LIVER CIRRHOSIS

A CASE PRESENTATION OF LIVER CIRRHOSIS

1. A CASE PRESENTATION ON LIVER CIRRHOSIS Submitted by, Anvy Thankachan Pharm D 4 th year

2. A 75 yr old Male patent was admitted in the Gastroenterology dept with complaints of Loose stools for one week A bdominal distension & Abdominal pain associated with breathing difficulty for 10 days

3. SUBJECTIVE

4. PATIENT DETAILS NAME: Mr.X SEX: M AGE:75 DEPARTMENT: GASTROENTROLOGY IP NO: K-10759 DOA:13/2/17 DOD:17/2/17

5. History of Present illness: Loose stools since one week, Abdominal distension& Abdominal pain associated with breathing difficulty of 10 days duration. On examination he is conscious ,oriented , no pallor / icterus. vitals: temp: 98.6, PR: 80/min, RR: 22/ min, BP: 130/90 Abdomen: Distended, free fluid present PAST MEDICAL HISTORY: Cirrhosis with portal hypertension& HT

6. PAST MEDICATION HISTORY : T.udiliv 300mg BD T.Pan 40mg OD T.Neurobionforte 0-1-0 T. Lasilactone OD T.Ciplar 20mg BD SOCIAL HABITS: NIL FAMILY HISTORY : NOT KNOWN

7. OBJECTIVE

8. Laboratory Investigation PARAMETERS 13/2 17/2 Hb 11.8 10.7 PCV 34.4 30 PLT 1.81L 1.51L DC N: L: E: 66.7 23.3 0.82 65.8 20.2 2.74 Parameters 13 14 15 16 17 urea 92.9 100.4 97.1 91.7 88.5 creatinine 2.23 2.21 2.11 2.35 2.12 sodium 126.8 126.2 126.6 - 122.3 potassium 5.54 4.77 4.01 - 4.49 RFT

9. LFT DATE 13/2/ 17/2/ S . PROTEIN (6.4-8.2) 8.6 7.71 S . ALBUMIN (3.5-5.2) 2.95 3.35 GLOBULIN (2-3) 5.6 4.4 ALK PHOSPHATASE (50-136 ) 91.9 67.9 S . BILIRUBIN T (0.3-1.2) 1.54 1.87 S . BILIRUBIN DIR (0.1-0.3 ) 0.52 0.75 SGPT(30-64 ) 34.5 37.2 SGOT (15-37) 54.6 57.4

10. OTHER INVESTIGATIONS USG Abdomen was done on 13/2 LIVER: Coarse in echo texture with surface irregularities . multiple hyperechoic nodules noted Gall bladder: Physiologically distended , Echo free lumen , wall thickness normal Both kidneys are normal in shape, size, position, & echotexture Splenomegaly , moderate ascites

11. ASSESSMENT

12. DIAGNOSIS: From the objective and subjective data patient is diagnosed with Cirrhosis of liver with portal hypertension Child class B , MELD score 19 Ascites, Esopageal varices Renal failure, systemic Hypertension

13. Liver cirrhosis is defined histologically based on 3 criteria: Diffuse disease Presence of fibrosis Replacement of normal liver architecture by abnormal nodules

14. ETIOLOGY OF CIRRHOSIS Chronic viral Hepatitis(B,C,D) Metabolic liver diseases: Hemochromatosis Wilson disease fatty liver Cholestatic liver diseases Drugs and herbals (INH , Methyldopa,Methotrexate )

15. CLINICAL PRESENTATION SIGNS AND SYMPTOMS LABORATORY TEST Assymptomatic 1.Hypoalbuminemia Hepatomegaly, splenomegaly 2.Elevated PT Pruritus, jaundice , palmar edema 3.Thrompocytopenia Gynaecomastia 4. Elevated ALP Ascites, edema , pleural effusion 5.Elevated AST,ALT,GGT Malaise, anorexia Encephalopathy Respiratory difficulties Spider angiomata Hyperpigmentation

16. PATHOPHYSIOLOGY In areas of hepatocellular injury, hepatic Stellate cells undergo an abnormal transformation. Stellate cells in the affected areas begin to resemble Fibroblast ,express contractile proteins and become a Major source of collagen and other matrix proteins That proliferate during fibrosis , causing permanent Hepatic scarring Deposition of fibrous material disrupts normal Blood flow resulting in elevation in portal Blood pressure

