A male pt of age 59 yrs presented with loss of appetite, belchings delirium tremens and was diagnosed as having ALD with portal hypertension.

1. CASE PRESENTATION ON
ALD WITH PORTAL
HYPERTENSION
PRESENTED BY:
CH.BINDU MADHAVI
V/VI PHARMD
Y17PHD0805
DEPARTMENT OF PHARMACY PRACTICE

2. INTRODUCTION:
• ALCOHOLIC LIVER DISEASE: Alcoholic liver disease
is a result of overconsuming alcohol that damages the
liver, leading to a buildup of fats, inflammation, and
scarring. It can be fatal.
• PORTAL HYPERTENSION: Portal hypertension
is an increase in the pressure within the portal vein,
which carries blood from the digestive organs to the
liver.

3. SUBJECTIVE DATA:
• A male patient of age 59 years was admitted in the hospital
with C/O loss of appetite since 15 days. c/o belching's,
delirium tremors since 1 day. He is a chronic alcoholic ,h/o
alcohol intake 1 day back. h/o alcohol withdrawl symptoms,
h/o syncope 3 months back. Binge drinking since 4 months,
c/o nausea, c/o jaundice since 15 days, abdominal distension,
h/o loose stools 3 days back.
• He is having a history of CLD since 3 years, HTN since 20
years, DM since 4 months on regular medication.
• His medical history includes TAB. TELMA – 20 mg OD
and TAB. METFORMIN -500 mg BD .
• His bowel and bladder habits are normal, his sleep is
disturbed, his appetite is decreased ( anorexia) .

4. OBJECTIVE DATA:
• PHYSICAL EXAMINATIONS:
• Pt- conscious BP- 140/90mmHg PR- 120 beats/min
• RR- 18 cycles/min Sp𝑂2 - 98% 𝑃0𝐼1𝐶0𝐶0𝐿0
• SYSTEMIC EXAMINATIONS:
• CVS- 𝑆1𝑆2
+
RS - BA𝐸+ CNS- NFND
P/A- distended

5. Laboratory investigations:
Haematology D1 D2 D3 D4 D5
WBC ( ) 16000/cu.mm 12100/cu.mm 12100/cu.mm 12400/cu.mm
RBC ( ) 3.19million
HAEMOGLOBIN ( ) 11.9g/dl 10.9g/dl 10.9g/dl 10.7g/dl 11.1g/dl
HAEMATOCRIT ( ) 34.3%
MCV ( ) 107.5fl
MCH ( ) 37.4pg
NEUTROPHILS ( ) 88%
LYMPHOCYTES ( ) 9%
PROTHROMBIN TEST TIME ( ) 18.2 sec 21.2 sec

6. Biochemistry And LFT D1 D2 D3 D4 D5
SERUM CREATININE ( ) 0.4mg/dl 0.30mg/dl 0.30mg/dl 0.30mg/dl
SERUM SODIUM ( ) 130mmol/l 122mmol/l 122mmol/l
SERUM POTASSIUM ( ) 3.4mmol
BILURUBIN TOTAL ( ) 15.68mg/dl 15.42mg/dl 17.72mg/dl 19.36mg/dl
BILIRUBIN DIRECT ( ) 13.97mg/dl 13.52mg/dl 16.61mg/dl
BILIRUBIN INDIRECT ( ) 1.71mg/dl 1.9mg/dl 2.75mg/dl
SGOT/AST ( ) 161 IU/L
SGPT/ALT ( ) 52 IU/L
ALP ( ) 468 IU/L
TOTAL PROTEIN ( ) 6.2 g/dl
SERUM ALBUMIN ( ) 3 g/dl
ALB/GLOB RATIO ( ) 0.94
SERUM LIPASE ( ) 200 IU/ml 200 IU/ml
SERUM CHLORIDE ( ) 85.8mmol

7. OTHER INVESTIGATIONS:
• REAL TIME ULTRASONOGRAPHY OF THE
ABDOMEN:
• IMPRESSION-Chronic liver disease
Hepatomegaly
no detectable flow in portal vein – no
thrombosis
over distended gall bladder with calculi
moderate ascites
mild splenomegaly

8. ASSESSMENT:
• Based on the subjective and objective data the final diagnosis was
found to be ALCOHOLIC LIVER DISEASE WITH PORTAL
HYPERTENSION
• DEFINITION:
ALD: Alcoholic liver disease is a result
of overconsuming alcohol that damages
the liver, leading to a buildup of fats,
inflammation, and scarring. It can be fatal.
PORTAL HTN: Portal hypertension is an increase in the pressure
within the portal vein, which carries blood from the digestive
organs to the liver.

9. • ETIOLOGY:
• ALD:
• Drinking alcohol, obesity, hepatitis
• PORTAL HYPERTENSION:
TYPE OF CAUSE CAUSES
Intrahepatic causes Alcohol abuse,
Hepatitis B and C infections,
Fatty liver (NASH, non-alcoholic steatohepatitis),
Pre-hepatic causes Portal vein thrombosis or blood clots within the portal vein
Congenital portal vein atresia or failure of the portal vein to develop
Post-hepatic causes Hepatic vein thrombosis
Inferior vena cava thrombosis
Restrictive pericarditis

10. RISK FACTORS:
ALD:
• Sex
• Genetics
• Liver
conditions
• Alcohol
consumption
PORTAL HYPERTENSION:
• Alcoholic
hepatitis
• Alcohol abuse
• Risk of cirrhosis

