Upload
abdul-hamid-alraiyes
View
4.422
Download
7
Tags:
Embed Size (px)
DESCRIPTION
this case will help you managing the alcoholic hepatitis complicated with Hepatorenal syndrome
Citation preview
41 Y/O male with h/o ETOH dependence (12 cans of 16oz beers at least daily) last drink 4 days ago
Pt's mother reports that he has had drowsiness, paradoxic sleep patterns x 2 weeks
Transferred from Lutheran on 9/28 2/2 tonic-clonic seizure
PMHx:with h/o ETOH dependence
Social Hx:(12 cans of 16oz beers at least daily)
last drink 4 days ago
CAGE cant be done 2nd to the mental status
Jobless 2nd to ETOH
Surgical and previous admissions(hospital or
detoxification center Hx:None
Blood Tx:2 units PRBC at Lutheran Hosp.
ROS:Pt mental status Changed
Medication: None / NKDA
V/S HR: 90
RR: 16
SPO2: 95%
RA
BP: 120/65
Drowsy
no asterixis but has intention
tremors.
Chest/ CTA Bil.
CVS/ S1+S2+0
Abd/ showed mild distention
with mildly enlarged liver.
EXT/ 1+ pitting edema
Component 9/28/2007
WBC 12.0 (H)
RBC 2.96 (L)
Hemoglobin 9.3 (L)
Hematocrit 27.5 (L)
MCV 93
Platelet 57 (L)
Component 9/28/2007
Glucose 70
Sodium 132 (L)
Potassium 2.7 (C)
Chloride 103
Carbon Dioxide 22
BUN 4 (L)
Creatinine 0.80
Calcium 8.0 (L)
Phosphorus, Serum 3.1
Magnesium 1.9
Component 9/28/2007
Protein, Total 6.2
Albumin 1.7 (C)
Bilirubin, Direct 8.1 (H)
Bilirubin, Total 14.3 (H)
Alkaline Phosphatase 307 (H)
ALT (SGPT) 24
AST (SGOT) 111 (H)
Lipase 27
CT head: report states cortical atrophy, no
acute process.
Abd US : report liver demonstrates diffuse
echogenicity consistent with fatty
infiltration. GB normal. No definite stone.
Pancreas appears diffusely enlarged.
Consistent with pancreatitis.
The pt admitted to a RMF
Dx: ETOH withdrawal seizure
Meningitis
Hepatic encephalopathy
ID consult
GI consult
No another episode of seizure
Started on: Alcohol withdrawal protocol
Multivitamins,
Folate.
Thiamin
Meropenem & Vancomycin started
ID 2 FFPs, Vit K. given
LP on him when his INR is less than 1.5
UA normal
Blood / urine C+S no growth for 4 days
No sputum Culture done
GI Hepatitis panel A, B, C which came back all negative.
HIV negative.
Pt continued to be agitated with decrease level of alertness.
Transferred to a STEP DOWN UNIT
(HDU)
Component 10/1/2007
Tube # 1
Color Low: (Colorless) Colorless
Clarity Low: (Clear) Clear
Supernatant Low: (Colorless) Colorless
WBC /uL < 1
RBC Direct /uL 127
Neutrophils % 69
Lymphocytes % 27
Monocytes % 4
Occult Blood Low: (Negative) Negative
Collection Date 1 10/01/07
Total Protein, CSF 15-45 mg/dL 37
Glucose, CSF 40-75 mg/dL 65
Culture no growth
http://depts.washington.edu/uwhep/calculations/childspugh.htm
http://depts.washington.edu/uwhep/calculations/childspugh.htm
http://www.mayoclinic.org/meld/mayomodel6.html
http://www.mayoclinic.org/meld/mayomodel6.html
GI Liver parenchyma with incomplete portal-portal
bridging fibrosis, consistent with early cirrhosis,
extensive macrovesicular steatosis (70%), portal
and lobular neutrophils infiltration and Mallory
body formation,consistent with alcoholic hepatitis.
Discriminant function
= (4.6 X [PT- control]) + total bilirubin
= (4.6 X [PT- control]) + total bilirubin
Component 10/3/2007
Protein, Total 6.2-8.3 g/dL 5.8 (L)
Albumin 3.4-4.8 g/dL 1.8 (C)
Bilirubin, Direct 0.1-0.3 mg/dL 10.3 (H)
Bilirubin, Total 0.1-1.5 mg/dL 18.9 (C)
Alkaline Phosphatase 40-200 IU/L 233 (H)
ALT (SGPT) 7-40 IU/L 34
AST (SGOT) 7-40 IU/L 96 (H)
Prothrombin time 11.0-13.0 sec 18.2 (H)
INR 0.9-1.1 1.8 (H)
Magnesium 1.6-2.8 mg/dL 2.1
Phosphorus, Serum 2.5-4.8 mg/dL 3.6
GI Prednisolone 40 mg “NG” QD started
A randomized trial of prednisolone in patients
with severe alcoholic hepatitis.
MJ Ramond, T Poynard, B Rueff, P Mathurin, C
Theodore, JC Chaput, and JP Benhamou NEJM
1992;326:507
Urine out put
240 cc/24hrs.
