Team 12 Esophageal Varices Case Hepatic Vein Thrombosis

Team 12: Esophageal Varices Case Hepatic Vein Thrombosis Marianna Sargsyan Michael Ramsey Michael Tran Long Phan Matthew Sorensen 2015 PHRM 648 GI Group Presentation

Patient Case HPI: • 55 yo female with complaint of vomiting blood • Bright red blood per rectum for the past 2 days. • Vomited after a dose of lactulose

Patient Case PMH: • Cirrhosis secondary to HCV • Hepatic encephalopathy • PUD • HTN • Cellulitis

Patient Case FH: • Father: CAD and CABG SH: • lives alone • quit smoking 10 years ago • does not drink alcohol

Patient Case Medications: • Sucralfate 1 g PO BID • Omeprazole 20 mg PO BID • Bumetanide 1 mg PO BID • Spironolactone 50 mg PO QD • Propranolol 40 mg PO BID (may not be taking)

Patient Case Vital Signs • BP: 108/60 • P: 120 • RR: 14 • T: 37. 8°C

Patient Case Labs • • Na 127 m. Eq/L K 4. 3 m. Eq/L Cl 101 m. Eq/L CO 2 22 m. Eq/L BUN 57 mg/d. L SCr 1. 9 mg/d. L Glu 155 mg/d. L Hgb 7. 8 g/d. L Hct 24. 4% WBC 26. 4 × 103/mm 3 Neutros 59% Bands 17% Lymphs 23% Monos 1% Plt 68 × 103/mm 3 a. PTT 42. 1 s PT 16. 5 s INR 1. 8 AST 104 IU/L ALT 49 IU/L Alk phos 114 IU/L T. bili 4. 3 mg/d. L D. bili 3. 3 mg/d. L Protein 5. 5 g/d. L Alb 2. 5 g/d. L Ca 8. 4 mg/d. L Phos 4. 4 mg/d. L

Patient Case Current Problem List • Bleeding varix • Anemia • Hematochezia • Possible infection vs SBP (elevated WBC) • Encephalopathy? • Renal insufficiency • Hyponatremia • Dehydration • Coagulopathy • Chronic hepatitis C

Patient Case EVL • Found a large varix with a large red spot and bulge that began to spurt blood during procedure

Nonpharmacologic Interventions • Blood volume resuscitation • Endoscopic variceal ligation (EVL) • Discontinue propranolol temporarily • Schlerotherapy

Therapeutic Interventions • Octreotide • Antibiotic prophylaxis for treatment of variceal bleeding • Norfloxacin PO 400 mg BID x 7 days • Alternative – Ciprofloxacin – Ceftriaxone IV 1 g/day

Optimal Plan for Patient • Resuscitation of blood volume • Octreotide 50 ug bolus then 50 ug/hour x 5 days max • EVL once bleeding stops • Ceftriaxone IV 1 g/day for 7 days • EVL once bleeding has stopped

Monitoring • CMP • CBC (Hb/Hct) • Glucose levels (octreotide) • Blood pressure and heart rate

Patient Education • Octreotide: Generally well-tolerated – SE: diarrhea, hyperglycemia, headache, dizziness • EVL: hypotension, GI discomfort, moderate bleeding • Avoid Triggers: coffee, spicy foods, alcohol

Hepatic Vein Thrombosis • Also known as Budd-Chiari Syndrome (BCS) • Defined by obstruction of hepatic venous outflow anywhere from the small hepatic veins to the junction of the inferior vena cava and the right atrium.

Type of BCS Primary BCS: • Obstruction (thrombosis or phlebitis) occurs within the vessel. • Caused by prothrombic factors, hereditary or acquired Secondary BCS: • Compression by a source outside the veins (a benign or malignant tumor, trauma, an abscess or a cyst)

Epidemiology and Demographics • Incidence: 1 in 2. 5 million persons per year • Women most commonly affected (~⅔ of cases) • Median age: 35 years old

Symptoms • Fever • Abdominal pain • Abdominal distention • Ascites • Hepatomegaly • Lower limbs edema

Clinical Presentation • Subacute: Insidious onset, may take up to 3 months to develop symptoms – Ascites and hepatic necrosis may be minimal due to decompression of the sinusoids by portal and hepatic venous collaterals • Acute: clinical manifestations develop rapidly (over the course of weeks) with intractable ascites and hepatic necrosis • Chronic: Patients present with complications of cirrhosis

Diagnosis Lab Test: non- specific • Assessment of liver injury and function: serum aminotransferases, alkaline phosphatase, prothrombin time (PT), albumin, bilirubin • Ascites protein content > 3. 0 g/d. L and serum ascites albumin gradient >1. 1 g/d. L

Diagnosis • Doppler Ultrasonography • Computed Tomography • Magnetic Resonance Imaging (MRI) • Liver Biopsy: for patients for whom diagnosis remains uncertain

Treatment: Acute • Anticoagulation Therapy: use LMWH first, followed by warfarin • Balloon angioplasty • Stenting • TIPS • Portal systemic Shunts • Liver transplant for patients who don’t respond to TIPS • Supportive

Treatment: Chronic • Lifelong anticoagulation: warfarin (INR 2 -3) • Treat liver dysfunction and complications • Invasive interventions should be reserved for symptomatic patients who don’t improve with medical therapy • Liver transplantation

References Ferri, Fred F. , M. D. , F. A. C. P. "Budd-Chiari Syndrome. " Ferri's Clinical Advisor 2016. 1 st ed. N. p. : Elsevier, 2016. 259 -60. Clinical. Key. Elsevier, 22 Nov. 2015. Web. 22 Nov. 2015. <https: //wwwclinicalkey-com. proxy. lib. pacificu. edu: 2443/#!/content/book/3 -s 2. 0 B 9780323280471001347? scroll. To=#f 0015>.