Cirrhosis with Portal Hypertension

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4/18/12

Age:37 yrs 50kg Sex: Male II

weight:

Unit: MED

4/18/12

Reasons for Admission

Vomiting since 5 days (3-4 episodes per day) and one episode of hematemesis Yellowish discoloration of eyes from 10 days

Dark yellow colored urine since 10 days 4/18/12

PMHx: Nothing Significant Social History: Known Alcoholic since 16 years. (Drinks Approximately 180ml of whisky per day.) Known Smoker since 15 years (smokes one packet of Beedies per day) 4/18/12

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Day 1
BP: 120/80 mmHg Pulse: 80 BPM Weight: 50 kg

O/E

Alcohol smell on breath+ Pedal edema+ Abdominal distension + (88 cm)

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Advised for:

Complete Haemogram Blood urea and Serum creatinine ECG

LFT, Upper GI Endoscopy, USG abdomen Strict I/O chart and weight monitoring
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Provisional Diagnosis

Alcoholic liver disease ? Portal Hypertension

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Drug DNS with MVI

Dose 1 pint

Route IV

Frequency 75 ml/hour

T.Thiamine propyl disulphide Inj.Pantoprazole

75mg

PO

0-1-0

40mg

IV

1-0-0

Inj.Ondansetron

4mg

IV

1-1-1

Tab. Propranolol Tab. Torsemide + Spiranolactone Syp. Lactulose Tab. Amoxacillin + Clavalunate 4/18/12

10 mg

PO

1-1-1 1-1-0

10 mg + 100 mgPO

15 ml 625 mg + 500mg

PO PO

1-1-1 1-0-1

Hematology:

DAY 2:

Biochemistry:
RBS:92 mg/dl Urea:20 mg/dl Secr:0.8 mg/dl AST:170(0-40) ALT:83(0-40) ALP:203(37-147) Total Protein:6.9 mg/dl Albumin: 3.0(3.4-4.5)mg/dl A/G Ratio:0.8 (1.2-2.5)

Hb:8.8 g% WBC:6800 Cells/Cumm DLC: N:90%(40-75) E:02% L:08% (20-25) M:00% ESR: 35 mm/hr PLT:75000(1.5-5) PCV:32.4%(45+_7) MCV:66fl(77-93)

Bilirubin:T:5.64(0.1.1) MCH:26pg(27-32) D:3.85(0-0.2) MCHC:27 %(31-35) ECG: Within normal limit Impression :Microcytic anemia with blood loss with relative Neutrophilia and thrombocytopenia 4/18/12 Stool examination: Occult blood : Positive

Day 2 (contd)

BP: 120/70 mmHg Weight: 49 kg

Pulse: 74 BPM

No fresh complaints. Vomiting subsided Icterus+ Platinychia+ Hepatosplenomegaly +

USG Abdomen:
Cirrhosis of liver, Mild to moderate ascites, splenomegaly
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DAY-3
BP: 100/70 mmHg Pulse: 80Bpm kg O/E No fresh complaints Icterus + , Fine tremors
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Weight: 49

Edema+, Platinychia+

Day 4
BP: 110/70 mmHg Pulse:80 BPM Weight: 49 kg O/E Patient felt comfortable. Icterus+ Fine tremors+, Free fluid+, Hepatomegaly +,edema+
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Rpt PLT:82000

DAY 5
BP:110/70 mmHg Pulse:80 BPM Weight: 49 kg O/E Patient complains of tremors of hands. Edema + icterus+
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DAY 6
BP:100/70 mmHg Pulse:76 BPM Weight: 48.5 kg O/E Patient felt comfortable. No fresh complaints. Advice: Prothrombin time: 19 sec

Inj. Vitamin K 1 amp (10 mg) IM 1-00 for 3 days and perform Prothrombin 4/18/12 time.

DAY 7
B.P:100/60 mmHg Pulse:76 BPM Weight: 47 kg O/E: No fresh complaints and edema has reduced and abdominal girth is 75 cm.
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Treatment as per chart

Day 8
B.P:100/70 mmHg Pulse:80 BPM O/E: Icterus+, tremor+, hepatomegaly+ Advice: Thiamine propyl disulphide stopped. T.L-Ornithine-L-Aspartate500mg PO 1-0-1 T.Torsemide+spiranolactone made as 1-0-0

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Day 9
B.P:120/70 mmHg Pulse:88 BPM Weight: 46 kg O/E: Icterus+, hepatomegaly+, Weakness, Decreased appetite. Adv. Discharge. Inj.Vitamin K and inj ondansetron stopped. Prothrombin time: 13 sec Follow up at OPD after 1 week.
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Discharge Medications
v

T.Torosemide+spir anolactone 10 mg + 100 mg PO 1-00 X 4 days

T.Pr opr anolol days

10mg PO 1-0-1 X 7

T.Chlor diazepoxide week

25 mg PO 0-0-1 X 1

T.Amoxicillin+Clavulanicacid 625 mg PO 1-0-1 X 2 days 4/18/12

Pharmaceutical Care Plan

Objective Subjective

Vomiting Elevated: Hepatomegaly Bilirubin

AST Splenomegaly ALT Abdominal distension ALP Pedal edema

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Final Diagnosis:
Cirrhosis with Portal Hypertension, Ascites and Hepatic Encephalopathy

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Goals of Therapy
o

Identify and eliminate cause of cirrhosis. Improve the signs and symptoms. Prevention of further complications.

To maintain health related quality of 4/18/12

Treatment Options
Management of Portal Hypertension & Varices
Primary Prophylaxis Non selective Beta blocker : Propranolol Nadolol
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Treatment Options
Management of Ascites: Diuretic therapy: Spiranolactone, furosemide Liver transplantations Spontaneous Bacterial Peritonites: Cefotaxime, Oral ofloxacin, Amoxicillin
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TIPS

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Goals Achieved

Signs and symptoms were relieved Patient was convinced to stop alcohol

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Monitoring Parameters

Liver function tests Complete haemogram & Serum electrolytes USG Abdomen Ascitic fluid examination

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Problems Identified

Untreated indication: Anemia Input output chart was not maintained

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Patient Counseling

About Diseases: About signs and symptoms About complications About medications: Medication adherence About missed dose Dont take any OTC medication. About Life style modifications:

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Thank You
4/18/12