CASE PRESENTATION

DEPARTMENT : Gastroentrology
A male patient of age 46 yrs old was
admitted with the following complaints

c/o :

yellowish discoloration of urine,

eyes since 1week.
• O/E :
conscious and oriented .
CVS : s1 and s2 +
P/A : soft ,tenderness [-]
CNS : NAD
RS : BAE + clear
•SOCIAL HISTORY:
•RESIDENCE : Hyderabad
•OCCUPATION : not available
•MARITAL STATUS : single
•ALCOHOL : chronic alcoholic
•SMOKING : NO
•DIET : Diabetic soft diet.
•PAST MEDICAL HISTORY : DM-II form 3 years
•PAST MEDICATION HISTORY : not available
•SURGICAL HISTORY : NIL
•FAMILY HISTORY : not available.
•PREVIOUS ALLERGIES : NIL.
PHYSICAL EXAMINATION :
S .No D1 NORMAL
VALUES

B.P mm/hg 120/80 120/80

P.R BPM 80/min 72/min

R.R CPM 20 12-20

TEMP (F) 98.6 98.6

 LABORATORY PARAMETERS
parameters Day-1 Normal value

Haemoglobin 13.8g 12-15.5 gm %

platelets 247 150-400 x 10 3 /L

RBC 4.78 4.2-5.4 million cells of blood

WBC 6.5 4000-11000cells/mm3

Uric acid 2.7 * 3.4 - 7 mg/dl

Total protein 5.5* 6.6-8.7g/dl
ALP 77 35-120U/L
T.Bilirubin 1.5 * 0.1 to 1.2 mg/dL
Direct bilirubin 0.3 0.3 mg/dL
Indirect Bilirubin 0.4 0.2-0.8mg/dL
Globulin 4.2* 2-3.5g/dl
Albumin 3.6 3.5 to 5.5 g/dL
GGT 62 * 9-48u/l
ALT 23* <45U/L

AST 45 * <35U/L

Sodium 131 * 135-145 meq/l

chloride 87* 96 - 106 meq/l

BUN 6* 7 to 20 mg/dL
Investigations :

• USG abdomen shows

Hepatomegaly with gall bladder sludge.
DIAGNOSIS :

ALCOHOLIC HEPATITIS
TYPE - 2 DM
SOAP NOTE :
Subjective : yellowish discoloration of urine, eyes since
1week.
Objective :
globulin – decreased
tot .protein – decreased
Ast - increased
Alt - increased
GGT - increased
uric acid – decreased
BUN - decreased
uric acid - decreased
 CORE

CONDITION:

• yellowish discoloration of urine, eyes since 1week.

• Elevated liver enzymes like ALT ,AST.
• Elevated GGT level
• Decreased BUN, uric acid level.
• Decreased sodium ,chloride level.
• Elevated tot.bilurubin , globulin level.
• chronic alcoholic .
OUTCOME:

• To relieve signs and symptoms.

• Identify the cause of hepatitis , where possible
• Evaluate the location, extent, and severity of
the liver damage and assess organ function
• Detect and evaluate complications
• To decrease further progression and recurrence
of hepatitis.
• To increase quality of life of the patient
REGIMEN:
• Haemodynamic stability should be done
immediately
For Alcoholic hepatitis :
• Abstinence of alcohol .
• Hydration therapy
• Nutrition Therapy include , including vitamin A,
vitamin D, thiamine, folate, pyridoxine, and zinc.
• Steroids –prednisolone.
For hepatomegaly :
• Hepatoprotectives
• prophylactic antibiotics to treat infections in liver
.
DRUG CHART
Brand name Generic name Dose Freq Route D D
1 2

INJ.PAN PANTOPRAZOLE 40mg BD IV  

INJ.THIAMINE THIAMINE 100mg OD IV  

INJ.URSOCOL URSODEOXYCHOLIC ACID 300 mg BD IV  

TAB.ATOCOR ATORVASTATIN 20 mg BD PO  

TAB.ZOXYL MI FORTE GLIMIPRIDE+METFORMIN 1 TAB OD PO X 

SYP. COOZ LACTULOSE 15 ML HS PO  X

INJ. MONOCEF CEFTRIAXONE 1 GM IV BD  

 DIABETIC CHART :
• DAY -1 - 212 mg/dL – 8AM HAI infusion - 0.5ml
• - 157mg/dl - 10PM
• - 147 mg/dl - 2PM
• - 157 mg/dl - 6PM
• DAY2 - 157 mg/dl - 8AM
• - 143mg/dl - 10AM
EVALUTION :

• Patient was made haemodynamically stable.

• USG abdomen shows
Hepatomegaly with gall bladder sludge.
• Should normalize elevated blood sugar level.
• monitor the liver enzymes.
• Patient was discharged in stable condition.
 PRIME
PHARMACEUTICAL RELATED PROBLEMS: Nil

RISK FACTORS :

PANTOPRAZOLE – OSTEOPOROSIS –related fractures for hip

THIAMINE – injection site reaction
URSODEOXYCHOLIC ACID – rash ,diarrhea ,respiratory infections .
ATORVASTATIN – increased liver enzymes ,dark urine, jaundice.
GLIMIPRIDE – hypoglycemia, increased liver enzymes , disulfiram like
reactions, hyponatremia , jaundice.
METFORMIN – hepatitis ,cobalamin deficiency
LACTULOSE- bloating symptom
DRUG INTRACTIONS
• metformin - glimepiride
potential signs and symptoms of hypoglycemia
like headache ,dizziness , tachycardia .
• atorvastatin - pantoprazole
Combining these medications may increase the
blood levels and effects of atorvastatin
MISMATCH :

THAIAMINE -100MG/GLUCOSE -25MG

EFFICACY :
NIL
 DISCHARGE MEDICATIONS :
Tab. ursodeoxycholic acid 300mg BD x 2weeks
Tab. glimepiride 1mg- metformin 1000 mg
OD BBF -2 weeks .
Tab. Zincovit OD after food -2 weeks.
PLAN :
• Take medicines regularly.
• Don’t miss the dose . If you miss the dose take it
as soon as possible . If it a time for next dose then
Skip the dose.
• Use a appropriate foot wear .
• Have your feet checked at least once each year.
• Go for eye checkup for every 6 months .
• Blood glucose monitoring should be done.
• to maintain alcohol abstinence in patients
• Intake of Vitamin E helps in decreasing inflammation.
• Advice to rehabitation center for withdrawal of alcohol .
• take a high protein diet .
• advice to give family ,social support to patient .
• Coconut water is filled with vitamins and minerals .
• Typical sources of saturated fat include animal products, such as
red meat, whole-fat dairy products, and eggs, and also a few
vegetable oils, such as palm oil, coconut oil, and cocoa butter.
Saturated fat can increase your levels of "bad" LDL cholesterol.
• take fiber rich foods like whole grain foods etc
• Do regular exercises.
• Take adequate amount of water .
• Avoid alcohol .
• Fallow physicians instructions carefully .
 DRUG COUNCELLING
• THIAMINE- should to be taken with meal.
• URSODIOL- should betaken with food.
• Don’t use any antacids during therapy because
they inhibit the absorption of URSODIOL
• Advice patient to report symptoms of
hypoglycemia while using metformin-glimipride
combination.
REFERENCE :
• American college of gastroentrology
• Micro medics
• AASLD
THANK YOU