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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: 37.7C 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} ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 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: __________________________________________________________________________________ ____________________________________________________________________________________________ Ascites:______________________________________________________________________________________ ____________________________________________________________________________________________ Hepatic encephalopathy:________________________________________________________________________ ____________________________________________________________________________________________ What are the potential problems associated with: (a)the current treatment of peritonitis – think of side effects of the antibiotics being used. ____________________________________________________________________________________________ ____________________________________________________________________________________________( b) analgesic use in this patient? ____________________________________________________________________________________________ 3) ____________________________________________________________________________________________ 4 What are the pharmacokinetic and pharmacodynamic changes you need to consider in a patient like Mr LD? ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 5 What are the potential problems with aminoglycoside use for peritonitis in this patient – what could be used? ____________________________________________________________________________________________ ____________________________________________________________________________________________ 6 What are the potential problems with analgesic use in this patient? What could be used instead?