1. CASE PRESENTATION ON ALCOHOLIC LIVER DISEASES

2. SCENARIO:
Here is a 68y old male patient admitted to k block and diagnosed as alcoholic liver disease, liver cirrhosis, ascites and portal hypertension and hospitalised for 9 days.
SOAP NOTE:
SUBJECTIVE:
c/o swelling of lower limb up to knee since 15 days
c/o distension of abdomen since 10 days
c/o itching over the body since 1 month
PAST MEDICAL HISTORY:
Liver cirrhosis with portal hypertension
h/o hematemesis 6 months back
Upper GI bleed stopped medication after one month

3. OBJECTIVE:
Vital signs are normal
HB was low 8.9 gm./dl, MCH and MCHC was decreased
ESR was elevated 95 mm/hr
Polymorphs were elevated 69
Eosinophil's are elevated to 12
Slight elevation of RDW 16.6(12-15%)
Apetite was reduced.
SGPT 110 µl
SGOT 80 µl
PT time:4 min(2-3 min)
Traces of albumin in urine

4. ENDOSCOPY:
Severe PHG noted, few prominent veins at lower end D1,D2.
PHYSICAL EXAMINATION:
Pallor
Hyper pigmented skin lesions all over body
Pitting oedema
Splenomegaly
P/A:Fluid thrill and horse shoe dullness
ULTRASONOGRAPHY ABDOMEN:
Gross hepatomegaly, moderate uncomplicated ascites.

5. INTERPRETATION OF LABORATORY DATA:
Low HB shows anaemia and low MCH and MCHC implies microcytic anaemia and RDW was increased in chronic liver diseases
Elevated ESR signifies inflammation
Eosinophil were elevated in allergic conditions(IGE mediated)
Neutrophils are elevated in systemic bacterial infections and stress (exercise, acute hemorrhage,hemolysis)
AST and ALT levels are increased in hepatocellular injury
PT time was prolonged due to coagulation defects

6. PHG: portal hypertensive gastropathy.
chronic gastritis associated with cirrhosis. Exact mechanism is not known but portal hypertension is important .
Albumin was reduced to 3.5 g/dl(4-6g/dl)
Splenomegaly is the important sign of portal hypertension
Due to excessive alcoholism, decrease in NADP / NADPH
This leads to hepatomegaly.

7. ASSESMENT:
Based on the above subjective and objectives the physician diagnosed the condition as
alcoholic liver disease, liver cirrhosis, ascites and portal hypertension
PROBLEM LIST:
Swelling of lower limb
Distension of abdomen
Itching all over body
Loss of apetite
Liver cirrhosis
Moderate ascites
Portal hypertension
varices
Anaemia

8. Swelling of lower limb:
A reduction in serum albumin and reduced oncotic pressure contribute to collection of fluid to extracellular space and produce swelling of lower limbs
Abdominal distension:
Abdominal distension notably of flank is due to ascites
Pruritus:
Hyperpigmentation due to increased deposition of melanin. scratch marks of skin is pruritus sign and IGE mediated common feature of liver disease

9. Loss of apetite:
Damage to hepatocyte alters the metabolic functions and digestive problems leading to loss of apetite
Liver cirrhosis:
due to hepatotoxins like alcohol hepatocyte injury occurs and the stellate cells are activated loses retinoid and develop fibroblast and inflammatory response. Collagen deposition occurs and leads to fibrosis. In advance stages these collagen bands progress to bridging fibrosis resulting in hepatic cirrhosis.
Anaemia:
Chronic alcoholism causes haemolysis or bone marrow depression causing anaemia

10. Moderate ascites:
With abdominal distension
Pressure builds up in hepatic portal vein and fluid exudates and accumulates in area with lowest pressure and greatest capacity (peritoneal space) leading to ascitis.
Portal hypertension
Due to cirrhosis there will be resistance to blood flow to liver causing increased portal venous pressure than inferior venacava causing portal hypertension.

11. Varices:
Due to portal hypertension varices and collaterals from portal to systemic circulation occurs.
PLAN:
Goals of therapy:
To alleviate the symptoms
Clinical improvement or resolution of acute complications such as variceal bleeding and resolution of hemodynamic instability
Lowering of portal hypertension
To prevent further complications like hepatic encephalopathy.

12. Pantoprazole :
40 mg(1-0-0) iv is given for first day of admission for prophylaxis of hyper gastric secretion.
spironolactone 50 mg(1-0-1) twice a day was given for all 9 days of hospitalization.(14/9/13 to 22/9/13)
Drug of choice for ascites. maximum dose can be given 400 mg /day.
This drug is steroid chemically related to mineralocorticoid aldosterone, act from from interstitial side of tubular cells combine with mineralocorticoid receptor inhibits AIP ,increases sodium excretion .

13. Propranolol 40mg once a day given for all 9 days
This drug reduce cardiac output via blockade of the β1 cardiac receptors and the blockade of the adrenergic dilatory tone of the mesenteric arterioles, resulting in unopposed α-adrenergic–mediated vasoconstriction. The net effect is the decreased blood flow to the mesenteric vascular system and decreased portal vein pressure.
Also prevent re bleeding in PHG

14. Sodium Pico sulphate syrup :2 tablespoons a day for first 3 days.
This drug hydrolysed by colonic bacteria to bis(p-hydroxy -phenyl) pyridyl 2 –methane. stimulate colonic peristalsis by direct action of mucosa and it is an osmotic diuretic and produce watery stools
For constipation
Hydroxyzine hydrochloride :25 mg (101) twice a day for first 5 days.
Anti histamine drug and indicated for pruritus
Rabeprazole 20 mg once a day for 8 days
Indicated for non variceal bleeding disorder which progress to hepatic encepalopathy.

15. Sporolac (lactobacillus sporogenes) for one day as the patient has loose stools. lactobacillus preparations are intended to replace colonic microflora,restores intestinal function and supress the growth of pathogenic microorganisms.

16. Drug drug interactions:
1. Propranolol - spironolactone: (moderate)
Effect: hyperglycaemia, QT interval prolongation and arrhythmias.
Management: Monitor serum pot levels, BP and blood glucose levels.
Drug food interaction:
Food-propranalol moderate interaction increases propranalol conc.
Alcohol-propranalol minor interaction may inc or decrease propranalol conc.

17. Drugs on discharge:
Spironolactone 100 mg once a day for 10 days
Propranalol 40 mg once a day for 20 days
Multivitamin capsule once a day for 20 days
Patient counselling:
Restrict sodium intake to 2 g/day
Alcohol abstinence
Alcohol rehabilitation
Take high carbohydrate ,high calorie diet to reduce protein breakdown
Maintain healthy life style
Do not consume caffeine
Drink clear liquids

18. THANK U