1. Case presentation IG R2 소예리 / Prof. 김병호

2. 11934644 원 O 근 M/52 Adm on 2010-08-04 Chief complaint abdominal pain Present illness M/52, 2010 년 1 월 B-viral LC 로 진단받고 levovir 복용하며 지내던 자로 liver transplantation 고려하여 장기이식 대기 상태인 환자. 내원 1 주 전부터 abdominal pain 이 mild 하게 지속되고 내 원 2 일 전 식사 후 vomiting 2 회 있어 ER 방문하여 치료 후 귀가하였으나 식욕부진, 전신 쇠약감, 전신 부종 있어 입원.

3. Past medical history DM / HTN / Tb / Hepatitis ( - / - / - / + ) : chronic hepatitis B, LC Op Hx ( - ) Personal history Smoking (-), Alcohol (-) Family history none

4. Review of system General generalized weakness (+) fatigue (+) febrile sense (+): 4,5 일전 chilling (-) edema(+) Skin rash (-) itching (-) pigmentation (-) bruise (-) Head & Neck headache (-) sore throat (-) nasal obstruction (-) Eye & ENT visual disturbance (-)tinnitus (-) Respiratory cough (-) sputum (-) dyspnea (-) hemoptysis (-) Cardiac chest pain (-) palpitation (-) orthopnea (-)

5. Gastrointestinal A/N/V/D/C (+/-/-/-/-)abd. pain (+) : epigastric area, mild hematemesis (-)melena (-) hematochezia (-) Urinary dysuria (-) frequency (-) urgency (-) RU sense (-) flank pain (-) oliguria (+): 소변량 적어 이전에 처방받은 이뇨제 자가 복용 Musculoskeletal pain (-) myalgia (-) claudication (-) Neurologic syncope (-) seizure (-) dizziness (-) numbness (-) Review of System

6. Vital sign 90/70 – 72 회 /min – 17 회 /min – 36.5°c weight: 64.7kg height: 161cm General alert consciousness chronic-ill looking appearance Skin no rash no pigmentation Head & Neck no neck vein engorgement no neck LN enlargement Eye & ENT isocoric pupil with PLR (++/++) whitish sclera pale conjunctiva PI (-) PTH (-/-) Physical Examination

7. Thorax clear breathing sound without crackle or wheezing regular heart beat without murmur Abdomen soft and distended abdomen normoactive bowel sound Td / RTd / muscle guarding ( + / - / - ) : epigastric no palpable mass no abdominal bruit no splenomegaly no hepatomegaly Back & Extremities CVA tenderness (-/-) pretibial pitting edema (++/++) Physical Examination

8. CBC/DC 12,530/mm² - 8.2 g/dl - 28.1% - 98K (seg 84%) PT (INR) 4.67 aPTT 104.6 Chemistry TB/DB 7.64/6.15 mg/dL Prot/Alb 6.0/2.6 g/dL AST/ALT 246/39 IU/L ALP/GGT 88/19 IU/L BUN/Cr 26/3.5 mg/dL Na/K/Cl 125/6.3/99 mmol/L Ca/P/U 8.4/7.4/2.3 mg/dL LD/CK 968/284 U/L CRP 4.02 U/L Glu 6 mg/dL ABGA 7.15 - 17.7 - 107.1 - 6.1 - 96.6% lactate 119.3 mg/dL Anion gap: 19.9 mEq/L U/A RBC many/HPF WBC 10-29/HPF Bilirubin (2+) Protein (2+) Glucose (-) pH 5.0 SG 1.014 Initial Lab Finding

9. Chest X-ray

10. EKG

11. #1. Ascites with Abdominal pain #2. Elevated Creatinine #3. Hyperkalemia #4. Oliguria #5. Lactic acidosis #6. Hypoglycemia #7. Anemia #8. known B-viral liver cirrhosis Initial Problem List

12. Initial Assessment & Diagnostic / Therapeutic Plan #1. Ascites with Abdominal pain → r/o AGE r/o SBP (Spontaneous Bacterial Peritonitis) D) CBC/DC F/U, CRP, Procalcitonin Paracentesis (Cell count, Albumin, SAAG…) T) Blood, Ascites culture iv Antibiotics (3 차 cephalosporin)

