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Challenging cases of hospitalized patients with cirrhosis Danielle Brandman, MD, MAS Associate Professor of Clinical Medicine Program Director, Transplant Hepatology Fellowship October 17, 2019

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Page 1: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Challengingcasesofhospitalizedpatientswithcirrhosis

DanielleBrandman,MD,MASAssociateProfessorofClinicalMedicine

ProgramDirector,TransplantHepatologyFellowshipOctober17,2019

Page 2: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Disclosure

•  Grant/researchsupport:Grifols

Page 3: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

•  Hyponatremia•  GIbleeding•  Ascitesorhepatichydrothorax•  Livermass•  Frailty•  Endoflife?

Page 4: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case1

•  63MwithHCVcirrhosisishospitalizedduetoworsenedfluidretention,withascitesandlowerextremityedema

Page 5: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case1

•  63MwithHCVcirrhosisishospitalizedduetoworsenedfluidretention,withascitesandlowerextremityedema

•  Hedeniesfeverorfrankabdominalpain,thoughisuncomfortablefromabdominaldistension.

Page 6: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case1

•  63MwithHCVcirrhosisishospitalizedduetoworsenedfluidretention,withascitesandlowerextremityedema

•  Hedeniesfeverorfrankabdominalpain,thoughisuncomfortablefromabdominaldistension.

•  Hefindsitdifficulttowalkasaresultofseverelegedema

Page 7: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case1

•  VS:T37HR65BP110/70RR20SpO298%•  Gen:chronicallyill•  CV:3+BLEedema,anasarca•  Resp:normalotherthandecreasedBSatbases•  GI:distendedabdomenwithdullnesstopercussion,nontender

•  Labs:WBC4,hct32,plt60,INR1.9,Na122,Cr2.5,totalbili6,albumin2.8

Page 8: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case1

•  Whatisyourstrategyformanagementofthispatient’svolumeoverload?

•  Howwouldyouhandlehishyponatremia?

Page 9: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness
Page 10: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case2

•  57FwithNASHcirrhosisishospitalizedforthe4thtimein2monthswithshortnessofbreath

Page 11: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case2

•  57FwithNASHcirrhosisishospitalizedforthe4thtimein2monthswithshortnessofbreath

•  Shehasahistoryofhepatichydrothoraxthathasgottenprogressivelyworseovertime

Page 12: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case2

•  57FwithNASHcirrhosisishospitalizedforthe4thtimein2monthswithshortnessofbreath

•  Shehasahistoryofhepatichydrothoraxthathasgottenprogressivelyworseovertime

•  Sheundergoestherapeuticthoracentesisnowtwiceweekly,with1-2Lfluidremovedeachtime

Page 13: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case2

•  57FwithNASHcirrhosisishospitalizedforthe4thtimein2monthswithshortnessofbreath

•  Shehasahistoryofhepatichydrothoraxthathasgottenprogressivelyworseovertime

•  Sheundergoestherapeuticthoracentesisnowtwiceweekly,with1-2Lfluidremovedeachtime

•  Sheisfrustratedwithherfrequenthospitalizationsandpoorqualityoflife

Page 14: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case2

•  57FwithNASHcirrhosisishospitalizedforthe4thtimein2monthswithshortnessofbreath

•  Shehasahistoryofhepatichydrothoraxthathasgottenprogressivelyworseovertime

•  Sheundergoestherapeuticthoracentesisnowtwiceweekly,with1-2Lfluidremovedeachtime

•  Sheisfrustratedwithherfrequenthospitalizationsandpoorqualityoflife

•  Diureticdoseshavebeenincreasedtothehighesttolerabledose,withhigherdosesassociatedwithAKI,hyponatremia,and/orhyperkalemiainthepast

Page 15: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case2

•  VS:T36.4HR73BP109/53RR24SpO295%2LNC

•  Gen:chronicallyill•  Resp:Decreasedbreathsoundsthroughoutalllungfieldsontheright

•  Labs:WBC6,hct28,plt51,INR1.6,Na130,Cr1.02,totalbili2,albumin2.7

Page 16: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case2

•  Whattreatmentoptionsareavailabletothispatient?

