Chapter 45: Ascites Management in Portal Hypertension and Cirrhosis: Back to Drinking Level II

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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

• Identify signs and symptoms of cirrhosis and associated complications.

• Provide pharmacotherapeutic and lifestyle recommendations for managing ascites due to portal hypertension and cirrhosis.

• Develop a patient-specific regimen and monitoring parameters to meet the needs of a patient with ascites, esophageal varices, and hepatic encephalopathy.

• Interpret laboratory values associated with ascites.

• Provide appropriate patient education for the recommended pharmacologic and nonpharmacologic therapy to control complications of cirrhosis, as well as to prevent further complications.

PATIENT PRESENTATION

Chief Complaint

“I look like I’m pregnant and it’s getting worse.”

HPI

Robert Smith is a 38-year-old man with a history of alcoholic cirrhosis who has been admitted to the hospital due to an unexplained 8-kg weight gain over the past 6 days, abdominal swelling and pain, shortness of breath, and mild confusion.

PMH

• Alcoholic cirrhosis diagnosed 2 years ago, Child–Pugh Grade A on diagnosis

• EGD performed at time of cirrhosis diagnosis showed no esophageal varices

• Allergic rhinitis

• Hypertension

FH

Father is alive and well at the age of 70 without significant disease. Mother died at age 47 due to complications of type 1 DM.

SH

Recently separated from wife of 10 years and lives alone. Works as a plumber. History of extreme alcohol abuse but had quit drinking on cirrhosis diagnosis. Admits to heavy alcohol use over the past 2 months since separating from his wife and went on a drinking binge about 1 week ago.

Meds

• Fluticasone furoate two sprays per nostril once daily

• Levocetirizine 5 mg once daily

• Lisinopril 10 mg once daily

All

NKDA

ROS

Abdominal discomfort described as occurring throughout the abdomen, shortness of breath, and mild confusion. Patient denies chills or fevers.

Physical Examination

Gen

Pleasant, chronically ill black man appearing to be in mild distress and fatigued

VS

BP 118/76, P 78, RR 27, T 37.2°C; Wt 94.2 kg, Ht 6′2″

Skin

(+) Palmar erythema, (+) spider angiomata, otherwise normal color

HEENT

PERRL, EOMI, clear sclerae, TMs normal, mucous membranes moist

Neck/Lymph Nodes

Supple, no thyroid nodules

Lung/Thorax

Mild bilateral crackles, decreased breath sounds in right lower lobe likely due to enlarged liver and ascites