Download Gastro case 2 _ALD_ S_L v0_1

Gastroenterology Case 2: Drug use in and management of Alcoholic Liver Disease - Ian Coombes
A 48 year old (86kg) man Mr LD is admitted to the Gastroenterology ward.
PC: Massive abdominal distension, abdominal pain
HOPC: Increasing abdominal distension, pain and lethargy over the last week and a bit confused.
Frequent admissions in the last 12 months.
PMH: Alcoholic liver disease, Chronic renal impairment
Social History: Lives alone in sheltered accommodation, Alcohol abuse
Medications on Admission
 Omeprazole, po 20mg bd
 Lactulose, po 20mL tds prn
 Thiamine, po 100mg daily
 Vitamin K, IM 10mg daily
 Spironolactone, po 100mg daily
Allergies: NKA
Laboratory and Other Tests
On examination:
HR: 108 reg
BP: 130/70 mmHg
RR: 24/min Temp: 37.7C
Ascites+++, abdominal pain, inappropriate speech, lethargic, GCS = 12
Cool clammy peripheries
U&Es
Sodium
Potassium
Urea
Creatinine
Glucose
130 mmol/L
3.9 mmol/L
9.9 mmol/L
130 micro mol/L
4.3 mmol/L
(134 - 146 mmol/L)
(3.5 - 5.0 mmol/L)
(2 – 8.5 mmol/L)
(60 – 110 micro mol/L)
(4 – 7 mmol/L)
Haematology
Haemoglobin
White Cell Count
Platelets
INR
100g/L
16.7 x 109/L
256 x 109/L
1.9
(113 - 159 g/L)
(3.9 – 12.7 x 109/L)
(150 - 396 x 109/L)
(1 - 1.3)
Total protein
61 g/L
(60 – 80 g/L)
Albumin
23 g/L
(32 – 52 g/L)
Bilirubin
86 umol/L
(< 21 umol/L)
ALT
63 U/L
(< 45 U/L)
GGT
96 U/L
(< 60 U/L)
ALP
107 U/L
(< 110 U/L)
AST
143 U/L
(<40 U/L)
Diagnosis: Decompensated alcoholic liver disease with probable spontaneous bacterial peritonitis
LFT/Gastro
Plan: Meds:
 Ampicillin 1g iv tds and gentamicin iv 80mg bd
 Lactulose 30mL tds plus lactulose enemas prn
 diazepam reducing regimen as per protocol
 + other usual meds
Diagnostic ascitic tap with albumin cover
Fluid restriction 1.5L/day, low salt diet, daily weights
Blood cultures
1.
Which of the laboratory test are indicative of the presence of liver disease in this patient? Which of these tests
are used to assess disease severity? {Hint =Think of what the liver makes and metabolises}
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2. What are the common complications of chronic liver disease (seen in this patient + any others) and describe
briefly the main forms of treatment for each of the complications. Consider current therapy
Peritonitis: __________________________________________________________________________________
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Ascites:______________________________________________________________________________________
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Hepatic encephalopathy:________________________________________________________________________
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What are the potential problems associated with: (a)the current treatment of peritonitis – think of side effects
of the antibiotics being used.
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b) analgesic use in this patient?
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3)
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4 What are the pharmacokinetic and pharmacodynamic changes you need to consider in a patient like Mr LD?
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5
What are the potential problems with aminoglycoside use for peritonitis in this patient – what could be used?
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6
What are the potential problems with analgesic use in this patient? What could be used instead?