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Alcoholic Hepatitis & Hepatorenal Syndrome
1.
2. 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
3. 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
4.
5. 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
7. 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
8. 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.
9. 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
10. 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)
19. 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.
21. 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
22. 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
25. Component 10/4/2007 Component 10/5/2007
BUN 3 (L) BUN 10
Creatinine 1.10 Creatinine 2.80 (H)
26. 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
27.
28.
29. 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
30.
31.
32.
33.
34.
35. 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
49. 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
50. 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
51.
52. 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
53. 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
54. 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
55. 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
56. 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
57. 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
58. 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
59. 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