1. Monday,
February 17,
2014
Case presentation on
ALCOHOLIC LIVER DISEASE
with PORTAL HYPERTENSION
Presented by : ABHIMANYU
PHARM.D
1
PARASHAR

2. 2
 IP
no. : 220024
 UNIT
: medicine 1
 AGE
: 50 yrs
 SEX
: male
 WEIGHT
: 63 Kgs
Monday, February
17, 2014

3. 3
Monday, February 17,
2014
Reasons for admission :
c/o :
 swelling of legs x 1 month (PEDAL EDEMA)
 Distention of abdomen x 1 month
(ASCITIS)
 constipation x 1 month

4. 4
Monday, February 17,
2014
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

5. 5
Monday, February 17,
2014
SHx :
 Chronic
alcoholic x 15 yrs.
 Smoker x 15 yrs. Left 1 year back
 No Hx of hematuria , yellow discoloration ,
malena and fever

6. 6
Allergies :
 NIL
KNOWN ALLERGIES
Monday, February 17,
2014

7. 7
FHx :
 Not
significant
Monday, February 17,
2014

8. 8
 DIET
: mixed
 APPETITE
 SLEEP
: good
: good
 BOWEL
and BLADDER : normal
Monday, February 17,
2014

9. 9
Monday, February 17,
2014
PROVISIONAL DIAGNOSIS
 Liver
cirrhosis with decompensation with
portal hypertension and essential
hypertension

10. 10
Monday, February 17,
2014
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.

11. 11








Monday, February 17,
2014
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.

12. 12
DAY NOTES :
Monday, February 17,
2014

13. 13
Monday, February 17,
2014
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

14. 14
 Scrotal
 ADV
Monday, February 17,
2014
swelling : present
: tapping 1000 ml (paracenteses)
Start tab FUROSEMIDE + SIPRANOLACTONE
U/C , S/E , ECG , no flaps

15. 15
Monday, February 17,
2014
Ascitis with everted umbilicus and dilated veins

16. 16
LAB REPORTS :
Monday, February 17,
2014

17. Monday, February 17,
2014
17
Hematology
Biochemistry
Hb : 8.8 g %
RBS : 82 mg/dL
WBC : 8400 cells
UREA : 80 mg/dl
DLC :
N : 69 E : 5
L : 25 M : 1
B:0
PLT : 2.97 LAKHS
ESR : 129 mm/Hr
Electrolytes
Urine
analysis
Na : 140
mmol/l
PUS CELLS :
3
SeCr : 1.1 mg/dl
Cl : 114
mmol/l
SUGAR : 2 %
AST : 38 IU
K : 3.9 mmol/l
ALT : 28 IU
ALP : 250 IU (37-320)
BILLIRUBIN :
T : 0.66 mg/dl
D (BC) : 0.42 mg/dl
RBC : 2-3
cells
ALBUMIN :
+++

18. 18
 IMP
Monday, February 17,
2014
: 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 )

19. 19
TREATMENT CHART :
Monday, February
17, 2014

20. 20
50/20
mg
furosemide
/
50/20
mg
Monday, February 17,
2014

21. 21
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, February 17,
2014

22. 22
 ADV
: PT/INR , paracenteses ,
 collect
ascitic fluid
Monday, February 17,
2014

23. 23
Monday, February
17, 2014
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 )

24. 24
Monday, February 17,
2014
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

25. 25
Monday, February 17,
2014
Ascitic fluid culture report
(15/7/2012)
 Gram
 AFB
stain : no cells , no bacteria
not seen

26. 26
Monday, February 17,
2014
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

27. 27
Monday, February 17,
2014
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

28. 28
Monday, February 17,
2014
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

29. 29
Monday, February 17,
2014
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

30. 30
Monday, February 17,
2014
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

31. 31
Monday, February 17,
2014
PHARMACEUTICAL CARE
PLAN (SOAP)

32. 32
Monday, February 17,
2014
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

33. 33
Monday, February
17, 2014
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 )

34. 34
Monday, February 17,
2014
FINAL DIAGNOSIS
 Based
on subjective and objective
evidence the patients was diagnosed as
ALCOHOLIC LIVER DISEASE with PORTAL
HYPERTENSION and ESSENTIAL
HYPERTENSION

35. 35
Monday, February 17,
2014
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

36. 36
 In
Monday, February
17, 2014
alcoholic cirrhosis, the nodules are
usually <3 mm in diameter; this form of
cirrhosis is referred to as micronodular

37. 37
Monday, February 17,
2014
Risk Factor
Comment
Quantity
In men, 40–80 g/d of ethanol produces
fatty liver
160 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.

38. 38
Monday, February 17,
2014
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

39. 39
 Laboratory
Monday, February 17,
2014
tests
 Hypoalbuminemia
 Elevated prothrombin time
 Thrombocytopenia
 Elevated alkaline phosphatase
 Elevated aspartate transaminase (AST),
 alanine transaminase (ALT)
 γ-glutamyl transpeptidase (GGT)
 Elevated billirubin

40. 40
Monday, February
17, 2014

41. Monday, February 17,
2014
41
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
1–4
4–6
>6
Prothrombin
time (seconds
prolonged)
Grade A, < 7 points; grade B, 7–9 points; grade C, 10–15 points.

42. 42
Monday, February 17,
2014
MAYO ESLD (MELD)
 MELD
score =
0.957 × Loge(creatinine mg/dL) + 0.378
× Loge(bilirubin mg/dL) +1.120 × Loge(INR) +
0.643


43. 43
 MELD
Monday, February 17,
2014
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.

44. 44
Monday, February 17,
2014
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.

45. 45
 Prevention
Monday, February 17,
2014
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 hepatorenal syndrome, pulmonary insufficiency,
and endocrine dysfunction is necessary

46. 46
 Hepatic
Monday, February 17,
2014
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

47. 47
Monday, February 17,
2014
TREATMENT OPTIONS
 Patient
specific :
 for portal hypertension
Propranalol
nadolol
 for
Ascites:
aldosterone antagonists (spiranolactone)
loop diuretics

48. 48
ADJUVENT THERAPY
 Ursodeoxycholic
acid
 Multivitamin supplements
 pantoprazole
Monday, February 17,
2014

49. 49
Monday, February 17,
2014
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.

50. 50
Monday, February 17,
2014
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

51. 51
Monday, February 17,
2014
MONITORING PARAMETERS
 Liver
function test
 BLOOD SUGAR
 Blood Pressure
 Electrolytes (Na and K)
 body weight
 prothrombin time
 Complete hemogram
 USG Abdomen

52. 52
Monday, February 17,
2014
PATIENT COUNSELLING

53. 53
About the disease

Non curable disease.

Risk factor

Signs and symptoms
Monday, February 17,
2014

54. 54
About medication

Name and purpose

Dose and frequency

Medication adherence

Possible adverse effects

Missed dose
Monday, February
17, 2014

55. 55
Monday, February 17,
2014
About life style modification
Stop taking alcohol
Smoking cessation
Nutritious diet

56. Monday,
February 17,
2014
QUIT BEFORE ITS
LATE
THANK
YOU
56