13. Initial Assessment & Plan #2. Elevated Creatinine #3. Hyperkalemia #4. Oliguria #5. Lactic acidosis → ARF c lactic acidosis: r/o Hepatorenal syndrome D) ABGA, lactate f/u, urine electrolyte (FeNa, FeBUN), Urine output check T) Kalimate enema, po 복용 Terlipressin + Albumin supply Hydration, Bicarbonate supply, CRRT 고려

14. Initial Assessment & Plan #6. Hypoglycemia #7. Anemia #8. known B-viral liver cirrhosis → r/o Hepatic failure D) Anemia study (CBC/DC, PB smear, reticulocyte, s-iron, TIBC, ferritin, folate, VitB12, …), PT, LFT, GMT f/u, A-P US T) Glucose/nutritional support Transfusion Liver transplantation 진행

15. Clinical course

16. r/o AGE, r/o SBP (Spontaneous Bacterial Peritonitis) S) Abdominal distension, pain O) CRP: 4.02 mg/dL, Procalcitonin: 7.14 ng/mL ▶ Paracentesis: ⓦ 12,000 (PMN: 11760, 98%), SAAG 2.4 A) SBP P) IV antibiotics ( ceftriaxone 2g q24h) IV Albumin supply

17. r/o Hepatorenal syndrome S) Generalized edema, Oliguria O) BUN/Cr: 26/3.5 mg/dL Na/K: 125/6.3 mmol/L eGFR: 19.69 mL/min Urine Na: 14 mmol/L urine output: 0-10mL/hr (I/O: 1850/45)

18. Type 1: 발생 2 주 이내에 Cr 이 2 배 이상 상승하여 2.5 mg/dL 을 넘거나, eGFR 이 50% 이상 감소하여 20 mL/min 이하로 되는 경우 예후 : 중앙 생존기간이 2 주에 불과하여 간이식을 요함. 유발 요인 : 순환 장애를 유발하는 요인들 - 세균 감염이나 혈장량 보충 없이 대량 복수 천자를 하는 경우, 위장관 출혈 등이 이러한 유발 요인이다. 자발성 세균성 복막염 환자의 20% 에서 간신증후군이 발생 치료 1 형은 예후가 극히 불량하여 단시일 내에 사망 ; 간이식이 궁극적인 치료 이식을 기다리는 기간 동안에 생명 유지, 신기능 개선이 치료 목표 - 약물치료 ; 혈관 수축제 (Terlipressin) 와 혈장 확장제 (Albumin) 의 병용 치료 - TIPS - 신대치요법 Hepatorenal syndrome

19. A) ARF c metabolic acidosis: Hepatorenal syndrome P) Kalimate enema / po Hydration, Bicarbonate supply, 필요시 CRRT 고려 Terlipressin, Albumin

20. Hepatic failure S) Generalized weakness O) Child C (11) MELD score: 43.37 CBC: 12,530/mm² - 8.2 g/dl - 28.1% - 98K (seg 84%) PT (INR) 4.67 Glu 6 mg/dL TB/DB 7.64/6.15 mg/dL AST/ALT 246/39 IU/L A) Hepatic failure P) Transfusion (FFP, pRBC) Liver transplantation

21. Clinical course Adm 8/4 AM 11:50 Abdominal pain Paracentesis Iv Ceftriaxone Anemia, prolonged PT Transfusion (FFP, pRBC) Terlipressin, Albumin CRRT ICU 8/4 PM 23:50 SBP Generalized edema, oliguira Hepatorenal syndrome ARF c metabolic acidosis Hepatic failure CRRT 8/5 PM 16:50 CPR 8/5 PM 19:50 -20:55 GI bleeding → Arrest CPR 8/5 PM 21:05 -21:22 CPR Intubation, iv inotropics Expire 8/5 PM 23:50

22. GI bleeding → Arrest CPR

23. → Hepatic failure d/t SBP with Hepatorenal syndrome Final diagnosis