Group A

Jowharah Khalifa Al-Mulhim

262040002
Case
A 45 years old male visits emergency department of
hospital complaining of malaise anorexia, pruritus,
fatigue, loss of libido, passage of dark urine, and pale
stool. Sometimes he vomits blood and his stool also
contain blood. He reports that his sypmtoms are
gradually worsening over few months.
On examination he is found pale, jaundiced, abit
confused and drowsy. His abdomen is distended, with
shifting dullness indicative of ascites. Liver and spleen
are palpable 3 & 4 fingers below the costal margin.
Spider naevi, liver palms, coarse flapping tremors,
ankle edema, swelling of the breast and testicular
atrophy are also noticed.
Lab investigations revealed hypochromic microcytic
anaemia (Hb = 8 gm/dl), low serum albumen, High
serum bilirubin and moderately raised liver enzymes (
tbil = 5.8 mg/dl, dBil = 3.6 mg/dl, sGOT= 140 IU/dl,
sGPT = 80 IU/dl, LDH = 350 IU/ dl)
CT scan shows a hepatosplenomegaly, and
enlargement of collateral vessels beneath the
anterior abdominal wall, endoscopy shows
esophageal and rectal varices as well as portal
hypertensive gastropathy.
Liver Biopsy suggest cirrhosis with nodules of
liver tissue of varying size surrounded by fibrosis.

Dx: chronic liver cirrhosis with portal hypertension

Problem list
Impaired liver function
Confusion and drowsiness –hepatic
encephalopathy-
Ascites
Portal hypertension and portosystemic shunting:
Actively bleeding esophageal varices
Splenomegaly
Caput medusa
Hemorrhoids.
Microcytic hypochromic anaemia.
Pathophysiology
Damage to the hepatic parenchyma leads to
activation of the stellate cell, which becomes
contractile and obstructs blood flow in the
circulation. In addition, it secretes TGF-β1, which
leads to a fibrotic response and proliferation of
connective tissue. Furthermore, it disturbs the
balance between matrix metalloproteinases and
the naturally occurring inhibitors (TIMP 1 and 2),
leading to matrix breakdown and replacement by
connective tissue-secreted matrix.
Pathophysiology (Continue…)

The fibrous tissue forms nodes, which

eventually replace the entire liver
architecture, leading to decreased blood
flow throughout. The spleen becomes
congested, which leads to hypersplenism
and increased sequestration of platelets.
Portal hypertension is responsible for most
severe complications of cirrhosis.
Therapeutic objectives
Stabilize patient and treat encephalopathy
Treatment of ascites and portal hypertension.
Correct anaemia
Follow up
instructions
treatment of encephalopathy
Flumazinel ( to antagonize the endogenous
benzodiazepins)
 Laxative

Total Cost Suitabilit Safety Efficacy Drug

y

12 ++++ ++++ +++ +++ Lactulose

13 +++ ++++ ++++ ++++ Lactulol

Portal Hypertension
Treatment of Variceal Hemorrhage:
1- Resuscitation(2 large bore IV canulas for fluid
replacement)
2- Urgent endoscopy (banding, injection
sclerotherapy)
3- Pharmacological therapy:
 Treatment of Variceal Hemorrhage

Efficacy Safety Suitability Cost Total

Octreotide ++++ +++ ++++ +++ 14

Vasopressin +++ + +++ ++++ 11

Prophylaxis of rebleeding

Group Efficacy Safety Suitability Cost Total

Selective β1 antagonist + +++ + +++ 8

Non-Selective β antagonist ++++ ++ +++ ++++ 13

Selective B1 antagonist work only on the heart

Non-selectives work on heart and peripheral vessels to
reduce CO and the venous return.
 Non-Selective β antagonist

Drug Efficacy Safety Suitability Cost Total

Propranolo
++++ ++ +++ ++++ 13
l
Nadolol ++++ ++++ ++++ +++ 15

Acts by:
Reducing portal and collateral blood flow along with reduction in cardiac output.
Splanchnic vasodilation occurs.
 Propranolol is given twice daily
 Nadolol is lipid soluble and given once daily(20 mg po)
Treatment of ascites
Salt restriction
Diuretics:

Drug Efficacy Safety Suitability Cost Total

Loop diuretics ++++ + + +++ 10
(furosemide)
Thiazides ++ +++ + ++++ 11
K-sparing ++++ +++ ++++ +++ 14
(spironolactone
)
Osmotic ++ ++ + +++ 8
Diuretics
Treatment of ascites
Drug Efficacy Safety Suitability Cost Total
Spironolactone ++++ +++ +++ ++++ 14
Triamterene ++ + ++ + 6
Amiloride ++ +++ +++ + 9
Correction of anemia
Folic acid supplement

Iron supplement
Prescription
 Name: sex: male age: 45
 File number: date: / /

 Diagnosis: liver cirrhosis with Ascites

 Rx:

 Octeotride 50 microgram I.V bolus followed by Octeotride 50 microgram/h infusion for 5 days

 Spironolactone PO 100 mg OD +frusamide 40 mg PO OD.

 .
 Lactilol powder PO 0.5 gm/kg stat

 Nadolol tab. 20 mg PO OD

 Flumazenil: IV infusion of 2mg over 10min

 Folic acid tab. 5mg PO OD for 3 months

 Ferrous sulphate tab. 190mg PO OD for 3 months

Dr.name :
DR sig :
Instruction & follow up
Educate the Pt. about the diease and compilcations.
Avoid risk factor ( alcohol , viral hepatitis , unprotect
sex )
 LFT, ultrasound, CBC
follow up
Thank You