About its life style modifications and treatment in hospital

1. CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION
, ESOPHAGEAL VARICES, UPPER GI BLEEDING AND SHOCK
SUBMITTED BY
K.GOUTHAM
612171602008
IV PharmD

2. Patient Demographics
Name: K.Seetha
Age: 30yrs
Reg no: 118914
DOA: 12/1/15
Ward: AMCU-1

3. PATIENT COMPLAINTS
Chief Complaints:
1. 2 Episodes of Bleeding from mouth since yesterday night
2. Passing loose black coloured stools since night
3. Vomitings since morning
Past Medical History: Chronic Liver Disease with Portal
Hypertension
Past Medication History: Not Available
Family History: Not Significant
Lab Investigations: Endoscopy
Haemoglobin-3gm%

4. DIAGNOSIS:
CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION,
ESOPHAGEAL VARICES, UPPER GI BLEEDING AND SHOCK

5. DAY-1 DAY-2
Patient is conscious and coherent
BP- 90/60mmHg
PR- 90/min
RR- 22/min
Temp- 98.6F
Respiratory System- BAE+, clear
CVS- S1S2 +
CNS- B/L Pupils NSRL
P/A- Soft, Spleenomegaly
SPO2- 89%
Urine Output- 700ml
Received 350ml O+ve blood
Patient is conscious and coherent
BP- 90/70mmHg
PR- 100/min
RR- 22/min
Temp- 99F
Respiratory System- BAE+, clear
CVS- S1S2 +
CNS- B/L Pupils NSRL
P/A- Soft, Spleenomegaly
SPO2- 85%
Urine Output- 700ml
Received 350ml O+ve blood

6. DAY-3 DAY-4
Patient is conscious and coherent
BP- 100/70mmHg
PR- 110/min
RR- 20/min
Temp- 99F
Respiratory System- BAE+, clear
CVS- S1S2 +
CNS- B/L Pupils NSRL
P/A- Soft, Distended, Splenomegaly
SPO2- 98%
Urine Output- 700ml
Received 350ml O+ve blood
Patient is conscious and coherent
BP- 100/70mmHg
PR- 91/min
RR- 20/min
Temp- 99F
Respiratory System- BAE+, clear
CVS- S1S2 +
CNS- B/L Pupils NSRL
P/A- Distended, Splenomegaly
SPO2- 87%
Urine Output- 700ml
Hb- 5gm%

7. DAY-5 DAY-6
Patient is conscious and coherent
BP- 100/90mmHg
PR- 82/min
RR- 22/min
Respiratory System- BAE+, clear
CVS- S1S2 +
CNS- B/L Pupils NSRL
P/A-Soft, Splenomegaly
Patient is conscious and coherent
BP- 100/70mmHg
PR- 82/min
Respiratory System- BAE+, clear
CVS- S1S2 +
CNS- B/L Pupils NSRL
P/A- Soft, Splenomegaly
No Active Bleeding

8. DAY-7 DAY-8
Patient is conscious and coherent
BP- 100/70mmHg
PR- 82/min
Respiratory System- BAE+, clear
CVS- S1S2 +
CNS- B/L Pupils NSRL
P/A- Splenomegaly
Urine Output Adequate
Hb- 3%
Patient is conscious and coherent
BP- 80/60 mmHg
PR- 92/min
Respiratory System- BAE+, clear
CVS- S1S2 +
CNS- B/L Pupils NSRL
P/A- Splenomegaly
No Further Bleeding

9. Day-9
Patient is conscious and coherent
Afebrile
Urine Output Adequate
BP- 110/80mmHg
PR- 82/min
Respiratory System- BAE+, clear
CVS- S1S2 +
CNS- B/L Pupils NSRL
P/A- Splenomegaly
Urine Output- 1000ml

