Death Meet M1

HOU – Dr.Ratnakar Sahoo

HOD and Moderator – Dr.MPS.Chawla and Dr.Ramesh
10/11/22
Case Details
• Name : Mr.R
• Age/Sex : 28 years/Male
• Address : New Moti Nagar, New Delhi
• DOA : 20/1/22
• DOE : 28/1/22
• Duration of stay : 8 days
• Final Diagnosis : Alcohol related Acute on Chronic Liver Failure (CTP Score
14) with Ascites-III with Hepatic Encephalopathy – III with Spontaneous
Bacterial Peritonitis with Coagulopathy with Moderate Anemia with Portal
Hypertension with Acute Kidney Injury / Sepsis with Septic Shock
Presentation
• 28/M, chronic alcoholic for 10 years, K/C/O alcoholic CLD diagnosed 1
month back, presented to ME-4 with :
1. C/O yellowish discolouration of sclera and urine * 1 year
2. C/O abdominal distention * 6 months
3. C/O altered sleep wake cycle * 1 month

O/E – Drowsy but arousable, oriented to TPP.

Pallor, Icterus, Pedal Edema, Asterixis present.
No Cyanosis, Lymphadenopathy.
BP = 94/60 mmHg, PR = 80/mt, spo2 = 95% RA, GCS = E3, V5, M6
• On S/E :
P/A : Distended, flanks full. Fluid thrill +. Splenomegaly +.
CNS : Plantar : Flexor B/L, B/L pupils reactive to light.
CVS : S1,S2+.M-.
RS : Bilateral air entry+. Mild basal crypts.
HOPI
• Patient was apparently normal 1 yr ago, following which he developed gradual
yellowing of sclera and urine.
• Patient then developed abdominal distention – generalised, gradually increased over
time * 6 months, and bilateral lower limb swelling * 6 months.
• For past 1 month, patient is having altered sleep cycle with day time sleepiness.
• 15 days age patient had 2 episodes of passing black, foul smelling, tarry stool. Similar
episode 4 days ago.
• C/O cough * 4 days present.
• No history of reduced urine output, dizziness, chest pain, palpitations.
• No history of vomiting blood, frank blood in stool, constipation.
• No history of abdominal pain.
Past History
• Known case of alcohol related CLD diagnosed 1 month ago.
(documents NA)
• Patient gives history of admission at PGI Chandigarh 15 days back for
UGI bleed, managed conservatively. Endoscopy not done. (Documents
NA).
Personal History
• Chronic alcoholic : 750ml/day country liquor * 10 years.
• Last intake alcohol 3 months ago
Treatment Given
• Inj Cefotaxime 2g IV TDS
• Inj.Pantoprazole 40mg BD
• Inj.Ondansetron 4mg IV SOS
• Inj.Thiamine 100mg IV BD
• T.Rifaximin 550mg BD
• Inj.Vit K 1 amp IV OD 3 days
• Syp. Lactulose 30ml TDS
• 3 PRBC
• 8 FFP
• Inj. Meropenem 1g IV BD
• Inj. Metrogyl 100ml IV TDS
• Inj. Noradrenaline
Course in Hospital – 20/1 to 21/1 (D1-D2)
• Patient provisionally diagnosed in ME4 as alcohol related DCLD. Routines, ascitic tap,
ECG and CXR were done. Poor prognosis of patient explained to attenders in written.
• Routines suggestive of Moderate Anemia and sepsis (Hb=8.1, TLC = 20500), AKI and
deranged LFTs.(U/Cr = 103/2.3 and TB/DB = 27.3/14.5). Ascitic tap s/o SBP (Total
Count 1000/uL of which 90%P) for which antibiotic Inj.Cefotaxime started. T.Rifaximin
and lactulose syrup for HE, Inj Vit K and 4 FFP for coagulopathy (outside INR = 6.46),
and Inj.Pantoprazole, Inj.Ondansetron and Inj.Thiamine given. 1PRBC transfused.
• ECG, CXR were within normal limits.
• Em USG done : CLD with portal HTN (20cm enlarged liver with altered echotexture
and 14.5cm enlarged spleen.)
• Patient started on Inj NA IVO shock (BP = 90/50) and Inj Human Albumin 20g IV OD.
(IVO hypoalbuminemia ; Alb = 1.6)
22/1 (D3)
• Issues – Sepsis with septic shock / AKI / HE-2 / Coagulopathy / Anemia / TCP

• Patient continued to remain in shock and dose of Norad drip increased.

