alcoholic hepatitis & hepatorenal syndrome

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

V/S HR: 90

RR: 16

SPO2: 95%

RA

BP: 120/65

Drowsy

no asterixis but has intention

tremors.

Chest/ CTA Bil.

CVS/ S1+S2+0

Abd/ showed mild distention

with mildly enlarged liver.

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

= (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

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

BUN 3 (L)

Creatinine 1.10

Component 10/5/2007

BUN 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 NRM MV

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

HCO3-

(Bicarbonate)

20.9 (L) 18.8 (L)

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)

Carbon Dioxide 18 (L)

BUN 64 (C)

Creatinine 5.50 (H)

Calcium 8.9

Prothrombin time 17.7 (H)

INR 1.7 (H)

Magnesium 2.7

Phosphorus 8.2 (H)

aPTT 35 (H)

Component 10/7/2007

WBC 17.3 (H)

RBC 2.74 (L)

Hemoglobin 9.0 (L)

Hematocrit 28.4 (L)

Platelet 204

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

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

Hepatorenal Syndrome Lancet. 2003;

362(9398):1819-27 (ISSN: 1474-547X)

Ginès P ; Guevara M ; Arroyo V ; Rodés J

Precipitating factors:1. Bacterial infection “SBP 20%”

2. Large volume paracentesis without plasma expansion

“5L or more 15%”

3. GI bleeding 10%

Hepatorenal Syndrome

Hepatorenal Syndrome Lancet. 2003;

362(9398):1819-27 (ISSN: 1474-547X)

Ginès P ; Guevara M ; Arroyo V ; Rodés J

Prognosis:

Type1 Vs Type2

Child -Pugh classification

Hepatorenal Syndrome

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

H&P

Blood & urine chem.

U/S

Cirrhosis

Portal Hypertension

Splanchnic vasodilatation

Severe arterial underfilling

Stimulation of

vasoconstrictor system

Renal vasoconstriction

Hepatorenal Syndrome

Liver

transplantation

TIPS

Vasoconstrictors

RRTHepatorenal 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

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

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

Noradrenalin and Albumin

Nephrology assessment and plan:Midodrine 12.5mg P.O. TID

Octreotide. + 200 microgram SQ TID

Albumin was given only with paracentesis

Hepatorenal Syndrome

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.