Case 9: Vietnamese man with jaundice
Tuesday, February 22nd, 2011This 45 year old Vietnamese man presented with a two day history of worsening abdominal pain, vomiting, worsening drowsiness, and confusion. He spoke no English but his family explained that he had previously been an alcoholic and intravenous drug abuser, and that he is on medication for his ‘abdominal swelling’ but that he is erratic with his compliance.
His initial observations were HR 110 BP 85/50 RR 32 Temp 39.5.
1. Give three signs of liver disease seen in this man?
Click to see the answerAscites, jaundice, gynecomastia, caput medusa
2. His potassium is found to be 6.9 on a blood gas. What is the likely cause and what is your emergency management of this result?
Click to see the answerPatients with ascites and liver cirrhosis are best managed with K+ sparing diuretics such as spironolactone along with sodium restriction. Close attention must be given to the potassium levels with regular blood tests, and often concurrent loop diuretics if further diuresis and potassium lowering is required. In this case the potassium is dangerously high and needs emergency treatment with cardioprotection with calcium chloride and insulin and dextrose to lower the potassium.
3. In light of the temperature, what is the most concerning differential diagnosis?
Click to see the answerThis man may be evolving spontaneous bacterial peritonitis. This can occur in up to a third of patients wth ascites and has a mortality rate of 20%. Paracentesis is mandatory and can be conducted in the ED with common organisms including E. Coli, Streptococci and Enterococci. Treatment is usually with 3rd generation cephalosporin’s.
4. What grade of hepatic encephalopathy is this man in?
Click to see the answerThe different grades of encephalopathy are often difficult to distinguish however a higher grade is indication to escalate to a higher level of care. This gentleman falls into grade 2 or 3, however the key aspect is to identify the underlying cause of the deterioration. Along with treating this precipitating factor, the nitrogen load from the gut must be reduced by using lactulose and enemas and antibiotics may be administered to lower amino acid production.
Grade 1: mild confusion, euphoria or depression, decreased attention, slowing of ability to perform mental tasks, irritability, disorder of sleep pattern such as inverted sleep cycle.
Grade 2: drowsiness, lethargy, gross deficits in ability to perform mental tasks, obvious personality changes, inappropriate behaviour, intermittent disorientation.
Grade 3: somnolent but rousable, unable to perform mental tasks, disorientation to time and place, marked confusion, amnesia, occasional fits of rage, speech is present but incomprehensible.
Grade 4: coma, with or without response to painful stimuli.