this case will help you managing the alcoholic hepatitis complicated with Hepatorenal syndrome

2. 41 Y/O male with h/o ETOH dependence (12
cans of 16oz beers at least daily) last drink 4
days ago
Pt's mother reports that he has had
drowsiness, paradoxic sleep patterns x 2
weeks
Transferred from Lutheran on 9/28 2/2 tonic-
clonic seizure

3. PMHx:
 with h/o ETOH dependence
Social Hx:
 (12 cans of 16oz beers at least daily)
 last drink 4 days ago
 CAGE cant be done 2nd to the mental status
 Jobless 2nd to ETOH
Surgical and previous admissions(hospital or
detoxification center Hx:
 None
Blood Tx:
 2 units PRBC at Lutheran Hosp.
ROS:
 Pt mental status Changed
Medication: None / NKDA

5.  no asterixis but has intention
 V/S tremors.
 HR: 90
 Chest/ CTA Bil.
 RR: 16
 CVS/ S1+S2+0
 SPO2: 95%
RA  Abd/ showed mild distention
 BP: 120/65
with mildly enlarged liver.
 Drowsy
 EXT/ 1+ pitting edema

6. Component 9/28/2007
WBC 12.0 (H)
RBC 2.96 (L)
Hemoglobin 9.3 (L)
Hematocrit 27.5 (L)
MCV 93
Platelet 57 (L)

7. Component 9/28/2007
Glucose 70
Sodium 132 (L)
Potassium 2.7 (C)
Chloride 103
Carbon Dioxide 22
BUN 4 (L)
Creatinine 0.80
Calcium 8.0 (L)
Phosphorus, Serum 3.1
Magnesium 1.9
Component 9/28/2007
Protein, Total 6.2
Albumin 1.7 (C)
Bilirubin, Direct 8.1 (H)
Bilirubin, Total 14.3 (H)
Alkaline Phosphatase 307 (H)
ALT (SGPT) 24
AST (SGOT) 111 (H)
Lipase 27

8. CT head: report states cortical atrophy, no
acute process.
Abd US : report liver demonstrates diffuse
echogenicity consistent with fatty
infiltration. GB normal. No definite stone.
Pancreas appears diffusely enlarged.
Consistent with pancreatitis.

9.  The pt admitted to a RMF
 Dx:
 ETOH withdrawal seizure
 Meningitis
 Hepatic encephalopathy
 ID consult
 GI consult
 No another episode of seizure
 Started on:
 Alcohol withdrawal protocol
 Multivitamins,
 Folate.
 Thiamin
 Meropenem & Vancomycin started

10.  ID
2 FFPs, Vit K. given

LP on him when his INR is less than 1.5

UA normal

Blood / urine C+S no growth for 4 days

No sputum Culture done

GI
 Hepatitis panel A, B, C which came back all negative.
 HIV negative.
 Pt continued to be agitated with decrease level of
alertness.
Transferred to a STEP DOWN UNIT
(HDU)

11. Component 10/1/2007
Tube # 1
Color Low: (Colorless) Colorless
Clarity Low: (Clear) Clear
Supernatant Low: (Colorless) Colorless
WBC /uL <1
RBC Direct /uL 127
Neutrophils % 69
Lymphocytes % 27
Monocytes % 4
Occult Blood Low: (Negative) Negative
Collection Date 1 10/01/07
Total Protein, CSF 15-45 mg/dL 37
Glucose, CSF 40-75 mg/dL 65
Culture no growth

12. http://depts.washington.edu/uwhep/calculations/childspugh.htm

13. http://depts.washington.edu/uwhep/calculations/childspugh.htm

14. http://www.mayoclinic.org/meld/mayomodel6.html

15. http://www.mayoclinic.org/meld/mayomodel6.html

19. GI
Liver parenchyma with incomplete portal-portal
bridging fibrosis, consistent with early cirrhosis,
extensive macrovesicular steatosis (70%), portal
and lobular neutrophils infiltration and Mallory
body formation,consistent with alcoholic hepatitis.

