NYU Medical Grand Rounds Clinical Vignette

1. NYU Medical Grand Rounds Clinical Vignette Jeffrey Mayne, MD Third Year Resident Internal Medicine 1/17/2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • The patient is a 46 year-old man with a past medical history of alcoholic cirrhosis who was admitted to an outside hospital with hematemesis.

3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Presented to the outside hospital three weeks prior for alcoholic hepatitis, jaundice and ascites. • Started on steroids and discharged on diuretics. • Remained alcohol free following discharge. • Re-presented 3 weeks after discharge with hematemesis.

4. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Emergent endoscopy revealed extensive clots throughout the esophagus. • Clots were removed, revealing actively bleeding varices. • Attempt at endoscopic control with band ligation and sclerotherapy not successful. • Developed massive hematemesis.

5. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Transfused 7 units red blood cells, 2 units platelets, 2 units of fresh frozen plasma. • A Blakemore tube was placed. • The patient was intubated for airway protection, ceftriaxone, octreotide and protonix were started. • The patient was transferred for evaluation for emergent transjugular intrahepatic portosystemic shunt (TIPS).

6. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History: None • Past Surgical History: None • Social History: Head of hedge fund, regular heavy social alcohol use with increase following stock market collapse • Family History: No liver disease • Allergies: None • Medications: • Propofol Octreotide • Vasopressin Ceftriaxone • Imipenem

7. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: Obese, intubated, following commands • Vital Signs: • T: 97.6 BP:110/60 • HR: 90 RR: 18 O2 sat: 96% 50% fiO2 • Eyes: conjunctival icterus • Skin: jaundiced, spider angiomata

8. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Abdomen: shifting dullness, large volume ascites • Extremities: no lower extremity edema • Remainder of Physical Exam was normal

9. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: White Blood Cell Count 19.1*109/L, Hemoglobin 9.3 mg/dL, Hematocrit 26.2, Platelets 152*109/L • Basic Metabolic panel: Sodium 117 mmol/L, Chloride 87 mmol/L, CO2 15 mmol/L, BUN 54 mg/dL, Creatinine 1.9 mg/dL, Calcium 6.6 mmol/L • Hepatic panel: AST 1741 IU/L, ALT 595 IU/L, Total Bilirubin 17.4 mg/dL, Conjugated Bilirubin 11.0 mg/dL, Total Protein 4.5 g/L, Albumin 2.0 g/L • INR 1.8, PTT 33.5 s, Ammonia 88 mcg/dL

10. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • ABG: pH 7.42, pCO2 22 mmHg, pO2 122 mmHg, Bicarbonate 14.6 mmol/L, Lactate 7.2 mg/dL • Paracentesis: Red Blood Cells 20,000 mm3, Nucleated Cells 920 mm3, 12% Polynuclear cells, Albumin 0.9 g/dL

11. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Chest X-Ray: Small right pleural effusion • CT Abdomen: Liver cirrhosis, portal hypertension, large volume pelvic and abdominal ascites, portal vein small but patent, patent hepatic veins.

12. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • MRI Abdomen: Mild to moderate iron deposition

13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working or Differential Diagnosis • Alcoholic liver disease with superimposed iron overload • Child-Pugh Score 12 • MELD Score 30 • Hematemesis secondary to esophageal variceal bleed • Renal failure

14. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1: • Transjugular Intrahepatic Portosystemic Shunt (TIPS) was attempted unsuccessfully due to thrombus within distal right main portal vein and small caliber of portal veins. • Gastric and esophageal balloons were deflated without active bleeding. • 4 liters ascites removed.

15. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 3: • Esophagogastroduodenoscopy (EGD) revealed grade II esophageal varices without stigmata of bleeding, gastric varices without bleeding. • Transjugular Intrahepatic Portosystemic Shunt (TIPS) performed with coil embolization of large coronary vein and large variceal cluster.

16. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 4: • Due to worsening renal function and volume overload, patient was started on Continuous Veno-Venous Hemofiltration (CVVH). • Vasopressin stopped. • Hospital Day 6: • CVVH stopped due to spontaneous improvement in renal function

17. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 8: • Patient extubated. • Encephalopathy managed with lactulose and rifaximin. • Hospital Day 12: • Patient transferred to regular room.

18. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 15: • Melenic stool complicated by hypotension requiring blood transfusions and monitoring in ICU. • Hospital Day 17: • Patient underwent TIPS revision, including embolization of coronary vein varix arising from the mid-splenic vein.

19. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 25: • Patient developed spontaneous bacterial peritonitis (SBP) requiring antibiotic treatment. • Hospital Day 50: • Discharged home with subsequent progressive clinical and biochemical improvement

20. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Day 450: • Patient working full-time, ascites well-controlled, hepatic encephalopathy well-controlled.

21. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Hematemesis secondary to esophageal variceal bleed • Cirrhosis secondary to alcohol and iron overload