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  • CHRONIC CIRRHOSIS WITH

    ASCITES

    SHWETA D. KAMBLI

    R.D. INTERN

  •  Name: Mrs. XYZ

     Age: 47

     Gender: Female

     Community: Maharashtrian

     State: Maharashtra; Taluka: Yawal; District:

    Jalgaon

     Residential area: Rural

     Economic Status: Lower socio-economic status

     Occupation: Farmer

     No. of family members: 7

     Addictions: None

     Dietary pattern: Non-Vegetarian

     SGA Score: C

     Date of Admission: 25/10/2016

     Date of Discharge: 26/11/2016

     Length of hospital stay: 32 days

    PATIENT PROFILE

  • CLINICAL ASSESSMENT

     Present Complaints: k/c/o Pulmonary hypertension, liver cirrhosis now admitted with c/o severe ascites;

    distension of stomach since 4 months; pedal edema, poor appetite, loss of weight, weakness, shortness of

    breath and dyspnea on exertion and heaviness of chest present.

     Past Medical History: 17 years back patient had a case of fluid accumulation in abdomen during post

    pregnancy duration. Patient took ayurvedic medications and it settled down.

     Family Medical history: None.

    Final Medical Diagnosis: LIVER CIRRHOSIS WITH ASCITES AND DILATED CARDIOMYOPATHY.

  • LIVER CIRRHOSIS

     Cirrhosis is a condition in which the liver slowly deteriorates and is unable to function normally due to

    chronic, or long lasting injury.

     In the early stages of cirrhosis, the liver continues to function.

     However, as cirrhosis gets worse and scar tissue replaces healthier tissue, this blocks the flow of blood

    through the liver.

     Chronic liver failure, which is also called end-stage liver disease, progresses over months, years, or

    even decades. With end-stage liver disease, the liver can no longer perform important functions or

    effectively replace damaged cells.

  • Pulmonary hypertension:

    • Liver disease can cause “portal hypertension,” meaning there is an increased

    blood pressure in the veins that enter the liver. This increased pressure causes

    blood to bypass the liver.

    • As a result, the blood vessels of the lungs are exposed to possible toxic

    substances and this can damage the small arteries of the lungs, causing

    pulmonary arterial hypertension (PAH).

    • The pulmonary arteries, which are responsible for transporting the blood from

    the right ventricle heart to the lungs, become narrowed and blocked due to the

    disease.

    • To properly pump the blood, the heart needs to work harder, becoming

    enlarged and weakened, increasing the risk of suffering right heart failure.

  • Dilated cardiomyopathy:

    • Cardiomyopathy refers to diseases of the heart muscle.

    • In dilated cardiomyopathy, the heart's ability to pump blood is decreased because the heart's main pumping

    chamber, the left ventricle, is enlarged, dilated and weak.

    • At first, the chambers of the heart respond by stretching to hold more blood to pump through the body.

    • With time, the heart muscle walls weaken and are not able to pump as strongly.

    Ascites:

    • The mechanism by which ascites develops in cirrhosis is multifactorial.

    • Severe sinusoidal portal hypertension and hepatic insufficiency are the initial factors. They lead to a

    circulatory dysfunction characterized by arterial vasodilation, arterial hypotension, high cardiac output,

    hypervolemia and to renal sodium and water retention.

  • Malnutrition:

    • Patients with cirrhosis frequently have either global malnutrition or alterations in specific aspects of

    nutritional status, such as micronutrient deficiencies, due to multiple mechanisms, including poor

    nutritional intake, poor absorption, and increased losses.

    • In addition, one of the most significant nutritional problems in cirrhotic patients is muscle wasting and

    sarcopenia.

    (McClain, C. J. (2016). Nutrition in Patients with Cirrhosis. Gastroenterology & Hepatology, 12(8), 507–510.)

  • ANTHROPOMETRIC ASSESSMENT

    MEASUREMENTS VALUES

    Height 147cm

    Weight 37 Kgs during admission

    Dry weight post tapping is 34 Kg)

    Dry Body mass index (BMI) 15.73Kg/m2

    Ideal Body Weight (IBW) 42Kg

  • DATE

    ABDOMINAL

    GIRTH

    CHARTING

    (cms)

    WEIGHT

    CHARTING

    (Kg)

    FLUID INPUT

    (ml)

    FLUID OUTPUT

    (ml)

    USG GUIDED

    ASCITIC FLUID

    TAPPING

    (ml)