20. Discriminant function
= (4.6 X [PT- control]) + total bilirubin

21. Component 10/3/2007
Protein, Total 6.2-8.3 g/dL 5.8 (L)
Albumin 3.4-4.8 g/dL 1.8 (C)
Bilirubin, Direct 0.1-0.3 mg/dL 10.3 (H)
Bilirubin, Total 0.1-1.5 mg/dL 18.9 (C)
Alkaline Phosphatase 40-200 IU/L 233 (H)
ALT (SGPT) 7-40 IU/L 34
AST (SGOT) 7-40 IU/L 96 (H)
Prothrombin time 11.0-13.0 sec 18.2 (H)
INR 0.9-1.1 1.8 (H)
Magnesium 1.6-2.8 mg/dL 2.1
Phosphorus, Serum 2.5-4.8 mg/dL 3.6
= (4.6 X [PT- control]) + total bilirubin

22. GI
Prednisolone 40 mg “NG” QD started
A randomized trial of prednisolone in patients
with severe alcoholic hepatitis.
MJ Ramond, T Poynard, B Rueff, P Mathurin, C
Theodore, JC Chaput, and JP Benhamou NEJM
1992;326:507

23. Urine out put
240 cc/24hrs.

24. Component 10/04/2007
Color Low: YELLOW YELLOW
Appearance Low: CLEAR CLEAR
Glucose Low: MG/DL NEGATIVE
Bilirubin Low: NEGATIVE NEGATIVE
Ketones Low: MG/DL NEGATIVE
Spec Gravity 1.003-1.03 1.015
pH 5.0-8.0 8.0
Protein Low: MG/DL NEGATIVE
Urobilinogen, Urine 0.2-1.0 EU'S 0.2
Nitrite Low: NEGATIVE NEGATIVE
Blood Low: NEGATIVE NEGATIVE
Leukocyte Low: NEGATIVE NEGATIVE

25. Component 10/4/2007 Component 10/5/2007
BUN 3 (L) BUN 10
Creatinine 1.10 Creatinine 2.80 (H)

26.  While prepping patient for placement of TLC
for CVP the pt desaturate to SPO2 70%
 Started on 100% NRB. SPO2 83%
 Intubated emergently.
 Tube feeds were stopped
 No signs of aspiration “by anesthesiologist”
Transferred to MICU

29.  The pt is intubated .
 On protective ventilation strategy.
 GCS [E1 V1 M3] 5/15
 V/S
HR 88

RR with ventilator 14

BP 117/60

T 36.5 C


35.  GCS 5/15
 Chest/ Bil diffuse course crackles and
decreased air entry on the RT.
 CVS/ S1+S2+0
 Abd/distended with 5cm enlarged liver +
shifting dullness no mass .
 EXT/ 3+ pitting edema.
 Skin: diffused spider angiomas and palmer
erythema

37. Component 10/5/2007 10/5/2007
Temperature 37.0 37.0
Mode MV
NRM
FIO2 100
100
pH 7.101 (C) 7.289 (L)
PaCO2 70.4 (C) 40.5
PO2 56 (L) 134 (H)
CR %O2 SAT 72.5 (L) 99.2
Base Excess -8.7 (L) -6.7 (L)
A-a Gradeint 12 526
20.9 (L) 18.8 (L)
HCO3-
(Bicarbonate)

38. Component 10/6/2007
WBC 15.9 (H)
RBC 2.27 (L)
Hemoglobin 7.4 (L)
Hematocrit 23.4 (L)
RDW-CV 22.5 (H)
Platelet 124 (L)
Bands 10.0
Prothrombin time 18.6 (H)
INR 1.8 (H)
aPTT 37 (H)