Component 10/04/2007
Color Low: YELLOW YELLOW
Appearance Low: CLEAR CLEAR
Glucose Low: MG/DL NEGATIVE
Bilirubin Low: NEGATIVE NEGATIVE
Ketones Low: MG/DL NEGATIVE
Spec Gravity 1.003-1.03 1.015
pH 5.0-8.0 8.0
Protein Low: MG/DL NEGATIVE
Urobilinogen, Urine 0.2-1.0 EU'S 0.2
Nitrite Low: NEGATIVE NEGATIVE
Blood Low: NEGATIVE NEGATIVE
Leukocyte Low: NEGATIVE NEGATIVE
Component 10/4/2007
BUN 3 (L)
Creatinine 1.10
Component 10/5/2007
BUN 10
Creatinine 2.80 (H)
While prepping patient for placement of TLC
for CVP the pt desaturate to SPO2 70%
Started on 100% NRB. SPO2 83%
Intubated emergently.
Tube feeds were stopped
No signs of aspiration “by anesthesiologist”
Transferred to MICU
The pt is intubated .
On protective ventilation strategy.
GCS [E1 V1 M3] 5/15
V/S HR 88
RR with ventilator 14
BP 117/60
T 36.5 C
GCS 5/15
Chest/ Bil diffuse course crackles and decreased air entry on the RT.
CVS/ S1+S2+0
Abd/distended with 5cm enlarged liver + shifting dullness no mass .
EXT/ 3+ pitting edema.
Skin: diffused spider angiomas and palmer erythema
Component 10/5/2007 10/5/2007
Temperature 37.0 37.0
Mode NRM MV
FIO2 100 100
pH 7.101 (C) 7.289 (L)
PaCO2 70.4 (C) 40.5
PO2 56 (L) 134 (H)
CR %O2 SAT 72.5 (L) 99.2
Base Excess -8.7 (L) -6.7 (L)
A-a Gradeint 12 526
HCO3-
(Bicarbonate)
20.9 (L) 18.8 (L)
Component 10/6/2007
WBC 15.9 (H)
RBC 2.27 (L)
Hemoglobin 7.4 (L)
Hematocrit 23.4 (L)
RDW-CV 22.5 (H)
Platelet 124 (L)
Bands 10.0
Prothrombin time 18.6 (H)
INR 1.8 (H)
aPTT 37 (H)
Component 10/6/2007
Glucose 82
Sodium 146
Potassium 4.4
Chloride 121 (H)
Carbon Dioxide 20 (L)
BUN 24 (H)
Creatinine 3.80 (H)
Calcium 8.7
Magnesium 2.2
Phosphorus 6.3 (H)
Protein, Total 5.7 (L)
Albumin 1.8 (C)
Bilirubin, Direct 10.5 (H)
Bilirubin, Total 18.0 (H)
Alkaline Phosphatase 179
ALT (SGPT) 23
AST (SGOT) 93 (H)
Ammonia 109 (H)
• Urine
• Blood
• Tracheal aspiration
Shows no growth for the 2nd time after 4 days
http://www.mayoclinic.org/meld/mayomodel6.html
CNS/ no sedation “on Ativan® withdrawal protocol / GCS 5/15
Resp/ on protective ventilation / DVT prophylaxis / PPI / daily CXR / US guided
aspiration ordered
CVS/ stable no vasopressors / 12 leads EKG N / 2D Echo
Renal/ anuric / IVF started 100cc/hr. FeNa 0.7% / Urine Na 12 / Cr 3.8 / BUN 24
ID/ T 36.5 / CXR / WBC 15.9 / C+S no growth / UA / no wounds / Lines and tubes
/ Meropenem + Vancomycin for “CrCl 30”
GI/ NPO / Lactulose cont. / Rifaximin started / prednisolone cont. / SOBT –ve /
ascitic tap / TPN started
Hem/ Low H&H 2U PRBC / FFP given the ascitic tap
Endo/ On prednisolone for 5 days. Blood sugar controlled with Insulin SS.
DDx ?:Acute alcoholic hepatitis
Respiratory failure
Acute renal failure
Change in mental status
GCS: [E4 V1 M3] 8/15
Chest/ Bil mild crackles and good air entry .
CVS/ S1+S2+ friction rub
Abd/distended with 5cm enlarged liver +
shifting dullness no mass .
EXT/ 4+ pitting edema.