10. S.
No
.
Drug Dose Freq ROA D-1 D-2 D-3 D-4 D-5 D-6 D-7 D-8 D-9
1. Inj. Ethamsylate 1 amp BD IV         
2. Inj. Ceftriaxone 1 gm OD IV         
3. Inj. Tranexamic acid 1 amp TID IV       X X X
4. Inj. Dopamine 2amp in
1b NS
16-18
d/min
IV  X X X X X X X X
5. IV Fluids 4b NS 8d/m IV  X X X X X X X X
3b NS 8d/m IV X   X X X X X X
6. Inj. Pantop 40mg OD IV     X X X X X
1 amp BD IV X X X X     
7. FFP Transfusion IV   X X X X X X X
8. Inj. 25% Dextrose TID IV X   X X X X X X
9. Inj. Ondansetron 1 amp BD IV X X X X     X
10. Tab. Propranalol 10mg OD Oral X X X X     
11. Syp. Lactulose 30ml HS Oral X X X X     
12. Tab. Paracetamol 500mg TID Oral X X X  X X X X X
13. Tab. B-Complex 1 tab OD Oral X X X  X X X X 

11. DRUG INTERACTIONS
PANTOPRAZOLE SODIUM -- PROPRANOLOL HYDROCHLORIDE :
Concurrent use of PROPRANOLOL and SELECTED CYP2C19 INHIBITORS may result in increased propranolol exp
Remedy : Use Omeprazole in place of pantoprazole.

12. ADVERSE EFFECTS
Inj.Ceftriaxone: Diarrhea, Eosinophilia, Thrombocytosis, Hypersensitivity reaction, Renal failure
Inj.25% Dextrose: Hyperglycemia, Hyperosmolarity, Hypervolemia, Pulmonary edema
Inj.Dopamine: Chest pain, Hypertension, Palpitations, Tachyarrhythmia, Nausea, Vomiting,
Headache, Oliguria, Dyspnea, Dyspnea
Inj.Ethamsylate: Thromboembolic disorder, Rash, Acute intermittent porphyria, nausea, abdominal
discomfort, bitter taste, headache
Syp.Lactulose: Bloating symptom, Diarrhea, Epigastric pain, Flatulence, Nausea, Vomiting,
Hypernatremia, Hypokalemia
Inj.Ondansetron: Constipation, Diarrhea, Increased liver enzymes, Fatigue, Malaise,
Electrocardiogram abnormal, Prolonged QT interval
Tab.Propranolol: Diarrhea, Vomiting, Dizziness , Sleep disorder, Fatigue, Bradyarrhythmia,
Cardiogenic shock, Congestive heart failure, Heart block, Heart failure, Hypotension, Prolonged PR
interval, Shortened QT interval, Erythroderma, Anaphylaxis, Bronchospasm

13. Inj.Tranexamic Acid: Abdominal pain , Anemia (oral), Deep venous thrombosis, Thromboembolic
disorder, Anaphylaxis, Hypersensitivity reaction , Central retinal artery occlusion, Visual disturbance,
Pulmonary embolism.
Tab.Pantoprazole : Abdominal pain, Diarrhea, Flatulence, Atrophic gastritis, Clostridium difficile
diarrhea.
Tab.Paracetamol: liver and kidney damage, when taken at higher-than-recommended doses, unusual
bleeding or bruising, stomach cramps or pain.
FFP Transfusion: mild urticaria, Transmission of infections, Graft-versus-host disease, hypervolemia,
Transfusion-related acute lung injury (TRALI).

14. PATIENT EDUCATION
About Disease:
Chronic liver disease: Chronic Liver Duisease is a disease process of the liver that involves a process of progressive
destruction and regeneration of the liver parenchyma leading to fibrosis and cirrhosis. Chronic liver disease refers to disease
of the liver which had lasted over a period of 6 months. It consists of a wide range of liver pathologies which include
inflammation (chronic hepatitis), liver cirrhosis, and hepatocellular carcinoma.
Causes: Hepatitis B, Hepatitis C, Alcoholic liver disease, Amiodarone, Methotrexate, Haemochromatosis, Autoimmune,
hepatitis, Primary Biliary Cirrhosis.
Portal Hypertension: Portal hypertension is an increase in the blood pressure within a system of veins called the portal
venous system. Veins coming from the stomach, intestine, spleen, and pancreas merge into the portal vein, which then
branches into smaller vessels and travels through the liver. If the vessels in the liver are blocked due to liver damage, blood
cannot flow properly through the liver. As a result, high pressure in the portal system develops. This increased pressure in the
portal vein may lead to the development of large, swollen veins (varices) within the esophagus, stomach, rectum, or umbilical
area (belly button). Varices can rupture and bleed, resulting in potentially life-threatening complications.
Causes: Cirrhosis, blood clots in the portal vein, blockages of the veins that carry the blood from the liver to the heart, a
parasitic infection called schistosomiasis
Symptoms: 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, Encephalopathy or confusion

