What's the Take Home?
A 63-Year-Old Man With Worsening Liver Failure
Ronald N. Rubin, MD1,2 —Series Editor
1Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
2Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania
Rubin RN. A 63-year-old man with worsening liver failure. Consultant. 2021;61(7):e19-e21. doi:10.25270/con.2021.07.00001
The author reports no relevant financial relationships.
Ronald N. Rubin, MD, Temple University Hospital, 3401 N Broad Street, Philadelphia, PA 19140 (firstname.lastname@example.org)
A 63-year-old man who has profound deterioration in his condition is brought to his primary care physician by his family.
History. The patient has significant liver disease of at least 5 years’ duration. It was first discovered by abnormalities found as a result of liver function testing but has become more clinically severe over time. About 3 years prior to presentation, the patient was admitted to the hospital with hepatomegaly and abdominal pain associated with alcohol binge drinking. A comprehensive evaluation, including a liver biopsy, had revealed alcoholic hepatitis at that time. A background history taken at that hospitalization had revealed heavy, long-term alcohol misuse involving an excess of 5 drinks of spirits per day. Since then, attempts to break the alcohol addiction have been in place with varying degrees of adherence.
About 18 months prior to his current presentation, ascites had appeared, which had initially responded to diuretic therapy. Over the last 2 months, the patient had been consuming large amounts of alcohol. His family reported increased edema of the feet and lower extremities, increased abdominal girth, decreased mental acuity with lethargy, and yellowing of the skin.
Physical examination. On hospital day 1, the patient exhibited confusion and had obvious jaundice. His temperature was elevated at 38 °C and blood pressure was low at 100/70 mm Hg. His skin had many spider telangiectasia and was deeply jaundiced. He had significant ascites with a caput medusae. A firm liver edge and spleen tip were palpable despite the ascites. There was 4+ edema of the feet and lower extremities to the knee. There was mild mental confusion and asterixis.
Diagnostic testing. Initial results from laboratory testing revealed a low hemoglobin level of 11.0 g/dL, an elevated white blood cell count of 18,000/μL that was predominantly neutrophils, and a low platelet count of 89,000 × 103/μL. His serum sodium level was low at 112 mEq/dL, potassium level was low at 2.9 mEq/dL, and serum albumin level was low at 2.3 g/dL. His prothrombin time (PT) was elevated at 30 s with an elevated international normalized ratio (INR) of 4.0. His aspartate aminotransferase level was 225 U/dL and alanine aminotransferase level was 80 U/L with an elevated alkaline phosphatase level of 411 U/L. His blood alcohol level was 0.
Treatment and management. The patient was admitted to the hospital with initiation of general measures, including gentle diuresis to lower his body weight by 0.5 to 1.0 kg/d, antibiotics in the form of ceftriaxone (all cultures on hospital day 3 were negative, and paracentesis showed an ascitic fluid neutrophil count of < 100 cells/μL, and oral lactulose. Specific therapy in the form of prednisolone was also initiated.
On hospital day 7, there was some modest improvement in mentation, but the physical findings had otherwise minimally changed. Repeat laboratory test results showed an elevated bilirubin level of 18 mg/dL, a low albumin level of 2.1 g/dL, and an elevated creatinine level of 2.7 mg/dL. His PT remained elevated at 30 s with an INR of 4.0.
Answer and discussion on next page.