Page 17: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case2

•  Whattreatmentoptionsareavailabletothispatient?

•  Whatifherlabslookedlikethis:–  INR2.7,Na130,Cr1.02,totalbili7

Page 18: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness
Page 19: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case3

•  47Mwithalcoholrelatedcirrhosispresentswithalteredmentalstatus

Page 20: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case3

•  47Mwithalcoholrelatedcirrhosispresentswithalteredmentalstatus

•  Hehadbeentakinglactuloseasprescribed,buthisfamilynotesthathehasnothadabowelmovementinthepast24hours

Page 21: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case3

•  47MwithalcoholrelatedcirrhosisisbroughtintotheEDwithalteredmentalstatus

•  Hehadbeentakinglactuloseasprescribed,buthisfamilynotesthathehasnotbeenhavingmanybowelmovements

Page 22: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case3

•  47MwithalcoholrelatedcirrhosisisbroughtintotheEDwithalteredmentalstatus

•  Hehadbeentakinglactuloseasprescribed,buthisfamilynotesthathehasnotbeenhavingmanybowelmovements

Page 23: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case3

•  VS:T36.7HR80BP117/62RR12SpO299%•  Gen:chronicallyill,musclewasting•  Neuro:lethargic,onlybrieflywakesupwithverbalstimuli.Orientedx0.+clonus

•  Labs:WBC5,hct33,plt95,INR1.9,Na136,Cr0.97,totalbili4.7,albumin2.6

Page 24: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case3

•  Whatareyourinitialstepsformanagement?

Page 25: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case3

•  Afteraggressivelydosinglactuloseq2hours,thepatientdevelopsabdominaldistensionandhasnotpassedanystool

Page 26: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case3

•  Afteraggressivelydosinglactuloseq2hours,thepatientdevelopsabdominaldistensionandhasnotpassedanystool

Page 27: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case3

•  Whatwouldbeyournextstepsinmanagement?

Page 28: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness
Page 29: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case4

•  63Fwithcirrhosisduetoprimarybiliarycholangitispresentswithhematemesisandmelena

Page 30: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case4

•  63Fwithcirrhosisduetoprimarybiliarycholangitispresentswithhematemesisandmelena

•  Shehad2priorepisodesofbleedingduetoesophagealvariceswithinthepast3months

Page 31: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case3

•  VS:T37HR115BP90/54RR12SpO299%•  Gen:alert,mildlyuncomfortable•  GI:soft,NT,ND,nodetectableascites.Rectalwithmelena

•  Labs:WBC7,hct20(baseline31),plt48,INR2.8,Na137,Cr0.65,totalbili2.5,albumin3.1

Page 32: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case4

•  Whatareyournextstepsinmanagement?

Page 33: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case4

•  Upperendoscopyisperformedandshows3columnsoflargeesophagealvariceswithhighriskstigmata

Page 34: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case4

•  Upperendoscopyisperformedandshows3columnsoflargeesophagealvariceswithhighriskstigmata

•  Thegastroenterologistisunabletosuccessfullyplacebandsduetoscarringfrompriorbandligation.Activebleedingbeginsattheendofthecase.

Page 35: Challenging cases of hospitalized patients with cirrhosis...• CV: 3+ BLE edema, anasarca • Resp: normal other than decreased BS at bases • GI: distended abdomen with dullness

Case4

•  Upperendoscopyisperformedandshows3columnsoflargeesophagealvariceswithhighriskstigmata

•  Thegastroenterologistisunabletosuccessfullyplacebandsduetoscarringfrompriorbandligation.Activebleedingbeginsattheendofthecase.

•  Whatoptionsfortreatmentareavailable?


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