17. Also changes occur in vaso constrictory and vasodilatory mediators occurs A decrease in production of NO (vasodilator) and increase in levels of vasoconstrictor such as endothelin , combines to increase in resistance to blood flow through sinusoidal space

18. COMPLICATIONS OF CIRRHOSIS Edema and ascites Spontaneous bacterial peritonitis ( SBP) Bleeding from esophageal varices Hepatic encephalopathy Hepatorenal syndrome Hepatopulmonary syndrome Hypersplenism Liver cancer (hepatocellular carcinoma

19. TREATMENT Identify and eliminate possible causes of cirrhosis(alcohol abuse) Asssess risk for variceal bleeding and begin pharmacologic prophylaxis (beta adrenergic blockers) Evaluate patient for clinical signs of ascites and manage with pharmacologic therapy (diuretics and paracentesis ) Monitor for hepatic encephalopathy, treat with dietary restriction , therapy to low ammonia level Monitor frequently for hepato renal syndrome, pulomonary insufficiency , and endocrine dysfuntion

20. PLAN

21. BRAND NAME GENERIC NAME Dose & Freq 13 14 15 16 17 T.udiliv Ursodeoxycholic acid 300mg BD + + + + + Neurobione forte Vit B12, B1, B2 OD + + + + + Ciplox Ciprofloxacin 500mg BD + + + + + Aldactone Spironolactone 100mg OD + - - - - Lasix Furosemide 40mg BD + + + + + Pan 40 Pantoprazole 40mg OD + + + + + Bifilac Lactobacillus  sporogenes TID + + + + + Inj. Terlipressin Terlipressin 0.5 mg OD - - - + + Inj. Perinorm Metoclopromide OD - - - - + Inj.Tramadol Tramadol 50mg OD - - - - + T. Ciplar Propanolol 20mg BD + + + + + INJ. H. Albumin20% Albumin 20% + - - - - Paracentesis also done on 13/2

22. DISCHARGE MEDICATIONS T.ciplox 500mg BD for 3 days T. Pan 40 BD T.Neurobionforte 0-1-0 T.Udiliv 300mg BD T.Lasix 40mg1-0-0 C.Bifilac TID for 5 days

23. PHARMAClST lNTERACTlONS DRUG- DRUG lNTERACTlONS PROPRANOLOL AND SPlRONOLACTONE ----Both increase serum potassium. ----Monitor closely. ClPROFLXAClN AND TRAMADOL ----both drugs increase the risk of causing seizures esp. n elderly pts. . --monitor closely

24. METOCLOPRAMDE AND TRAMADOL ----The risk of seizure is increased during co administration ---caution is advised but given only for 1 day. FUROSEMlDE AND PANTOPRAZOLE ----- Chronic use of PPl may induced hypomagnesaemia and risk increased during concomitant use of diuretics. ----- Monitor serum magnesium levels prior to the initiation of the therapy and periodically thereafter if treatment prolonged.

25. ClPROFLOXACN AND FOOD ---- concurrent Ingeston of daIry products (milk ,yogurt) or calcum fortfed foods ( cereals, orange juce ) meals that contan these products inecrease activty of drug. Management: ---- antbotc should not be taken wth diary products or calcum fortified foods alone or should be ingested atleast 2 hour before or after ciprofloxacn admnstraton . DRUG –FOOD INTERACTIONS

26. RECOMENDATIONS Propanolol not included in the discharge medication, a 20 mg three time a day is helpful for prevention from reoccurance variceal bleeding T.Lasix + spironolactone is more effective than T.Lasix alone combination Pantoprazole once daily is enough Monitor urinary potassium and sodium level Monitor LFT and RFT The most reliable manifestations of cirrhosis is determination of prothrombin time which is not done here. Notreatment given for anemia

27. PATIENT EDUCATION

28. Regarding Drugs Complete the course of anitbiotics Pantoprazole should be take half hour before food Do not take NSAIDs While using ursodeoxycholic acid , avoid diet containing excessive cholesterol and calories

29. Regarding life style modification Limit Sodium L imit your sodium intake. Sodium causes fluid retention, causing increased swelling in the legs and abdomen.  Limit Protein T oo much protein raises ammonia levels and can cause hepatic encephalopathy. This is a brain disorder caused by the buildup of toxins, which can lead to coma Eat plenty of vegetables and fruits Daily intake of egg white is recommended for correction of hypoalbunemia

30. Advice to the patient Seek emergency if u develops severe signs and symptoms of hyponatremia, such as nausea and vomiting, confusion, seizures, or lost consciousness Include leafy vegetables in ur diet