Bimonthly assessment- october

https://swathibogari158.blogspot.com/2020/09/chronic-decompensated-liver-disease.html

1.Cause of ascites
Cirrhosis with Portal hypertension
The accumulation of ascitic fluid represents a state of total-body sodium and water excess
Hypoalbuminemia and reduced plasma oncotic pressure favor the extravasation of fluid from the plasma to the peritoneal fluid.

2. The relationship between cellulitis and lymphoedema appears to be
a vicious cycle; a pre-existing lymphatic
defect predisposes to cellulitis, episodes
of cellulitis damage the lymphatic system.
 
lymphoedema predispose to recurrent
episodes of cellulitis.

Repeated episodes of cellulitis are common with lymphedema. 

Cellulitis is a bacterial infection of the deeper layers of skin and the fat and soft tissue layers under the skin.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2804019/

3. https://jnnp.bmj.com/content/63/3/279

Asterixis or “liver flap” and constructional apraxia are often present in the early stages of hepatic encephalopathy.
Asterixis consists of infrequent involuntary flexion-extension movements of the hand (one flap every one to two seconds), which may result in part from an impairment of the normal inflow of joint position sense to the brain stem reticular formation.

https://pmj.bmj.com/content/87/1031/605

Increased ammonialevels leads to lactate accumulation in the brain ➡️ microglial activation ➡️ increased levels of pro inflammatory cytokines and neuroinflammation ➡️ encephalopathy. 

Lactose syrup reduces the intestinal absorption of ammonia . It reduces the ph of colonic content and prevents absorption of ammonia 

https://images.app.goo.gl/FuVddJ18AssTr49P9

4.Rifaximin

https://www.researchgate.net/publication/327934281_Rifaximin_has_the_potential_to_prevent_complications_of_cirrhosis

 Of patients receiving rifaximin (n = 140) and placebo (n = 159), 53.6% and 49.1%, respectively, had baseline Model for End-Stage Liver Disease (MELD) score ⩾ 12 and international normalized ratio (INR) ⩾ 1.2. Baseline ascites was observed in 36.4% (rifaximin) and 34.6% (placebo) of patients. In patients with MELD score ⩾ 12 and INR ⩾ 1.2, rifaximin reduced the relative risk (RR) of any first complication experienced during trial by 59% [hazard ratio (HR) = 0.41, 95% confidence interval (CI): 0.25–0.67; p < 0.001] versus placebo. For patients with baseline ascites, rifaximin reduced the RR of any first complication experienced during trial by 42% versus placebo (HR = 0.58, 95% CI: 0.34–1.0; p = 0.045). For some subgroups, there was a decrease in RR of complications of SBP, variceal bleeding, and acute kidney injury/hepatorenal syndrome with rifaximin versus placebo, although there were few events reported in the study. 

Conclusion: Rifaximin may reduce the incidence of cirrhosis-related complications and the recurrence of overt HE.

Hepamerz

https://pubmed.ncbi.nlm.nih.gov/18983791/

80 patients were randomized to two treatment groups, L-ornithine-L-aspartate (20 g/d) or placebo, both dissolved in 250 mL of 5% dextrose water and infused intravenously for four hours a day for five consecutive days with 0.5 g/kg dietary protein intake at the end of daily treatment period. Outcome variables were postprandial blood ammonia and mental state grade.

Although, improvement occurred in both groups, there was a greater improvement in L-ornithine-L-aspartate group with regard to both variables

Case 2

https://sainiharika469.blogspot.com/2020/09/hello-everyone.html?m=1

1. Att was stopped in this patient because he is having elevated bilirubin and liver enzymes which was thought to be due to anti tubercular drugs.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4024786/

 

2.pt had history of low grade fever with dry cough,wt loss ,loss of appetite ,chest x ray showing fibrosis changes,ct showing pleural thickening , sputum for AFB positive.

3. Cause of ascites 

Ascitic fluid analysis shows high SAAG with low protein which indicates cirrhosis ,budd chiari syndrome ,or massive liver metastasis. There are no signs of hepatomegaly and abdominal pain ( triad of budd chiari along with ascites )

There is no lympadenopathy and ct abdomen showed no signs  of metastasis.

4.

Anti tubercular drugs can be continued, starting with the least hepatotoxic drug and adding one more every week by monitoring liver function test for any hepatitis 

As pt is diabetic with chronic liver disease insulin was given 

Lactulose syrup to prevent hepatic encephalopathy

Protein powder to correct Hypoalbuminemia 

Vit k for deranged coagulation profile

Case 3

 

https://sushma29.blogspot.com/2020/09/ascites-secondary-to-nephrotic-syndrome.html?m=1

1. Cause  of nephrotic syndrome  

https://images.app.goo.gl/LLUQXRUP1c8HV9NT7

Can be FSGS - scarring of some glomeruli ,may be idiopathic or may result from comorbidity

Membranous nephropathy - thickening of membranes within the glomeruli ,may be associated with malaria, hepatitis B, lupus.

Amyloidosis  - amyloid proteins accumulate in organs. 

In kidney ,they damage glomeruli

Diabetic nephropathy - pt has normal blood sugar levels

Management - renal biopsy to know the cause of nephrotic syndrome 

Diuretics to reduce edema

Watch for hypokalemia (spironolactone)

Protein rich diet to correct hypoalbuminemia

Ana,anti ds DNA, c3 c4 levels to r/o autoimmune

2. Pros and cons of renal biopsy

Pros -adequate diagnosis and treatment 

Prognosis of the patient

Cons - elderly pts ,comorbidities, 

use of anti platelet and anticoagulation treatment

https://images.app.goo.gl/ZaBsNvxF2SvUhSiF6