Skin: diffused spider angiomas and palmer
erythema
Normal
Component 10/7/2007
Glucose 126 (H)
Sodium 147
Potassium 5.1 (H)
Chloride 126 (H)
Carbon Dioxide 18 (L)
BUN 64 (C)
Creatinine 5.50 (H)
Calcium 8.9
Prothrombin time 17.7 (H)
INR 1.7 (H)
Magnesium 2.7
Phosphorus 8.2 (H)
aPTT 35 (H)
Component 10/7/2007
WBC 17.3 (H)
RBC 2.74 (L)
Hemoglobin 9.0 (L)
Hematocrit 28.4 (L)
Platelet 204
Component 10/6/2007
Fluid Type Ascites
Color Low: (Colorless) Yellow
Clarity Low: (Clear) Clear
WBC /uL 29
RBC Direct /uL 250
Neutrophils % 25
Lymphocytes % 25
Mono/Macrophage % 5
Fluid Comment Ascites
Albumin, Body Fluid g/dL 0.8
Glucose, Fluid mg/dL 114
Total Protein g/dL <2.0
No episodes of hypotension
No signs of bacterial infection
UA and Urine electrolytes FeNa 0.7%
Urine Na 12
No Proteinuria
No casts
U/S no obstruction or hydronephrosis no signs of parenchymal renal disease
Type 1: been arbitrarily set as a 100% increase in serum
Creatinine reaching a value greater than (2·5 mg/dL) in less than 2 weeks.
Type 2
Hepatorenal Syndrome
Hepatorenal Syndrome Lancet. 2003;
362(9398):1819-27 (ISSN: 1474-547X)
Ginès P ; Guevara M ; Arroyo V ; Rodés J
Precipitating factors:1. Bacterial infection “SBP 20%”
2. Large volume paracentesis without plasma expansion
“5L or more 15%”
3. GI bleeding 10%
Hepatorenal Syndrome
Hepatorenal Syndrome Lancet. 2003;
362(9398):1819-27 (ISSN: 1474-547X)
Ginès P ; Guevara M ; Arroyo V ; Rodés J
Prognosis:
Type1 Vs Type2
Child -Pugh classification
Hepatorenal Syndrome
Hepatorenal Syndrome Lancet. 2003;
362(9398):1819-27 (ISSN: 1474-547X)
Ginès P ; Guevara M ; Arroyo V ; Rodés J
Hepatorenal Syndrome
Hepatorenal Syndrome Lancet. 2003;
362(9398):1819-27 (ISSN: 1474-547X)
Ginès P ; Guevara M ; Arroyo V ; Rodés J
H&P
Blood & urine chem.
U/S
Cirrhosis
Portal Hypertension
Splanchnic vasodilatation
Severe arterial underfilling
Stimulation of
vasoconstrictor system
Renal vasoconstriction
Hepatorenal Syndrome
Liver
transplantation
TIPS
Vasoconstrictors
RRTHepatorenal Syndrome Lancet. 2003;
362(9398):1819-27 (ISSN: 1474-547X)
Ginès P ; Guevara M ; Arroyo V ; Rodés J
Reversal of Type 1 Hepatorenal Syndrome With
the Administration
of Midodrine and Octreotide
HEPATOLOGY 1999;29:1690-1697.PAOLO ANGELI,1 ROBERTA VOLPIN,1 GIORGIO GERUNDA,2
RAFFAELLA CRAIGHERO,1 PAOLA RONER,1 ROBERTO MERENDA,2
PIERO AMODIO,1 ANTONIETTA STICCA,1 LORENZA CAREGARO,1
ALVISE MAFFEI-FACCIOLI,2 AND ANGELO GATTA1
Hepatorenal Syndrome Lancet. 2003;
362(9398):1819-27 (ISSN: 1474-547X)
Ginès P ; Guevara M ; Arroyo V ; Rodés J
Reversal of Type 1 Hepatorenal Syndrome With
the Administration
of Midodrine and Octreotide
HEPATOLOGY 1999;29:1690-1697.PAOLO ANGELI,1 ROBERTA VOLPIN,1 GIORGIO GERUNDA,2
RAFFAELLA CRAIGHERO,1 PAOLA RONER,1 ROBERTO MERENDA,2
PIERO AMODIO,1 ANTONIETTA STICCA,1 LORENZA CAREGARO,1
ALVISE MAFFEI-FACCIOLI,2 AND ANGELO GATTA1
Midodrine & Octreotide
Effects of Noradrenalin and Albumin in Patients With
Type I Hepatorenal Syndrome: A Pilot Study HEPATOLOGY 2002;36:374-380.
Christophe Duvoux,1 David Zanditenas,1 Christophe H´ezode,1 Anthony Chauvat,2 Jean-
Luc Monin,2
Franc¸oise Roudot-Thoraval,3 Ariane Mallat,1 and Daniel Dhumeaux1
Noradrenalin and Albumin
Nephrology assessment and plan:Midodrine 12.5mg P.O. TID
Octreotide. + 200 microgram SQ TID
Albumin was given only with paracentesis
Hepatorenal Syndrome
Component 10/25/2007
Glucose 112 (H)
Sodium 137
Potassium 4.2
Chloride 103
Carbon Dioxide 23
BUN 40 (H)
Creatinine 2.40 (H)
Calcium 7.8 (L)
Magnesium 2.2
Phosphorus, Serum 5.1 (H)
Component 10/25/2007
WBC 12.0 (H)
RBC 2.15 (L)
Hemoglobin 7.0 (L)
Hematocrit 20.6 (L)
Platelet 125 (L)
Staging of alcoholism.
Child-Pugh classification.
MELD score.
Discriminant function.
Hepatorenal syndrome: Types.
Precipitating factors.
Diagnosis.
Differential diagnosis.
Prognosis.
Treatment.