Case presentation 11 6

Case presentation

1. Noon Didactics Case discussion Sidney Hoskins, MS3 11/6/18

2. Alcoholic hepatitis Characteristic clinical features RUQ abdominal pain Jaundice (usually months prior to presentation) Fever Ascites with abdominal distention Anorexia and proximal muscle wasting

3. all of the Scores Calculations we use to help guide treatment and predict prognosis MELD Score Child-Pugh Score Maddrey Discriminant Function Lille Score

4. MELD Score Model for End-stage Liver Disease Factors  dialysis at least twice/week?, Cr, total bili, INR, Na Helps prognosticate 90-day mortality in patients with acute liver failure For transplant planning and mortality in acute alcoholic hepatitis This patient’s score on admission was 26 points 19.6% 3-month mortality

5. Child- pugh score Predicts abdominal surgery peri -operative mortality Another tool to classify cirrhosis and prognosticate Factors  total bili, albumin, INR, ascites, encephalopathy P atient’s score was 13 on admission 82% mortality peri -operatively in this patient Stratifies into three different classes (Class A, Class B, Class C) This patient is Child Class C  life expectancy of 1-3 years

6. Child-Pugh Classes

7. Maddrey discriminant function D isease severity in patients with alcoholic hepatitis Gives recommendation for steroid treatment Factors  PT and total bilirubin P atient’s score was 66.8 points >32 points indicates a poor prognosis and potential benefit from steroid administration

8. Lille score Assess response to steroid administration after 7 days of Tx Factors  age, albumin, initial total bili, total bili at day 7, Cr, PT Patient’s score was 0.019 = good prognosis Continue for 28 days if signs of improvement If no signs of improvement, d/c steroids and consider alternative Tx

9. Corticosteroids in acute cirrhosis P rednisolone for 28days with a 16 day taper Must have good follow up! Contraindications to steroid administration include chronic Hep C or Hep B infection and active bacterial or fungal infection Pentoxifylline Vasodilator and anti-inflammatory agent, also inhibits TNF synthesis May prevent hepatorenal syndrome 400mg TID Usually stopped when total bili is <5mg/ dL

10. SAAG Serum Ascites Albumin Gradient Defines the presence of portal HTN in patients with ascites Serum albumin – ascitic fluid albumin Gradient > 1.1 suggests portal HTN with 97% accuracy Gradient <1.1 suggests portal HTN is not present

11. Hospital course Started on lactulose, steroids and albumin MELD Score: 26 points  20 points (7-10% 3-month mortality) Child-Pugh Score: 13 points  10 points (Child Class C) AST : 574  83 Total Bili: 11.6  6.7 INR: 2.1  1.6

12. Summary Can use many tools and calculators to help guide treatment in alcoholic hepatitis AND communicate to patients the severity of their condition MELD Score Child-Pugh Score Maddrey Discriminant Function Lille Score