Case Presentation BY

Dr/ Mohamed Moustafa

CASE FOLLOW UP

PERSONAL DATA:

• R.M is 40 years Male admitted to

Inpatient department of National

Hepatology Institute on 15/1/2014.

CHIEF COMPLAINTs :

• Increase in abdominal girth.

• Tense Ascites.

• Vomiting.

SOCIAL HABITS :

• No social habits.

PAST MEDICAL HISTORY:

• Known HCV Patient.

• Ascites .

• Jaundice for last 20 days..

• SBP since 9/2013 and he was on treatment.

• Oesopheagel Varices Grade ǀǀǀ & Made two

sessions of Band Ligation on 9/2013 –

11/2013 .

• Not Diabetic & Not HTN.

PAST MEDICATION :

Noracin 400 mg Tab. Once daily.

THERAPUTIC PLAN:

AUS.

SBP Investigation

(DiagnosticParacentesis).

Lab. Investigations .

Therapeutic paracentesis of 6 Litre

Ascetic Fluid Plus supplementry

Albumin (2 bottles) .(16/1/2014) ???

Culture/Other investigations:

U/S Shows

• Coarse Liver.

• Portal Hypertension.

• Marked Ascites.

• Splenomegaly.

• CBC

• Mild Microcytic Anemia.

• Thrombocytopenia.

Laboratory Results .

References 15/1 TEST/DATE

(0 – 35 ) 86 ALT

(0 – 35 ) 336 AST

(0.0 - 1 mg/dl) 10.27 TB

(0.0 – 0.25 mg/dl) 5.52 DB

( 3.5 – 5.2 g/dl ) 2.5 ALB.

( 30 – 120 U/L) 55 ALP

( 0 – 30 iu/l ) 49.2 GGT

2.56 INR

( 70 – 110 mg /dl) 76 GLUCOSE

Laboratory Results .

References 15/1 TEST/DATE

( 0.5 – 1.1) 2 CR

( 10 – 50 mg/dl ) 75 UREA

( 2.6 – 5.7 mg/dl) 10.1 URIC ACID

(135-145meq/l)

129.8 Na

(3.5-5 meq/l)

4.2 K

( 4 – 11 x10*3 ) 9.1 WBCs

( 11 – 18 g/dl ) 10.1 HB

5600 TLC (AS)

< 250 cells/mm*3

2756 (AS) PMN

FINAL DIGNOSIS:

• Ascites.

• SBP.

• Child pugh score is (11) & class

C chronic liver disease.

Management of SBP Diagnosis:

• Diagnostic paracentesis if there are

symptoms ( abdominal pain , fever >37.8, chills,

Change in mental status).

• SBP if PMN > 250 cells /mm3.

General management:

• Avoid therapeutic paratnentesis during active

infection .

• IV Albumin 1.5 - 1 gm/kg if BUN > 30 mg/dl ,

cr.>1 mg/dl , T.BIL > 4 mg/ dl.

• Avoid aminoglycosides. 9

1-cefotaxime 2gm every 8 hours (now

changed to 2gm every 12 h).

• 2-ceftriaxone 2 gm every 24 hours.

• 3-ciprofloxacin iv 400 mg every 12

hours.

• 4-Tazosin 4.5 gm every 6 hours.

• 5-meropenam 1gm every 8 hours.(USED

IN CASE OF CEFOTAXIME

RESISTANCE).

Treatment

FOLLOW UP

• -all these antibiotics taken for 5 days.

And may be taken up to 10 days according

to patient condition.

• Repeat diagnostic paracentesis at day 3

If ascitic PMN count decrease by

at least 25 %

• Continue till 5 days.

Prophylaxis :

Norfloxacin 400 mg once daily for life time.

11

• Alternative antibiotics ( Prophylaxis)

include

ciprofloxacin (750 mg once weekly, orally)

or

co-trimoxazole (800 mg sulfamethoxazole

and 160 mg trimethoprim daily, orally),

CURRENT MEDICATIONS:

Current Medications:

DAYS Freque

ncy Drug/Dose

19/1 18/1 17/1 16/1 15/1

√

√

√

√

√ TID Silymarin tab

√

√

√

√

√

TID Ursofalk Cap.

√ √ √ √

√

OD Risek Tab.

√

√

√ √

√

TID Gast Reg tab.

√

√

√

√

√

Q 12hr Claforan 2g IV

√

√

√

√

√ OD Lasix 40 mg

Tab

DC

√

OD

Aldactone

Tab.