11. PATHOPHYSIOLOGY:

12. CLINICAL PRESENTATIONS:
ALD: PORTAL HYPERTENSION
• Gastrointestinal bleeding marked by
black, tarry stools or blood in the
stools, or vomiting of blood due to
the spontaneous rupture and
hemorrhage from varices
• Ascites (an accumulation of fluid in
the abdomen)
• Encephalopathy or confusion and
forgetfulness caused by poor liver
function
• Reduced levels of platelets, blood
cells that help form blood clots, or
white blood cells, the cells that fight
infection

13. STANDARD TREATMENT:
ALD:
• BENZODIAZEPINES: used to ease
withdrawl symptoms in a person with
alcohol dependence
• ACOMPROSATE, NALTREXONE,
TOPIRAMATE: used to prevent
relapse into drinking alcohol
• CORTICOSTEROIDS/PENTOXIFY
LLINS: used to reduce inflammation
• PROBIOTICS AND ANTIBIOTICS
• STEM CELL THERAPY
• LIVER TRANSPLANTATION
PORTAL HYPERTENSION:
• BETA- BLOCKERS
• VASODILATORS
• RESTRICT SODIUM INTAKE

14. GOALS:
• To reduce signs and symptoms using symptomatic
therapy
• To avoid alcohol consumption
• To reduce disease progression
• To prevent further complications
• To improve the quality of life of patient

15. Drug information:
S.NO NAME OF THE DRUG DOSE ROA FREQ DURA CATEGORY INDICATION
1. INJ.MAGNEX FORTE
(Cefaperazone +sulbactam)
3 mg IV BD D1-D5 3rd generation cephalosporins
ꞵ lactam inhibitor
Used to bacterial infections
2. INJ.OPTINEURON 1 amp IV OD D1-D5 Vitamin B complex Used as vitamin B supplement
3. INJ.PANTOCID
(pantoprazole)
40 mg IV OD D1-D8 Proton pump inhibitor Prophylactic
4. TAB.BILE FIX
(ursodeoxycholic acid)
300 mg P/O TID D1-D8 Gall stone dissolving agent Used to treat jaundice
5. TAB.HEPTRAL
(S-adenosyl methionine)
400 mg P/O BD D1-D8 Antioxidant Used to treat liver diseases
6. TAB.THIOTRESS
(Glutathione)
500 mg P/O BD D1-D8 Vitamin supplement Used to treat liver disease
7. TAB.LASILACTONE
(Spironolactone+Furosemide)
50/20 mg P/O OD D1-D5 Aldosterone antagonist
Loop diuretic
Used to treat HTN
8. CAP.VIDEX
(Ayurvedic elemental Zinc)
1cap P/O OD D1-D8 Zinc supplement Used to treat Zn deficiency

16. S.NO NAME OF THE DRUG DOSE ROA FREQ DURA CATEGORY INDICATION
9. SYP.LACTIHEP
(Lactitol)
30 ml P/O H/S D1-D8 Synthetic Disaccharide Prophylactic to treat hepatic
encephalopathy
10. ENSURE PEPTIDE
(Enteral Nutrition Formula)
8 oz P/O TID D1-D8 Nutritional Supplement Used to treat nutritional
deficiencies
11. MOISTURE OINTMENT
(Menthol- ZnO)
L/A BD D4-D8 Mild Astringent Used to treat belching
12. TAB.MECON PLUS
(Multi vitamin)
10-25 mg P/O OD D8 Vitamin supplement Used to treat thiamine
deficiency
13. TAB.ANXOZAP
(Oxazepam)
15mg P/O TID D8 Benzodiazepines Used to treat alcohol
withdrawl symptoms
14. TAB.OLENAZ
(Olanzapine)
2.5mg P/O OD D8 Atypical Antipsychotic Used to treat tremors
15. TAB.CAMPRAL
(Acamprosate)
333mg P/O TID D8 GABA analogue Used to treat alcohol
withdrawl symptoms

17. DRUG INTERACTIONS:
TYPE BETWEEN SYMPTOMS MANAGEMENT
MODERATE OXAZEPAM - FUROSEMIDE This combination has additive effects in
lowering BP
Close monitoring of development of BP is
recommended.
MODERATE OXAZEPAM- SPIRONOLACTONE Headache, dizziness, fainting, changes
in pulse or heart rate
Close monitoring of development of BP is
recommended.
MODERATE OXAZEPAM - OLANZAPINE This combination may lower BP or
slow heart rate
Closely monitor excessive sedation and
cardiorespiratory depression.
MODERATE FUROSEMIDE - OLANZAPINE This combination has additive effects in
lowering BP
Close monitoring of development of BP is
recommended.

18. DRUG – FOOD INTERACTIONS
• MODERATE:
• OXAZEPAM – FOOD:
Alcohol can increase the nervous system side effects of oxazepam
such as dizziness, drowsiness and difficulty concentrating.
Hence limit the use of alcohol.
• OLANZAPINE- FOOD:
Alcohol can increase the nervous system side effects of oxazepam
such as dizziness, drowsiness and difficulty concentrating.
Hence limit the use of alcohol.

19. PATIENT COUNSELLING:
ABOUT DRUGS:
TAB.BILE FIX: administer with regard to meals
TAB. LASILACTONE: Administer with respect to
food
TAB.THIOTRESS: Administer with food
CAP.VIDEX: Administer after food
SYP.LACTIHEP: Administer 1 hour before sleep
TAB.OLENAZ: Administer at night after meals

20. LIFESTYLE MODIFICATIONS:
• Quiet smoking
• Weight loss
• Avoid alcohol consumption
• Do regular exercise
• Avoid raw sea foods, raw fish and shell fish
• Take vitamin or mineral supplements as
recommended.

21. Foods to avoid in ALD: