Case 2 (7.5 pts)
R. S., a 55-year-old man, has been admitted to the hospital for treatment of acute gastrointestinal bleed. He is well known to the medical community for his chronic alcohol abuse and encephalopathy.
Past History: R. S. has been hospitalized four times in the past 24 months; most recently he was discharged 12 weeks ago for treatment of upper gastrointestinal bleeding. He has a 40-year history of smoking and drinks an unknown quantity of liquor daily. On previous admissions he has been treated for pancreatitis, alcohol withdrawal seizures, cirrhosis and associated ascites, coagulopathy, esophageal varices, anemia, gastrointestinal bleed, and gastritis.
Current Status: His current problems include hepatic encephalopathy, gastrointestinal bleed, coagulopathy, jaundice, history of tuberculosis (age 15 with treatment), and hypoxia; all present were on previous admission. Medications at last discharge included spironolactone (25 mg twice a day), ranitidine (150 mg twice a day), antacid (Maalox), and multivitamins.
R. S. was found unconscious in a pool of blood and vomitus. He was taken to the hospital and admitted to the medical intensive care unit. Initial vital signs were as follows: blood pressure 90/60, heart rate 112, and respirations 12. Intravenous infusion with normal saline was begun through a central line; oxygen was started at 3 L by nasal cannula. Physical examination revealed icteric sclera, clear lungs, grade Ill/TV systolic ejection murmur, and abdomen soft and without masses, liver percussed at 12 cm below the costal margin, and skin markedly jaundiced. Deep tendon reflexes were brisk and equal bilaterally.
Lab tests revealed the following: sodium 137 mEq/L, potassium 4.8 mEq/L, chloride 102 mEq/L, carbon dioxide 23 mEq/L, blood urea nitrogen 132 mg/dl, creatinine 1.3 mg/dl, glucose 115 mg/dl, hematocrit 27.7%, hemoglobin 9.3 g, white blood cell count 17,800 mm3, platelets 259,000 mm3, direct bilirubin 7.8 mg/dl, total bilirubin 16.4 mg/dl, amylase 42 somogyi units/dl, alkaline phosphatase 127 mu/dl, ammonia level 200 mg. Blood gases were as follows: Po.2 85 mm Hg, PCO2 30 mm Hg, pH 7.35, prothrombin time (PT) patient 17 sec., prothrombin time (PT) control 12.3 sec., partial prothrombin time (PIT) 46/36 sec.
Treatment with blood replacement was initiated; it included transfusion of 6 units fresh frozen plasma and 5 units packed red blood cells, with antacids, ranitidine, vitamin K, thiamine, and lactulose by nasogastric tube.
On the following day R. S.’s mental status was improved and his laboratory studies were as follows: sodium 133 mEq/L. potassium 3.5 mEq/L, chloride 105 mEq/L, blood urea nitrogen 15 mg/dl, creatinine 0.7 mg/dl, glucose 114 mg/dl, hematocrit 38.7%, white blood cell count 5200 mm3, PT 15.7/12 sec., ammonia 93 mg, alkaline phosphatase 92 m/dl. Vital signs were as follows: blood pressure 116/72, heart rate 72, respirations 15, afebrile.
On day 2 he was oriented X3 and was transferred from the intensive care unit. During the course of his hospitalization his total bilirubin ranged from 16.4 mg/dl down to 10.7 mg/dl at discharge.
What is the physiological benefit of having a hepatic portal system?
Does R.S have elevated bilirubin? If yes, does the portion of the total bilirubin that is direct indicate pre hepatic, post hepatic or an intrahepatic problem?
What is ascites? How do hypoalbuminemia and increased serum aldosterone levels contribute to the development of ascites?
Explain the cause of the patients’ clotting defects.
The sclera of R. S.’s eyes are icteric and his skin yellowed. What is the cause of
these discolorations, and what do they indicate about his pathophysiology?
Explain why esophageal varices are the leading cause of death in patients with cirrhosis