Erosive

esophagitis &

Gastritis

Current Medications:

Freq

Drug/Dose 19/1 18/1 17/1 16/1 15/1

√

√

√

√

√ BID Denstin

DC √

0.5 BID Inderal tab.

DC Q 24hr Cefotriaxone2 g

IV

√ √

√

√

√

BID Albumin Vial

√

√

TID

Acetyl Cysteine

√

√

√

√

√ 2 /TID Gastro biotic cap

√

√

TID Lactulose Syrup

√

√

TID Lactulose Enema

PRN Perfelgan Vial

√

√

√

√

√

BID Ringer IV

Variceal hemorrhage

prophylaxis

Drugs Auditing summary:

1-Drug-Indication matching.

2-Untreated Conditions.

3- Improper drug selection.

4-Drug – Drug interactions.

5-Drug Metabolism / Elimination analysis.

6 -Drug adverse effect monitoring.

7-Drug dosing monitoring

(overdose &subtherapeutic dose).

8-Drug – lab. Results monitoring.

Drugs Auditing summary (cont.):

9- Failure to receive medications

(due to Economic , Psychological , Sociological or Pharmaceutical reasons).

10- Treatment Failure.

1-Drug-Indication matching.

A -There is no significant role of ACETYL

CYSTEINE (No added benefit) .

Recommendations:

• Acetyl cysteine should be stopped .

B –There is no significant role of

CEFTRIAXONE 2g/24 hr. for SBP Treatment

Patient is already taking CEFOTAXIME 2g /

12 hr.

Recommendations:

• CEFTRIAXONE must be stopped.

C – No significant role of Anti coma

measure as Pt. is fully conscious.

Recommendations:

• Stop anti coma measure

2-untreated conditions. A - INR = 2.56

Recommendations:

• Vit K (phytonadione 2.5 – 10 mg PO )

should be added to medication.

B – Hyponatremia ( Na = 129 mg/dl)

Recommendations:

• Fluid restriction (1000 – 1200 ml ).

C- Anemia ( Hb = 10 )

Recommendations:

• Ferrous sulphate + vit C (On discharge).

D – Hyperuricemia ( UA = 10.1 mg/dl).

Recommendations:

• Allopurinol tab. (200-300 mg/day on

divided doses ) (On discharge).

3- Drug Dosing Monitoring

( Subtherapeutic dose )

A – Albumin

Renal failure develops in 30 to 40 percent of

patients with SBP and is a major cause of

death .The risk may be decreased with an

infusion of intravenous Albumin (1.5 g / kg

body wt. within six hours of diagnosis and

1.0 g/kg body wt. on day three) .Albumin

infusion should be given if the

Creatinine is >1 mg/dL ,

BUN is >30 mg/dL or

Total bilirubin is >4 mg/dl.

4- Drug Metabolism/Elimination

Analysis

A- Inderal (propranalol).

Recommendations:

Renal Impairment

• Cr.Cl = 36.9 ml/min. (Jelliffe )

• No dosage adjustment provided in

manufacturer’s labeling. However, renal

impairment increases systemic exposure

to propranolol. Use with caution.

• Propranalol should be continued as

prophylactic of (OV) & Portal HTN.

B-Aldactone (spironolactone).

Recommendations:

Aldactone should be continued.

Renal Impairment

(Dose Adjustment )

• Pt. Cr.Cl = 36.9 ml/min. (Jelliffe )

Cr CL=30-49 mL/minute.

• Initial dose: 12.5 mg once daily or every

other day.

• Maintenance dose (after 4 weeks of

treatment with potassium ≤5 mEq/L):

12.5 - 25 mg once daily.

5 – Medical Error

Therapeutic paracentesis of 6 Litre

Ascetic Fluid (16/1).

Paracentesis is contraindicated

during acive infection.

BUT

In tense ascites may be applied.

Patient Councelling:

• Following a low-salt (also called “low-sodium”)

diet – This can help reduce the amount of

ascitic fluid.

• Taking a medicine called a “diuretic” –

Diuretics make people urinate much more than

usual.

• Taking Non-selective BB (Propranolol) as

prophylactic for (OV) If he has.

• Avoiding medicines such as “NSAIDs” that can

harm the liver & fluid accumulation and edema.

– NSAIDs include (aspirin, ibuprofen and

naproxen).

• Drugs that decrease arterial pressure or

renal blood flow such as ACE-inhibitors,

ARB , or α1-adrenergic receptor blockers

should generally not be used in patients

with ascites because of increased risk of

renal impairment.

• Checking your weight every day – Following

your weight will help your doctor monitor

your condition.

• Stopping your alcohol use (if you drink

alcohol).

REFRENCES:

• Medscape Web Site.

• LEXI COMP WEB SITE .