Cirrhosis of the Liver

Patient Presentation: 
C.M., a 57-year-old male, presents to the ED with complaints of abdominal pain, fatigue, and nausea.  The patient appears jaundiced and upon further assessment the patient is found to have ascites and gynecomastia.  C.M. is also found to be anorexic, weighing only 118 pounds and measuring 6 foot 2 inches tall.  The patient’s past medical history includes ETOH abuse and hypertension.  The patient’s vital signs are as follows:  Temperature: 38.2, Heart Rate: 98, O2 sats: 95%, Blood Pressure: 157/83, Pain: 10/10 Abdominal Pain.  C.M. reveals he has been experiencing symptoms for months but has been laid off for one year and did not seek treatment due to lack of insurance.

Lab Results:
BMP: Na+ 146, K+ 3.9, Cl- 103, BUN 22, Creatinine 1.43
Liver panel: Alk Phos 152, AST 103, ALT 99, serum albumin 2.3, Total Bili 14.4, Direct Bili 9.5
CBC: RBC 3.67, Hgb 11.4, Hct 32.5, Plt 87, PT 15.2, INR 1.3

Differential Diagnosis: 
Cirrhosis of the Liver, Hepatitis B, Hepatitis C

Tests:
An abdominal ultrasound is performed to visualize the abdominal organs.  The ultrasound reveals the liver and spleen are much larger in size than normal and numerous nodules are present at the liver. Due to ultrasound results and laboratory results, cirrhosis of the liver is confirmed.  C.M. is also found to have portal hypertension; subsequently, an endoscopy is performed and esophageal varices are verified.

Treatment:
The patient is started on a corticosteroid (Prednisone) and a beta-blocker (Propranolol) to manage the liver cirrhosis and the portal hypertension.  Vitamin supplements, including folate, vitamin B12, and thiamine, are prescribed due to malnutrition caused by excessive alcohol consumption.  C.M. undergoes a paracentesis procedure and variceal banding.  Once able to consume PO intake, the patient is placed on a low sodium diet.  The patient is also educated on his diagnosis and provided education regarding alcohol abuse and cessation.

Outcome:
The liver damage that has occurred is irreversible.  C.M. continues to receive paracentesis treatments on an outpatient basis.  Despite undergoing treatments, C.M. continues to abuse alcohol, which exacerbates his cirrhosis.  Due to his relentless alcohol abuse he is unable to receive a liver transplant and his disease has progressed to chronic liver failure.
Case created by Carmen Moore, 2011.