    25/10/2016 72 37 1000 550 2500ml

    27/10/2016 70 36 1000 1050 -

    29/10/2016 70 35 850 500 -

    31/10/2016 67 35 950 770 -

    2/11/2016 67 35 1000 590 -

    4/11/2016 66 36 1150 830 -

    6/11/2016 68 36 1000 610 1100ml

    8/11/2016 67 35 950 865 -

    10/11/2016 66 35.5 1000 900 -

    12/11/2016 66 35.5 1000 930 -

    14/11/2016 67 36 900 995 -

    16/11/2016 66 36 1025 740 -

    18/11/2016 65 36 1000 1050 500ml

    20/11/2016 63 35 1000 1250 -

    22/11/2016 62 34.5 1000 1400 -

    24/11/2016 63 34.5 1250 1250 -

    26/11/2016 Discharge

  • BIOCHEMICAL ASSESSMENT

  • TEST

    RESULT

    REFERENCE RANGE

    25/10/16 27/10/16 5/11/16 8/11/16 19/11/16 22/11/16

    Prothrombin time 14.2 13.50 13.30 13.0 11-14 Seconds

    WBC - - 6.04 4.22 4.73 4.75 4-10

    10^3/uL

    Hemoglobin 7.5 - 8.10 7.5 8 9.1 11.5-16g/dl

    Platelets 142 - 107 142 141 144 140-440 10^3/uL

    Sodium 142 - 138 138 - - 137-145mmol/L

    Potassium 4.10 - 4.2 3.7 - - 3.5-5.1mmol/L

    Chloride 103 - 100 100 - - 98-107 mmol/L

    Ammonia - - - 9.00 - - 9-33 umol/L

    AST/ SGOT 20 19 24 23 26 28 15-46 U/L

    ALT/ SGPT 14 12 13 15 18 21 13-69 U/L

    Bilirubin total 0.84 0.98 0.86 0.80 0.71 0.80 0.2 – 1.3 mg/dL

    Bilirubin Unconjugated (BU) 0.29 0.46 0.34 0.26 0.26 0.36 0-1 mg/dL

    Bilirubin Conjugated (BC) 0.00 0.00 0.00 0.00 0.00 0.00 0-0.3 mg/dL

    Bilirubin delta 0.55 0.52 0.52 0.54 0.45 0.44 0-0.2 mg/dl

    Alkaline phosphatase 55 44 57 52 57 81 38-126 IU/L

    Total proteins 7.21 6.48 7.15 6.74 6.54 7.08 6.3-8.2mg/dl

    Albumin 3.82 3.61 3.78 3.52 3.47 3.71 3.5 – 5 g/dL

    Globulin 3.39 2.87 3.37 3.22 3.07 3.38 2.4 – 3.5 g/dL

    Albumin/Globulin ratio 1.12 1.26 1.12 1.09 1.13 1.1 1.1 -2.2

    BNP Peptide 958 - - - - - >400 pg/ml- heart failure

    probable

    Blood sugar Random 93 - - - - - 65-165mg/dl

    Blood urea Nitrogen 11 - - - - - 7-17mg/dL

    Uric Acid 5.3 - - - - - 2.5-6.2 mg/dL

    Serum Creatinine 0.7 - 0.8 - 0.7 - 0.7-1.2mg/dL

    Adenosine deaminase activity (ADA)

    Sample type- Ascitic fluid 15.80

  • b. Other Investigations:

    Date Time Temperature

    (F)

    Pulse

    (b/min)

    Respiration

    (b/min)

    Blood Pressure

    (mmHg)

    25/10/2016 10:00am 98 76 20 100/70

    27/10/2016 10:00am 98 72 20 100/80

    5/11/2016 10:00am 98 71 22 100/60

    8/11/1016 10:00am 98 82 18 90/60

    19/11/2016 10:00am 97 70 20 90/60

    22/11/2016 10:00am 98 70 20 90/60

    CT Scan of abdomen: Indicate severe Ascites and Splenomegaly.

    Liver biopsy: Sections reveal variably sized nodules separated by fibrotic bands. Granulomas were not

    seen.

    Microbiological testing of the Ascitic fluid: No pus cells, no organisms seen.

  • MEDICATION DURING HOSPITAL STAY

  • MEDICATION DOSAGE

    MECHANISM OF ACTION

    SIDE- EFFECTS

    TAB. ENDOBLOC 10MG 1-0-0 Medicine used for the treatment of pulmonary hypertension. It works by widening the arteries and

    reducing the blood pressure.

    Peripheral edema, Nasal congestion, Sinus

    inflammation, Flushing

    TAB. CAVERTA 25MG 1-0-1 (5Days a

    week)

    Used for the treatment of high blood pressure. It works by relaxing the blood vessels and widening

    the blood vessels in the lung.

    headache, flushing of the face, and upset stomach.

    TAB. LANOXIN 0.25MG 1-0-0 Used to treat various heart conditions such as atrial fibrillation, atrial flutter and heart failure.

    nausea, vomiting, loss of appetite; fast, slow, or

    uneven heart rate

    TAB. LASILACTONE

    100MG 1-0-0

    Used in the treatment of fluid retention. Works by preventing the body to absorb too much salt,

    eliminating unneeded water and sodium from the body into the urine.

    Increased production of urine, dehydration,

    decreased blood pressure, weakness, drowsiness

    TAB.MULTIVIT GOLD 1-0-0

    Used for Maintaining the proper balance of body fluids and body's acid base balance, Neutralizing

    the free radicals and participates in vital redox reactions of the body, Raising the level of

    glutathione thus prevents cells against peroxidative damage, Works for the healing purpose,

    Improving the body's metabolism, Widening the blood vessels, Increasing the effects of insulin,

    Promoting the formation of active prothrombin in liver, Helping in bone and col