39. Component 10/6/2007
Glucose 82
Sodium 146
Potassium 4.4
Chloride 121 (H)
Carbon Dioxide 20 (L)
BUN 24 (H)
Creatinine 3.80 (H)
Calcium 8.7
Magnesium 2.2
Phosphorus 6.3 (H)
Protein, Total 5.7 (L)
Albumin 1.8 (C)
Bilirubin, Direct 10.5 (H)
Bilirubin, Total 18.0 (H)
Alkaline Phosphatase 179
ALT (SGPT) 23
AST (SGOT) 93 (H)
Ammonia 109 (H)

40. • Urine
• Blood
• Tracheal aspiration
Shows no growth for the 2nd time
after 4 days

41. http://www.mayoclinic.org/meld/mayomodel6.html

42.  CNS/ no sedation “on Ativan® withdrawal protocol / GCS 5/15
 Resp/ on protective ventilation / DVT prophylaxis / PPI / daily CXR / US guided
aspiration ordered
 CVS/ stable no vasopressors / 12 leads EKG N / 2D Echo
 Renal/ anuric / IVF started 100cc/hr. FeNa 0.7% / Urine Na 12 / Cr 3.8 / BUN 24
 ID/ T 36.5 / CXR / WBC 15.9 / C+S no growth / UA / no wounds / Lines and tubes
/ Meropenem + Vancomycin for “CrCl 30”
 GI/ NPO / Lactulose cont. / Rifaximin started / prednisolone cont. / SOBT –ve /
ascitic tap / TPN started
 Hem/ Low H&H 2U PRBC / FFP given the ascitic tap
 Endo/ On prednisolone for 5 days. Blood sugar controlled with Insulin SS.

44. DDx ?:
Acute alcoholic hepatitis
Respiratory failure
Acute renal failure
Change in mental status

45.  GCS: [E4 V1 M3] 8/15
 Chest/ Bil mild crackles and good air entry .
 CVS/ S1+S2+ friction rub
 Abd/distended with 5cm enlarged liver +
shifting dullness no mass .
 EXT/ 4+ pitting edema.
 Skin: diffused spider angiomas and palmer
erythema

46. Normal

47. Component 10/7/2007
Glucose 126 (H)
Sodium 147
Potassium 5.1 (H)
Chloride 126 (H) Component 10/7/2007
Carbon Dioxide 18 (L) WBC 17.3 (H)
BUN 64 (C) RBC 2.74 (L)
Creatinine 5.50 (H) Hemoglobin 9.0 (L)
Calcium 8.9 Hematocrit 28.4 (L)
Platelet 204
Prothrombin time 17.7 (H)
INR 1.7 (H)
Magnesium 2.7
Phosphorus 8.2 (H)
aPTT 35 (H)

49. Component 10/6/2007
Fluid Type Ascites
Color Low: (Colorless) Yellow
Clarity Low: (Clear) Clear
WBC /uL 29
RBC Direct /uL 250
Neutrophils % 25
Lymphocytes % 25
Mono/Macrophage % 5
Fluid Comment Ascites
Albumin, Body Fluid g/dL 0.8
Glucose, Fluid mg/dL 114
Total Protein g/dL <2.0

50. No episodes of hypotension
No signs of bacterial infection
UA and Urine electrolytes
FeNa 0.7%
Urine Na 12
No Proteinuria
No casts
U/S no obstruction or hydronephrosis no
signs of parenchymal renal disease

52. Hepatorenal Syndrome
 Type 1:
been arbitrarily set as a 100% increase in serum

Creatinine reaching a value greater than (2·5 mg/dL) in
less than 2 weeks.
 Type 2
Hepatorenal Syndrome Lancet. 2003;
362(9398):1819-27 (ISSN: 1474-547X)
Ginès P ; Guevara M ; Arroyo V ; Rodés J

53. Hepatorenal Syndrome
Precipitating factors:
1. Bacterial infection “SBP 20%”
2. Large volume paracentesis without plasma expansion
“5L or more 15%”
3. GI bleeding 10%
Hepatorenal Syndrome Lancet. 2003;
362(9398):1819-27 (ISSN: 1474-547X)
Ginès P ; Guevara M ; Arroyo V ; Rodés J