15. Esophageal Varices: Esophageal varices are enlarged veins in the walls of the lower part of the esophagus that bleed.
Scarring (cirrhosis) of the liver is the most common cause of esophageal varices. This scarring cuts down on blood flowing
through the liver. As a result, more blood flows through the veins of the esophagus.
The extra blood flow causes the veins in the esophagus to balloon outward. Heavy bleeding can occur if the veins break
open.
Symptoms: Black, tarry stools, Bloody stools, Light-headedness, Paleness, Symptoms of chronic liver disease
Vomiting, Vomiting blood, Low blood pressure
Shock: Hypovolemic shock is an emergency condition in which severe blood and fluid loss make the heart unable to
pump enough blood to the body. This type of shock can cause many organs to stop working.
Causes: Blood loss can be due to:
Bleeding from cuts
Bleeding from other injuries
Internal bleeding, such as in the gastrointestinal tract

16. ADMINISTRATION GUIDELINES:
Inj.Ceftriaxone: Reconstitution of the 250-mg and 500-mg vials with 0.9 mL and 1.8 mL of sterile water,
respectively, of appropriate diluent results in a concentration of 250 mg/mL.
Inj.Dextrose: Administer Intravenously thrice in a day.
Inj.Dopamine: Dilute with 250 mL or 500 mL of NS, initiate at a rate of 16-18 drops/min. Administer by IV
infusion only; do not give as a bolus.
Inj.Ethamsylate: It is administerd Intravenously twice in a day.
Syp.Lactulose: Administer orally at night may be mixed with fruit juice, water, or milk to improve taste.
Inj.Ondansetron: Administer Intravenously twice in a day.
Inj.Pantoprazole: Administer Intravenously once in a day.
Tab.Paracetamol: Administer orally with water after 30mins of taking food because concurrent use of
PARACETAMOL and FOOD may result in decreased peak PARACETAMOL concentrations for three times a day
fourth hourly.

17. Tab.Propranolol: Administer orally during or immediately after feeding once in a day.
Inj.Tranexamic Acid: Administer Intravenously three times a day.Do not inject more rapidly than 1 mL/min to
avoid hypotension

18. Life Style Modifications:
Do not drink alcohol: This will help prevent further damage to your esophagus and liver.
Eat healthy foods: Healthy foods include fruits, vegetables, whole-grain breads, low-fat dairy products, beans,
lean meats, and fish. You may need to eat foods that reduce stomach acid. Stomach acid can get into your
esophagus and cause the varices to break open and bleed.
Calories and Protein
People with cirrhosis may experience nausea, vomiting and weight loss due to loss of appetite, and as a result
may need extra calories and protein. To get the extra calories, eat four to seven small, frequent meals and
snacks.
Limit sodium: Need to decrease the amount of sodium you eat if you have swelling caused by fluid buildup.
Fluid buildup can cause increased pressure in your veins. Sodium is found in table salt and salty foods such as
canned foods, frozen foods, and potato chips.
Drink liquids as directed: Too much liquid can increase the pressure in your veins.
Maintain a healthy weight. An excess amount of body fat can damage liver. Obesity is associated with a
greater risk of complications of cirrhosis. Lose weight if obese or overweight.

19. Use chemicals sparingly and carefully. Follow the directions on household chemicals, such as cleaning
supplies and insect sprays. If work around chemicals, follow all safety precautions. Liver removes toxins from
body, so give it a break by limiting the amount of toxins it must process.

20. Thank You