation

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CASE PRESENTATION ON ALCOHOLIC LIVER DISEASES

SCENARIO:

Here is a 68y old male patient admitted to k block and diagnosed as alcoholic liver disease, liver cirrhosis, ascites and portal hypertension and hospitalised for 9 days.

SOAP NOTE

:

SUBJECTIVE

:

c/o swelling of lower limb up to knee since 15 days

c/o distension of abdomen since 10 days

c/o itching over the body since 1 month

PAST MEDICAL HISTORY

:

Liver cirrhosis with portal hypertension

h/o hematemesis 6 months back

Upper GI bleed stopped medication after one month

OBJECTIVE

:

Vital signs are normal

HB was low 8.9 gm./dl, MCH and MCHC was decreased

ESR was elevated 95 mm/hr

Polymorphs were elevated 69

Eosinophil's are elevated to 12

Slight elevation of RDW 16.6(12-15%)

Apetite was reduced.

SGPT 110 µl

SGOT 80 µl

PT time:4 min(2-3 min)

Traces of albumin in urine

ENDOSCOPY:

Severe PHG noted, few prominent veins at lower end D1,D2.

PHYSICAL EXAMINATION

:

Pallor

Hyper pigmented skin lesions all over body

Pitting oedema

Splenomegaly

P/A:Fluid thrill and horse shoe dullness

ULTRASONOGRAPHY ABDOMEN:

Gross hepatomegaly, moderate uncomplicated ascites

.

INTERPRETATION OF LABORATORY DATA:

Low HB shows anaemia and low MCH and MCHC implies microcytic anaemia and RDW was increased in chronic liver diseases

Elevated ESR signifies inflammation

Eosinophil were elevated in allergic conditions(IGE mediated)

Neutrophils are elevated in systemic bacterial infections and stress (exercise, acute hemorrhage,hemolysis)

AST and ALT levels are increased in hepatocellular injury

PT time was prolonged due to coagulation defects

PHG: portal hypertensive gastropathy.

chronic gastritis associated with cirrhosis. Exact mechanism is not known but portal hypertension is important .

Albumin was reduced to 3.5 g/dl(4-6g/dl)

Splenomegaly is the important sign of portal hypertension

Due to excessive alcoholism, decrease in NADP / NADPH

This leads to hepatomegaly.

ASSESMENT:

Based on the above subjective and objectives the physician diagnosed the condition as

alcoholic liver disease, liver cirrhosis, ascites and portal hypertension

PROBLEM LIST:

Swelling of lower limb

Distension of abdomen

Itching all over body

Loss of apetite

Liver cirrhosis

Moderate ascites

Portal hypertension

varices

Anaemia

Swelling of lower limb:

A reduction in serum albumin and reduced oncotic pressure contribute to collection of fluid to extracellular space and produce swelling of lower limbs

Abdominal distension

:

Abdominal distension notably of flank is due to ascites

Pruritus

:

Hyperpigmentation due to increased deposition of melanin. scratch marks of skin is pruritus sign and IGE mediated common feature of liver disease

Loss of apetite:

Damage to hepatocyte alters the metabolic functions and digestive problems leading to loss of apetite

Liver cirrhosis:

due to hepatotoxins like alcohol hepatocyte injury occurs and the stellate cells are activated loses retinoid and develop fibroblast and inflammatory response. Collagen deposition occurs and leads to fibrosis. In advance stages these collagen bands progress to bridging fibrosis resulting in hepatic cirrhosis.

Anaemia:

Chronic alcoholism causes haemolysis or bone marrow depression causing anaemia

Moderate ascites

:

With abdominal distension

Pressure builds up in hepatic portal vein and fluid exudates and accumulates in area with lowest pressure and greatest capacity (peritoneal space) leading to ascitis.

Portal hypertension

Due to cirrhosis there will be resistance to blood flow to liver causing increased portal venous pressure than inferior venacava causing portal hypertension.

Varices:Due to portal hypertension varices and collaterals from portal to systemic circulation occurs.

PLAN:

Goals of therapy

:

To alleviate the symptoms

Clinical improvement or resolution of acute complications such as variceal bleeding and resolution of hemodynamic instability

Lowering of portal hypertension

To prevent further complications like hepatic encephalopathy.

Pantoprazole :40 mg(1-0-0) iv is given for first day of admission for prophylaxis of hyper gastric secretion.

spironolactone 50 mg

(1-0-1)

twice a day was given for all 9 days of hospitalization.(14/9/13 to 22/9/13)

Drug of choice for ascites. maximum dose can be given 400 mg /day.

This drug is steroid chemically related to mineralocorticoid aldosterone, act from from interstitial side of tubular cells combine with mineralocorticoid receptor inhibits AIP ,increases sodium excretion .

Propranolol 40mg

once a day given for all 9 days

This drug reduce

cardiac output via

blockade

of the β1 cardiac receptors and the blockade of the adrenergic dilatory tone of the mesenteric arterioles, resulting in unopposed α-adrenergic–mediated vasoconstriction. The net effect is the

decreased

blood flow to the mesenteric vascular system and decreased portal vein

pressure.

Also prevent re bleeding in PHG

Sodium Pico sulphate syrup

:2 tablespoons a day for first 3 days.

This drug hydrolysed by colonic bacteria to bis(p-hydroxy -phenyl)

pyridyl

2 –methane. stimulate colonic peristalsis by direct action of mucosa and it is an osmotic diuretic and produce watery stools

For constipation

Hydroxyzine hydrochloride

:25 mg (101) twice a day for first 5 days.

Anti histamine drug and indicated for pruritus

Rabeprazole 20 mg

once a day for 8 days

Indicated for non variceal bleeding disorder which progress to hepatic encepalopathy.

Sporolac (lactobacillus sporogenes

) for one day as the patient has loose stools. lactobacillus preparations are intended to replace colonic microflora,restores intestinal function and supress the growth of pathogenic microorganisms.

Drug drug interactions:

1. Propranolol

- spironolactone

: (moderate)

Effect: hyperglycaemia, QT interval prolongation and arrhythmias.

Management: Monitor serum pot levels, BP and blood glucose levels.

Drug food interaction:

Food-propranalol moderate interaction increases propranalol conc.

Alcohol-propranalol minor interaction may inc or decrease propranalol conc.

Drugs on discharge:

Spironolactone 100 mg once a day for 10 days

Propranalol 40 mg once a day for 20 days

Multivitamin capsule once a day for 20 days

Patient counselling:

Restrict sodium intake to 2 g/day

Alcohol abstinence

Alcohol rehabilitation

Take high carbohydrate ,high calorie diet to reduce protein breakdown

Maintain healthy life style

Do not consume caffeine

Drink clear liquids

THANK U