54. Hepatorenal Syndrome
 Prognosis:
 Type1 Vs Type2
 Child -Pugh classification
Hepatorenal Syndrome Lancet. 2003;
362(9398):1819-27 (ISSN: 1474-547X)
Ginès P ; Guevara M ; Arroyo V ; Rodés J

55. Hepatorenal Syndrome
H&P
Blood & urine chem.
U/S
Hepatorenal Syndrome Lancet. 2003;
362(9398):1819-27 (ISSN: 1474-547X)
Ginès P ; Guevara M ; Arroyo V ; Rodés J

56. Cirrhosis
Liver
transplantation
Portal Hypertension
TIPS
Splanchnic vasodilatation
Vasoconstrictors
Severe arterial underfilling
Stimulation of
vasoconstrictor system
Renal vasoconstriction
RRT
Hepatorenal Syndrome Lancet. 2003;
362(9398):1819-27 (ISSN: 1474-547X)
Ginès P ; Guevara M ; Arroyo V ; Rodés J
Hepatorenal Syndrome

57. Hepatorenal Syndrome Lancet. 2003;
362(9398):1819-27 (ISSN: 1474-547X)
Ginès P ; Guevara M ; Arroyo V ; Rodés J
Reversal of Type 1 Hepatorenal Syndrome With
the Administration
of Midodrine and Octreotide
HEPATOLOGY 1999;29:1690-1697.
PAOLO ANGELI,1 ROBERTA VOLPIN,1 GIORGIO GERUNDA,2
RAFFAELLA CRAIGHERO,1 PAOLA RONER,1 ROBERTO MERENDA,2
PIERO AMODIO,1 ANTONIETTA STICCA,1 LORENZA CAREGARO,1
ALVISE MAFFEI-FACCIOLI,2 AND ANGELO GATTA1

58. Midodrine & Octreotide
Reversal of Type 1 Hepatorenal Syndrome With
the Administration
of Midodrine and Octreotide
HEPATOLOGY 1999;29:1690-1697.
PAOLO ANGELI,1 ROBERTA VOLPIN,1 GIORGIO GERUNDA,2
RAFFAELLA CRAIGHERO,1 PAOLA RONER,1 ROBERTO MERENDA,2
PIERO AMODIO,1 ANTONIETTA STICCA,1 LORENZA CAREGARO,1
ALVISE MAFFEI-FACCIOLI,2 AND ANGELO GATTA1

59. Noradrenalin and Albumin
Effects of Noradrenalin and Albumin in Patients With
Type I Hepatorenal Syndrome: A Pilot Study HEPATOLOGY 2002;36:374-380.
Christophe Duvoux,1 David Zanditenas,1 Christophe H´ezode,1 Anthony Chauvat,2 Jean-
Luc Monin,2
Franc¸oise Roudot-Thoraval,3 Ariane Mallat,1 and Daniel Dhumeaux1

60. Hepatorenal Syndrome
Nephrology assessment and plan:
 Midodrine 12.5mg P.O. TID
 Octreotide. + 200 microgram SQ TID
 Albumin was given only with paracentesis

61. Component 10/25/2007
Glucose 112 (H)
Sodium 137
Potassium 4.2
Chloride 103
Carbon Dioxide 23
BUN 40 (H)
Creatinine 2.40 (H)
Calcium 7.8 (L)
Magnesium 2.2
Phosphorus, Serum 5.1 (H)
Component 10/25/2007
WBC 12.0 (H)
RBC 2.15 (L)
Hemoglobin 7.0 (L)
Hematocrit 20.6 (L)
Platelet 125 (L)

64.  Staging of alcoholism.
 Child-Pugh classification.
 MELD score.
 Discriminant function.
 Hepatorenal syndrome:
Types.

Precipitating factors.

Diagnosis.

Differential diagnosis.

Prognosis.

Treatment.