• Nephrology opinion taken IVO AKI.
• 1 PRBC transfused IVO anemia. (Hb drop from 8.1 to 7.3)
• Blood and urine cultures were sent
• Pt developed fresh issue of TCP
• Other supportive management continued as yesterday
• Poor Prognosis explained to attenders.
23/1 (D4)
• Issues – Sepsis with septic shock / AKI / HE-3 / Coagulopathy / Anemia

• Supportive measures continued.

• Patient continued to need inotrope support to maintain BP 90/60,
failed to taper dose. AKI in worsening trend. (Cr = 2.3 > 3.1 now).
Repeat INR improved 2.17. Sensorium worsened to HE-3.
• NCCT head done ivo altered sensorium : NAD. 2D Echo done : Normal
EF, NAD.
24/1 (D5)
• Issues – Sepsis with septic shock / AKI / HE-3 / Coagulopathy / Anemia
• Supportive measures continued. Decrease in total counts(20000 to 17000). Improvement in
AKI. (Cr= 3.1 to 1.9). Hb built up to 9.6 after 1 PRBC Transfusion. Antibiotics were upgraded to
Meropenem.

25/1 (D6)
Same issues, supportive measures continued.
Clincially no improvement. Continued needing inotrope support to
maintain BP. 4 FFP Transfused.
Some improvement in AKI. (Cr=1.7 to 1.5). Other lab parameters
same.
26/1 (D7)
• Issues – Sepsis with septic shock / AKI / HE-3 / Coagulopathy / Anemia / TCP
• Supportive measures continued. Patient developed TCP. (PLT = 60,000)

27/1 (D8)
Same issues, supportive measures continued.
Worsening of AKI. (2.0 to 2.4)
28/1 (D9)
• ICU calls were sent IVO sick status of patient. Patient went into cardiac
arrest at 11AM. CPR started, intubated and adrenaline 3 doses given,
but failed to revive. Was declared dead at 11:30 AM 28/1/22.
 Investigations
20/1 21/1 22/1 24/1 25/1 26/1 27/1
Hb 8.1 7.3 8.3 9.6 9.0 8.1 9.6
TLC 20500 17000 18000 17000 17000 14000 16000
(84/10) (79/18) (78/10) (91/6) (85/10) (87/10) (79/17)

PLT 1L 50,000 80,000 1.1L 1.2L 60,000 60,000

Na/K 126/4.9 129/5.15 137/4.7 134/4.5 140/4.0 130/4.0 131/4.5
KFT 103/2.3 107/2.5 105/3.1 70/1.9 76/1.7 86/2.0 102/2.4
LFT 27.3/14.5 30.6/14.0 35.5/15.7 34.7/15.6 33.4/16.0
OT/PT 57/19 47/22 51/28 51/23 43/22 42/23 65/26
• Ascitic Cyto = 1000 cells, 90% Polymorphs
• Ascitic Bio = 141mg/dl, MPR = 0.8.
• SAAG = 1.5
• Ascitic ADA = 2.670

• INR = 6.7 (20/1), 2.67 (21/1), 2.21 (24/1), 2.80 (25/1)

• Sr.Procal : >10mg/ml
• Iron Profile : Iron = 99, TIBC = 107, Sat = 92.5%,
• Cardiac Profile : CK = 55, CKMB = 12,
• Amylase / Lipase : 32/90
• ABG = s/o R.Alkalosis
• Tridot : Negative
• Final Diagnosis : Alcohol related Acute on Chronic Liver Failure (CTP
Score = 14) with Ascites-III with Hepatic Encephalopathy – III with
Spontaneous Bacterial Peritonitis with Coagulopathy with Moderate
Anemia with Portal Hypertension with Acute Kidney Injury / Sepsis
with Septic Shock
• COD : Sepsis with Septic Shock / Hepatic Encephalopathy - III
ECG (20/1)
 IMP: CLD with portal
USG Whole Abdomen (20/1) HTN
ICU Call (20/1)
Nephro Call (21/1)
NCCT Head (23/1) IMP: Normal
3 PRBC transfused (21/1, 22/1 and 26/1)
8 FFP transfused(4 on 21/1 and 25/1 each)
Learning Points
• Alcoholic CLD has very high morbidity and mortality
• Primary level of prevention through educating masses, especially the
youth, about dangers of alcohol consumption is the most effective
approach to dealing with this problem
• Inter departmental coordination between Gastroenterology,
Hepatology, Medicine and Psychiatry is essential for management of
these patients
Thank You