Alcoholic Hepatitis & Hepatorenal Syndrome
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Alcoholic Hepatitis & Hepatorenal Syndrome

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this case will help you managing the alcoholic hepatitis complicated with Hepatorenal syndrome

this case will help you managing the alcoholic hepatitis complicated with Hepatorenal syndrome

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    Alcoholic Hepatitis & Hepatorenal Syndrome Alcoholic Hepatitis & Hepatorenal Syndrome Presentation Transcript

    • 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
    •  no asterixis but has intention  V/S tremors.  HR: 90  Chest/ CTA Bil.  RR: 16  CVS/ S1+S2+0  SPO2: 95% RA  Abd/ showed mild distention  BP: 120/65 with mildly enlarged liver.  Drowsy  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
    • 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 = (4.6 X [PT- control]) + total bilirubin
    • 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 Component 10/5/2007 BUN 3 (L) BUN 10 Creatinine 1.10 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 MV NRM 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 20.9 (L) 18.8 (L) HCO3- (Bicarbonate)
    • 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) Component 10/7/2007 Carbon Dioxide 18 (L) WBC 17.3 (H) BUN 64 (C) RBC 2.74 (L) Creatinine 5.50 (H) Hemoglobin 9.0 (L) Calcium 8.9 Hematocrit 28.4 (L) Platelet 204 Prothrombin time 17.7 (H) INR 1.7 (H) Magnesium 2.7 Phosphorus 8.2 (H) aPTT 35 (H)
    • 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
    • Hepatorenal Syndrome  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 Lancet. 2003; 362(9398):1819-27 (ISSN: 1474-547X) Ginès P ; Guevara M ; Arroyo V ; Rodés J
    • Hepatorenal Syndrome Precipitating factors: 1. Bacterial infection “SBP 20%” 2. Large volume paracentesis without plasma expansion “5L or more 15%” 3. GI bleeding 10% Hepatorenal Syndrome Lancet. 2003; 362(9398):1819-27 (ISSN: 1474-547X) Ginès P ; Guevara M ; Arroyo V ; Rodés J
    • Hepatorenal Syndrome  Prognosis:  Type1 Vs Type2  Child -Pugh classification Hepatorenal Syndrome Lancet. 2003; 362(9398):1819-27 (ISSN: 1474-547X) Ginès P ; Guevara M ; Arroyo V ; Rodés J
    • Hepatorenal Syndrome H&P Blood & urine chem. U/S Hepatorenal Syndrome Lancet. 2003; 362(9398):1819-27 (ISSN: 1474-547X) Ginès P ; Guevara M ; Arroyo V ; Rodés J
    • Cirrhosis Liver transplantation Portal Hypertension TIPS Splanchnic vasodilatation Vasoconstrictors Severe arterial underfilling Stimulation of vasoconstrictor system Renal vasoconstriction RRT 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 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 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
    • Noradrenalin and Albumin 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
    • Hepatorenal Syndrome Nephrology assessment and plan:  Midodrine 12.5mg P.O. TID  Octreotide. + 200 microgram SQ TID  Albumin was given only with paracentesis
    • 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. 